PFD report

Mrs Margaret Melia · Prevention of Future Deaths report

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Issued 18 Apr 2019•Black Country

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Inadequate discharge and pre-assessment process for subcutaneous fluid requirements
    Part of recurring concern: Unreliable management of patients’ fluid requirements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Review organisational pre-admission and admission policies and practices.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 6 November 2019.
  2. Action

    Include guidance requiring further information when pre-admission assessment occurred more than five days before admission, including medication and healthcare review updates.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 6 November 2019.
  3. Action

    Review the current admission process checklist.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 6 November 2019.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate discharge and pre-assessment process for subcutaneous fluid requirements

Wider context from the report

“1. Evidence emerged during the inquest that there was an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home over the requirement of subcutaneous fluids. ”

Is this part of a recurring concern?

Yes — Unreliable management of patients’ fluid requirements.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review organisational pre-admission and admission policies and practices.

Verbatim wording from the response

“We reviewed our policies and practices as an organisation in relation to our pre-admission and admission processes.”

Source location

2019-0320-Response-by-HC-One
Page 1 · response
Published 6 November 2019

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Include guidance requiring further information when pre-admission assessment occurred more than five days before admission, including medication and healthcare review updates.

Verbatim wording from the response

“On reviewing our practices, we identified that if a delay occurred between the pre-admission assessment conducted, there needed to be clearer guidance set out for colleagues within our Admission, Transfer and Discharge Procedure (Appendix 1). We have now included practice that in the eventuality the pre-assessment was completed more than five days prior to admission to the home, further information should be sought from the hospital ward/care home/social worker as soon as possible. This will include the update of any medication changes or outcome of any recent healthcare professional reviews of the person during this period, to avoid any misunderstanding that could result in harm.”

Source location

2019-0320-Response-by-HC-One
Page 1 · response
Published 6 November 2019

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the current admission process checklist.

Verbatim wording from the response

“We reviewed the current Admission process checklist.”

Source location

2019-0320-Response-by-HC-One
Page 1 · response
Published 6 November 2019

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Cascade the revised admission practice across homes through the Homes’ Bulletin.

Verbatim wording from the response

“The changes to practice have been cascaded across the organisation via our Homes’ Bulletin, which is sent to our homes.”

Source location

2019-0320-Response-by-HC-One
Page 1 · response
Published 6 November 2019

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the admission process checklist across all homes to reflect the revised practice.

Verbatim wording from the response

“Our Admission process checklist (Appendix 2), which is available within all our homes to ensure all aspects of the organisation’s pre-admission and admission processes are completed, has been updated to reflect this improvement in practice.”

Source location

2019-0320-Response-by-HC-One
Page 1 · response
Published 6 November 2019

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026