PFD report

Elsie Clarke · Prevention of Future Deaths report

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Issued 20 Aug 2015•Manchester South

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.

View original report
Concerns
12

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
9

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 raised12

  1. Failure of Out of Hours doctors to keep proper timed attendance records
  2. Failure to provide appropriate advice on calling the Coroner or police
    Part of recurring concern: Failure to reliably report deaths to coroners
  3. Failure to maintain food and hydration records
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.9

  1. Action

    Supervise staff on recording residents’ welfare and monitor records through daily senior-team checks and weekly Home Manager reviews.

    Stated by MERIDIAN HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 20 August 2015.
  2. Action

    Train staff on care-plan documentation and review care plans after admissions, changes in needs, and at least monthly.

    Stated by MERIDIAN HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 20 August 2015.
  3. Action

    Provide refresher training on the appropriate use of 999 and 111.

    Stated by MERIDIAN HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 20 August 2015.

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 of Out of Hours doctors to keep proper timed attendance records

Wider context from the report

“(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”

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 provide appropriate advice on calling the Coroner or police

Wider context from the report

“(10) The doctor advised the Home that in the present case there was no need to call the Coroner/police ”

Is this part of a recurring concern?

Yes — Failure to reliably report deaths to coroners.

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 maintain food and hydration records

Wider context from the report

“(6) There was a complete failure to maintain food and hydration records. ”

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 arrange GP attendance for residents not fully registered with a local GP

Wider context from the report

“(2) The staff did not know how to arrange for the attendance of a GP for a resident who was not yet fully registered with a local GP. In particular they appeared completely ignorant of the existence of a “Temporary GP Registration form”. ”

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

Lack of understanding of prompt Care Quality Commission reporting requirements

Wider context from the report

“(4) There seemed to be a complete lack of understanding about the legal requirement for prompt reporting of such matters as occurred in this case to the Care Quality Commission. ”

Is this part of a recurring concern?

Yes — Unreliable reporting of safety-relevant information to the CQC.

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

Gap in Out of Hours doctors’ training on reporting deaths to the Coroner

Wider context from the report

“(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”

Is this part of a recurring concern?

Yes — Failure to reliably report deaths to coroners.

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 seek assessment from an available visiting GP

Wider context from the report

“(5) When a local GP was visiting another patient at the Home, the staff seemed unaware that they could and should have asked that doctor to look at this patient/resident. ”

Is this part of a recurring concern?

Yes — Unreliable escalation by care staff for required medical attention.

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 staff training in appropriate use of 999 or 111

Wider context from the report

“(1) There was an apparent lack of training for the staff at Hurst Hall in the appropriate use of calling either 999 or 111. ”

Is this part of a recurring concern?

Yes — Failure to ensure care staff can initiate appropriate emergency calls; Failure to use the appropriate emergency contact route.

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 keep proper and sufficient resident care notes

Wider context from the report

“(7) There was a failure to keep proper and sufficient notes of the care afforded to each resident. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 provide full and effective shift handover

Wider context from the report

“(8) There was a failure to give full and effective “hand-over” at each shift change. ”

Is this part of a recurring concern?

Yes — Unreliable shift handover processes.

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 of Out of Hours doctors to carry or wear a watch for vital-sign assessment

Wider context from the report

“(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”

Is this part of a recurring concern?

Yes — Unreliable measurement of vital signs during clinical assessments.

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

Poor observation of residents’ basic needs

Wider context from the report

“(3) The level and quality of observation of the residents were very poor and did not include even some of the most basic issues such as whether the patient was warm, thirsty etc. ”

Is this part of a recurring concern?

Yes — Failure to reliably supervise and monitor residents in care accommodation.

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

Supervise staff on recording residents’ welfare and monitor records through daily senior-team checks and weekly Home Manager reviews.

Verbatim wording from the response

“Action taken The Care Home has undertaken supervision with all of the staff explaining the importance of clearly recording detailed information about the welfare of the Residents. These records are monitored weekly by the Home Manager and checked daily by the senior team to ensure compliance from staff in their effective completion.”

