Care Home Health related deaths

PFD Category
Reports: 407 Areas: 66 Earliest: Aug 2013 Latest: 15 Jan 2026

73% response rate (above 63% average). 62% of classified responses show concrete action taken.

Response Status
Responded 299 No Response 2 Historic 106
AI Classification
Action Taken 62%
Action Planned 20%
Noted 16%
Disputed 2%
Based on 402 classified responses
Reports by Quarter
PFD Reports
407 results
Ronald Nelson
All Responded
2026-0024 15 Jan 2026 Nottingham City and Nottinghamshire
Care Quality Commission Mulberry Court Care Home
Concerns summary (AI summary) Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Action Taken (AI summary) The CQC has taken regulatory actions by requiring the care home to submit an action plan, conducting a focused inspection, publishing an 'Inadequate' rating report, and issuing a Warning Notice regarding record keeping and care plan compliance. They will continue to monitor the service closely. Mulberry Court Care Home has implemented new systems and processes for record keeping and care plan compliance, including an enhanced staff training programme and updated care plan templates and risk assessments. They have also strengthened clinical oversight and communication processes following hospital discharge.
Peter Thompson
All Responded
2026-0018 13 Jan 2026 Derby and Derbyshire
Bank Close House Residential Care Home
Concerns summary (AI summary) Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.
Action Taken (AI summary) Bank Close House has instructed staff to request a blood glucose test from external healthcare professionals if a diabetic resident shows signs of illness and has asked GP surgeries to provide each diabetic resident’s HbA1c level.
Jean Waldron
All Responded
2026-0009 8 Jan 2026 Worcestershire
Ignite Health and Homecare Services
Concerns summary (AI summary) An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for carers.
Action Taken (AI summary) The agency has reinforced guidance to staff clarifying that wound care is outside their scope, issued formal reminders about escalating clinical concerns, and reviewed supervision processes to ensure adherence to scope-of-practice boundaries.
Dorothy Macdonald
All Responded
2025-0632 17 Dec 2025 Liverpool and Wirral
Westwood Hall Nursing Home
Concerns summary (AI summary) Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.
Action Taken (AI summary) Westwood Hall Nursing Home has adopted an approach of referring any resident who has fallen to the Falls Team, regardless of the circumstances, and staff have been made aware of this. Springcare are reviewing their Falls Policy and implementing a system to chase up referrals made to the Falls Team.
John Alston
All Responded
2025-0616 Lancashire and Blackburn with Darwen
NHS England
Concerns summary (AI summary) Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing appropriate support or placements.
Action Taken (AI summary) NHS Lancashire and South Cumbria ICB has changed and refined processes for sharing information when transferring patient funding to ensure all relevant details are shared with receiving ICBs. They now make clear to care providers when responsibility has transferred and hold weekly internal case progression meetings.
Alan Peet
No Identified Response
2025-0609 5 Dec 2025 Manchester South
Acer Mews Care Home Care Quality Commission
Concerns summary (AI summary) A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor documentation and compromised care.
Jacqueline Aarons
All Responded
2025-0576 10 Nov 2025 North London
Department of Health and Social Care
Concerns summary (AI summary) A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must be clear and actionable.
Noted (AI summary) The Department of Health and Social Care acknowledges the concerns raised but states that NHS England will provide a full response, as the concerns are more appropriately addressed by them.
Richard Worswick
All Responded
2025-0564 7 Nov 2025 Manchester South
Bamford Grange Care Home Stockport NHS Foundation Trust
Concerns summary (AI summary) Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Action Taken (AI summary) The care home has issued refresher guidance to staff on existing policies, emphasizing documentation of hospital communications, and implemented enhanced observations for unstageable pressure ulcers. They've also implemented a sepsis risk assessment for residents with chronic wounds and conduct regular audits of wound care entries. A Trust-wide alert was issued on 20 November 2025 regarding Transfer of Care documentation, ensuring two copies are printed. A Trust-wide audit will take place in February 2026 to check for documentation in patient records and a task and finish group will work on improving the quality of the discharge checklist starting January 2026.
