PFD report

Gloria Elizabeth MEKINS · Prevention of Future Deaths report

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Issued 28 May 2019•Teesside and Hartlepool

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
6

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 raised4

  1. Failure to provide first aid and airway-clearing assistance during choking
    Part of recurring concern: Unreliable airway management during emergency care
  2. Failure to remedy identified safety issues
  3. Failure to investigate choking-related events and identify safety issues
    Part of recurring concern: Failure to learn from deaths through systematic reviewPart of recurring concern: Inadequate safety incident investigations
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

    Submit a safeguarding alert to Hartlepool Social Services for further investigation.

    Stated by Rossmere Park Care CentreStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
  2. Action

    Implement a protocol for staff to follow after a resident’s death.

    Stated by Rossmere Park Care CentreStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
  3. Action

    Implement a DNACPR notification system using door markers and prominent notices in residents’ room folders.

    Stated by Rossmere Park Care CentreStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The first HCA did not discover choking; there were no choking signs, and subsequent airway checks found no obstruction.

    Stated by Rossmere Park Care CentreDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Failure to provide first aid and airway-clearing assistance during choking

Wider context from the report

“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”

Is this part of a recurring concern?

Yes — Unreliable airway management during emergency care.

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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

Failure to remedy identified safety issues

Wider context from the report

“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Failure to investigate choking-related events and identify safety issues

Wider context from the report

“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”

Is this part of a recurring concern?

Yes — Failure to learn from deaths through systematic review; Inadequate safety incident investigations.

Open source report

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

Lack of clarity about the existence of a DNA CPR

Wider context from the report

“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”

Is this part of a recurring concern?

Yes — Unreliable DNACPR decision-making, recording and communication; Unreliable emergency response arrangements in care homes.

Open source report

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

Submit a safeguarding alert to Hartlepool Social Services for further investigation.

Verbatim wording from the response

“However, it became apparent at the end of November that further investigation was required and I submitted a Safeguarding Alert to Hartlepool Social Services on 3.12.2018.”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019

Open published response

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

Implement a protocol for staff to follow after a resident’s death.

Verbatim wording from the response

“The CCG suggested we draft a Protocol for staff to follow after a death (sudden or otherwise) and we implemented this immediately following the Lessons Learned Meeting. The CCG also suggested that we draft a form where the home could document any concerns identified as risks associated with a resident’s decisions and advice to mitigate those risks.”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019

Open published response

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

Implement a DNACPR notification system using door markers and prominent notices in residents’ room folders.

Verbatim wording from the response

“Staff are advised which resident has a DNACPR Notice by means of a whiteboard within the Nurse’s office at Rossmere Park Care Centre – with the same facility in the Senior’s office on the Ground Floor. This shows against each resident’s room, whether a DNACPR is in place and the date it expires. The Daily Handover sheets also show clearly against each room which resident has a DNACPR.”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 2 · response
Published 2 August 2019

Open published response

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

Participate in lessons-learned meetings with safeguarding, commissioning, healthcare and police representatives.

Verbatim wording from the response

“I attended a Lessons Learned Meeting on 8th. January 2019, at which both Hartlepool’s Safeguarding and Commissioning Teams, a representative from the CCG (NHS) and the Police were present.”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019

Open published response

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

Produce a more user-friendly Choking Risk Assessment in consultation with the SALT team.

Verbatim wording from the response

“It was also apparent from my e-mails with your office that the Choking Risk Assessment used by Rossmere was not easily understood. We therefore liaised in depth with the”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The first HCA did not discover choking; there were no choking signs, and subsequent airway checks found no obstruction.

Verbatim wording from the response

“Although I have addressed your Matters of Concern below, the first point I must make is that your assertion in point 4 – Circumstances of Death – that “staff attended and believed she was choking” is incorrect as there is no evidence in any of the staff statements (which were written soon after the event) that ANY staff believed she was choking at the time of the incident.”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 1 · response
Published 2 August 2019

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

A separate internal investigation was considered inappropriate while CQC had been notified and the Coroner was conducting a full investigation.

Verbatim wording from the response

“In line with CQC requirements, I submitted a Notification 16 (Death of a Resident) to CQC on 2nd October 2018 before I went on leave.”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Produce a Health Concerns or Advice Sheet documenting identified risks and advice for residents and families.

    Stated by Rossmere Park Care CentreStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.

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

Produce a Health Concerns or Advice Sheet documenting identified risks and advice for residents and families.

Verbatim wording from the response

“The CCG suggested we draft a Protocol for staff to follow after a death (sudden or otherwise) and we implemented this immediately following the Lessons Learned Meeting. The CCG also suggested that we draft a form where the home could document any concerns identified as risks associated with a resident’s decisions and advice to mitigate those risks.”

Source location

2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019

Open published response
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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