Source location

Elsie-ClarkeR
Page 2 · response
Published 20 August 2015

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

Train staff on care-plan documentation and review care plans after admissions, changes in needs, and at least monthly.

Verbatim wording from the response

“Action taken Care plan training has been undertaken with all staff ensuring they clearly document the care each Resident has received. This is checked following the admission of any new Resident to the Care Home and where changes”

Source location

Elsie-ClarkeR
Page 2 · response
Published 20 August 2015

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

Provide refresher training on the appropriate use of 999 and 111.

Verbatim wording from the response

“Action taken The senior staff at Hurst Hall had previously attended first aid training which did cover appropriate use of 999 but they have also attended further refresher training on 21/7/15 which clearly explained the actions that need to be taken and the circumstances when these are required.”

Source location

Elsie-ClarkeR
Page 1 · response
Published 20 August 2015

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 nutrition and hydration protocols, risk assessments, food and fluid charts, and daily and periodic compliance monitoring.

Verbatim wording from the response

“Action taken Protocols are in place ensuring that all staff are aware that they need to clearly record what the Resident has had to eat and drink, particularly when they are on thickened fluids or if they are underweight or having any nutritional difficulties. Assessments have been completed to identify Residents who are at higher risk such as Mrs Clarke, particularly those who require specialist diets and food and fluid charts are now in place as required. These are reviewed daily by the Senior Team to ensure ongoing compliance and are further monitored during regular visits from the Operations Team and the Quality Assurance Team.”

Source location

Elsie-ClarkeR
Page 2 · response
Published 20 August 2015

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

Train senior staff on temporary GP arrangements and implement protocols for residents whose GP is unavailable or out of area.

Verbatim wording from the response

“Action taken Staff had sent a new patient registration document to the Surgery. They were not aware of the existence of a temporary registration form. We did receive these forms from the Surgery after the client's inquest. All senior staff have now attended training in relation to the action they need to take when a Residents’ GP is out of the area, and protocols are now in place to ensure that this does not happen again.”

Source location

Elsie-ClarkeR
Page 1 · response
Published 20 August 2015

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

Hold and document daily flash meetings to communicate significant changes and identify required activities and residents needing close monitoring.

Verbatim wording from the response

“Action taken A new handover process has been introduced which enables staff to share key information at the changeover of every shift. In addition, the Home Manager holds daily flash meetings with all members of the team to update them on any significant changes and identify any specific events or activities required that day. The flash meeting also updates the team on any Residents who require close monitoring. These meetings are documented and the records are held in the Care Home for review.”

Source location

Elsie-ClarkeR
Page 3 · response
Published 20 August 2015

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 central checks to ensure deaths trigger immediate notifications to the Care Quality Commission.

Verbatim wording from the response

“Action Taken The Home Manager did not submit the required notification until the 17/2/15. This was a clerical oversight and systems are now in place centrally to ensure that when a death is recorded there is a check made to ensure that the required notifications are sent to the Care Quality Commission immediately.”

Source location

Elsie-ClarkeR
Page 2 · response
Published 20 August 2015

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

Train senior staff on seeking assessment from another doctor or District Nurse and requesting an ambulance when necessary, with compliance monitoring.

Verbatim wording from the response

“Action taken Senior staff have undertaken additional training to ensure they are aware that they can ask another Doctor or the District Nurse to check a Resident they have concerns about if they are on the premises. They have been further advised that if they are in any doubt that they should request an ambulance. This continues to be monitored by the Home Manager, the Operations Team and Quality Assurance Team to ensure ongoing compliance.”

Source location

Elsie-ClarkeR
Page 2 · response
Published 20 August 2015

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

Introduce a shift-change handover process for sharing key information.

Verbatim wording from the response

“Action taken A new handover process has been introduced which enables staff to share key information at the changeover of every shift. In addition, the Home Manager holds daily flash meetings with all members of the team to update them on any significant changes and identify any specific events or activities required that day. The flash meeting also updates the team on any Residents who require close monitoring. These meetings are documented and the records are held in the Care Home for review.”

Source location

Elsie-ClarkeR
Page 3 · response
Published 20 August 2015

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