Brian Lloyd
All Responded
2025-0557 3 Nov 2025 North London
High Meadows Care Home
Concerns summary (AI summary) Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
Action Taken (AI summary) High Meadows Care Home provided staff training on catheterisation, documentation, and escalation, updated care plans to reflect the coroner's concerns, and reconfigured the telephone system to ensure calls are answered promptly. They have also ensured that portable phones are available in each unit, supported by several signal amplifiers installed throughout the home. High Meadows Care Home has created and implemented an escalation protocol for team leads, effective 23/10/2025, to ensure prompt and effective response to clinical or safety concerns.
Gloria Simon (2)
All Responded
2025-0555 31 Oct 2025 Liverpool and Wirral
Riversdale Care Home
Concerns summary (AI summary) Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.
Action Taken (AI summary) The care home revised its policy regarding new residents who are out of district with their own GP to register them with a local GP. In addition, a new audit has been developed on the company's digital systems which is completed 48 hours after the resident is admitted.
Gloria Simon (1)
All Responded
2025-0554 31 Oct 2025 Liverpool and Wirral
Marine Lake Medical Practice
Concerns summary (AI summary) A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review patient history or ensure timely observations.
Action Planned (AI summary) The practice plans to review the case with the staff member involved and is investigating the case formally as part of a Significant Event Analysis. It will share the outputs of this analysis with the coroner if helpful.
Thompson Elliott
All Responded
2025-0515 14 Oct 2025 Sunderland
Care UK
Concerns summary (AI summary) Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.
Action Taken (AI summary) Care UK has reinforced training, updated documentation, emphasized communication requirements, and improved medication knowledge among staff. They have updated the care home's contact list to include on-call numbers for team leaders and emphasized the need for hospital staff to ensure its return with the resident on discharge.
Walter Horton
All Responded
2025-0462 10 Sep 2025 South Yorkshire (East)
Mr Nick Mallaband, Acting Chief Medical…
Concerns summary (AI summary) Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing infection risk.
Noted (AI summary) The Trust acknowledges the concerns raised in the PFD report regarding the death of Mr. Horton, but states that a falls risk assessment was completed and wound care was delivered in accordance with Trust policy. The Trust maintains a skin integrity improvement plan and a discharge action group is in place.
Stuart Gilchrist
Partially Responded
2025-0460 10 Sep 2025 East Riding of Yorkshire and Hull
East Riding Council Health and Safety Executive Food Standards Agency
Concerns summary (AI summary) Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving equipment.
Noted (AI summary) East Riding Council confirms it does not have powers to specify equipment in first aid kits or publish guidance, instead signposting businesses to HSE guidance, and recommends the Regulation 28 be served to the HSE. HSE outlines health and safety legislation regarding workplace first aid provision and clarifies that there is no requirement for employers to provide specific equipment such as anti-choking devices, advising that the MHRA is responsible for regulation of medical equipment.
Margaret Taylor
All Responded
2025-0420 12 Aug 2025 Gloucestershire
Oak Tree Mews Care Home
Concerns summary (AI summary) A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.
Action Taken (AI summary) Oak Tree Mews Care Home has implemented changes including a new manager, full pre-assessments, updated care plans, a senior lead appointment, protected lunch times, dining area layout changes, amended staff lunch breaks, visitor declarations for food, a digital signing in system and staff First Aid Training.
Marion Jones
All Responded
2025-0413 7 Aug 2025 Manchester South
Care UK
Concerns summary (AI summary) A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, resulting in a fall that contributed to her decline.
Action Taken (AI summary) Care UK has updated its admission checklist, care plan forms, and audit processes to ensure pre-admission assessments for bed rails are completed and documented, and that care plans are comprehensive and up-to-date. They also clarified falls management and prevention policy and high/low beds should be considered as an alternative to bed rails.
Stephen Lawrence
All Responded
2025-0411 6 Aug 2025 Surrey
Eastcroft Nursing Home
Concerns summary (AI summary) A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.
Noted (AI summary) The nursing home acknowledges the report and states improvements have been ongoing since the incident. They refer to a CQC inspection report from January 2024 detailing actions taken since a previous inspection.
