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.
On 6th July 2023 I commenced an investigation into the death of Pamela George aged 70. The investigation concluded at the end of a 1-day inquest on 22nd January 2026 the conclusion of the inquest was a narrative one namely:
Narrative
The Deceased died at Derriford hospital from acute renal failure and sepsis caused by an infection underneath the breast in circumstances where there were missed opportunities by her care home to treat her and escalate medical concerns.
Circumstances of the death
Pamela George was 70 years of age when she died at Derriford hospital on 30th June 2023. She was a vulnerable lady who lacked capacity and was diagnosed with a learning disability and had suffered from significant ill health in the lead up to her death in that she had been an in-patient at Derriford Hospital from 1st May – 24th May 2023 and then been discharged to Cann House where she was registered as a temporary resident because of concerns with her previous supported living accommodation. She had been in hospital because of bilateral leg swelling and general deterioration and of note she had acute kidney injury on chronic kidney injury on admission which was treated successfully. She also had a large haematoma on the right iliac fossa which was managed conservatively and she also had a breast wound that was described as cracked and open. On discharge to Cann House the discharge summary from Hospital made it clear that because of her acute kidney injury she should have post discharge monitoring blood tests every 5-7 days. This was not done and it was accepted by the home that this meant no one was monitoring Pam ‘s bloods from the day she left hospital until she was readmitted to Hospital by ████████ on 29th June 2023 I was told by the home during evidence that Ms George did not have capacity, but they were unable to provide me with copies of mental capacity assessment during the inquest and accepted that her lack of capacity was not noted on the care plan.
Manger could not adequately explain what systems had been put in place to rectify this situation. I was further concerned that although the home’s note of 27th June 2023 suggests that Miss George’s fall had been brought to ████████ attention his note did not mention it. The note from the home describing the fall was not detailed enough in terms of observations or descriptions of pain and justification for not seeking further medical escalation could not be provided. ████████ saw Miss George on 27/06/23. No concerns about infection to her breast were noted and nothing was reported about a fall. This was despite the fact that the home had described the breasts as “Red raw “on 27th June 2023. ████████ saw Miss George at the home’s request on 29th June 2023 where sepsis was suspected. She was urgently admitted to Derriford Hospital where she died shortly afterwards from 1a Acute Kidney injury and sepsis.
Coroner’s concerns
1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed.
2. The infection which caused her sepsis was a bacterial infection which ████████ told me could only have been successfully treated with antibiotics. I am not satisfied that the breast infection was adequately managed at Cann House it being noted that there was no record of how the breast infection was progressing between 25th May and 27th June 2023 .
3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen. The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider.
4. The documentation surrounding the fall, the symptoms seen and measures taken to seek medical input were not clear.
5. There was little or no evidence that capacity had been appropriately documented with care plans remaining silent on the issue and records not analysing carefully what steps had been taken to help Miss George make decisions.
6. There was little or no evidence of policies in place generally at the home and in particular on medication, escalation and reporting of concerns .
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised12
Unclear documentation of falls, symptoms and measures taken to seek medical input
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.21
Action
Use wound and infection monitoring charts, including photographs, for structured documentation.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Stop accepting residents requiring one-to-one support under revised acceptance criteria.
Stated byPremiere Health LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 February 2026.
Action
Implement a clinical escalation protocol requiring early medical review when symptoms do not improve.
Stated byPremiere Health LimitedStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2026.
Action
Use a documented escalation procedure to notify placing authorities when needs may exceed home capability.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Deliver refresher training on record keeping and documenting infection progression.
Stated byPremiere Health LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 February 2026.
Action
Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Have managers immediately review incident forms for detail, completeness and clinical appropriateness.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Disseminate admission and discharge documentation guidance to junior staff.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Scan all hospital discharge summaries directly into residents’ care plans on receipt.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Provide care staff refresher training in incident reporting and falls management.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Conduct daily management checks of notes for residents declining personal care or presenting clinical concerns.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Complete and consolidate operational policies covering medication, infection control, incidents, escalation, safeguarding, concerns and hospital discharge.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Remind staff to document and communicate concerns to Social Workers and Adult Social Care throughout residency.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Deliver further mental capacity and Mental Capacity Act training to trained staff.
Stated byPremiere Health LimitedStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2026.
Action
Strengthen falls management and post-incident observation procedures for documenting falls, assessments and escalation reasoning.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Use mandatory post-fall observation charts for unwitnessed or potentially injurious falls.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Require registered nurses to act on escalated concerns and update care plans.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Reinforce staff training in infection recognition, wound documentation, sepsis awareness and escalation.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Require multidisciplinary reviews when residents’ needs increase significantly.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Store operational policies centrally in a digital governance system accessible to all staff.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Action
Implement a formal mental capacity assessment procedure covering documentation, care-plan recording and best-interest processes.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
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.5
1
Provide staff feedback on documenting care refusals and related record-keeping requirements.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
2
Conduct regular compliance audits of operational policies.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
3
Formally record escalation discussions and communications with commissioning bodies.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
4
Maintain governance oversight through clinical audits, supervision, competency checks, incident-trend monitoring and senior management visits.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
5
Remind staff to follow the established incident procedure.
Stated byPremiere Health LimitedStated completedThe respondent said that this action was complete when they made their response on 3 February 2026.
Pin
Get email alerts
Request correction
Information checked against the published report and official responses