Margaret Medlicott
All Responded
2025-0398 1 Aug 2025 Worcestershire
Capital Care Group
Concerns summary (AI summary) A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and were inadequately trained in risk assessments and care plan creation.
Action Taken (AI summary) The care group has implemented several changes, including revising its admissions policy, conducting mandatory training on challenging behaviour, implementing a new PCS training schedule, and conducting internal and organizational audits of care documentation. They also have updated the homes E-learning resources to cover updated expectations.
Joan Whitworth
All Responded
2025-0390 29 Jul 2025 Northumberland
Hillcare Group Northumbria Healthcare NHS Foundation T…
Concerns summary (AI summary) There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff were unaware of resident dietary restrictions, posing risks to resident safety.
Action Planned (AI summary) Hill Care Group has changed the electronic platform to record staff training, adding an alert function and automated compliance reports for the Home Manager. They have also added additional checks to governance systems, and revised agency worker check process including skills and training. The Trust is developing a Standard Operating Procedure (SOP), expected to be completed by October 2025, to guide staff in clarifying discrepancies in referrals by requesting key documents from Care Home staff and specifying clinical triggers for face-to-face assessments.
Evelyn Chancellor
All Responded
2025-0382 25 Jul 2025 North London
Ashton Lodge Care Home
Concerns summary (AI summary) Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Action Taken (AI summary) Ashton Lodge Care Home has already implemented several changes including conducting medication reviews, introducing structured rotas for staff in lounges, providing refresher training on falls prevention, and conducting daily supervision briefings. A full review of communal area layouts is underway.
Madeline Reding
All Responded
2025-0368 21 Jul 2025 East London
Aspray House Nursing Home
Concerns summary (AI summary) Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do Not Resuscitate orders, led to critical care gaps.
Action Taken (AI summary) Aspray House has implemented multiple changes including revising policies, providing staff training, purchasing equipment (defibrillator, anti-choking vest, pictorial choking first aid posters) updating care notes, and creating a flow chart for emergencies. They have also removed the management involved in the incident.
Melissa Mathieson
All Responded
2025-0367 21 Jul 2025 Avon
Alexandra Homes Ltd
Concerns summary (AI summary) The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and risk assessments.
Action Taken (AI summary) Alexandra Homes has updated their Report on Action Taken to Prevent Future Deaths, building on a previous report. Actions include introducing a new resident observation record, revising the client referral form, and implementing a compatibility profile and impact assessment.
Patricia Heaviside
Partially Responded
2025-0354 10 Jul 2025 County Durham and Darlington
Care Quality Commission Durham County Council Howlish Hall Care Home +1 more
Concerns summary (AI summary) The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply for Deprivation of Liberty Safeguards (DoLS) assessments for residents lacking mental capacity.
Disputed (AI summary) CQC inspected Howlish Hall in July 2025 and found breaches of fundamental standards and took urgent enforcement action by imposing conditions on the provider's registration. One condition required the provider to safeguard people from the risk of falls. Durham County Council will explore ways of identifying care homes that currently have no active DoLS authorisations in place or where renewals may be overdue. This will help them highlight potential gaps and ensure timely action is taken to proactively address any issues with the care home. The care home disputes the coroner's report, asserting that it is inaccurate and based on hearsay, and that the home always prioritized tenant safety.
Vera Fortey
All Responded
2025-0312 19 Jun 2025 Worcestershire
Green Range Limited
Concerns summary (AI summary) Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Action Taken (AI summary) The care home implemented an action plan addressing management of falls, record keeping, and staff training, including fall prevention training and training on the Care Docs Portal. The manager who was in post prior to September 2024 returned to her role as Care Home Manager in May 2025.
Kathleen Gregory
All Responded
2025-0408 18 Jun 2025 Suffolk
Beccles Medical Centre
Concerns summary (AI summary) A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Action Planned (AI summary) The medical centre will conduct a significant event analysis of the case focusing on the RESPECT form completion and wording and then disseminate the findings to the practice team. The practice will also conduct a practice-level review of the training given to clinicians on the completion of RESPECT forms and further training for clinical staff on the management of choking situations has been arranged.