Care Home Health related deaths
PFD Category
Reports: 407
Areas: 66
Earliest: Aug 2013
Latest: 15 Jan 2026
72% response rate (above 62% average). 70% of classified responses show concrete action taken.
PFD Reports
244 resultsJames Stewart
All Responded
2014-0526
4 Dec 2014
Bedfordshire & Luton
Bedfordshire Clinical Commissioning Gro…
Concerns summary
There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors and reliance on unqualified staff for medication initiation.
Gaenor Moore
All Responded
2014-0512
24 Nov 2014
Surrey
Salter Labs
Dolby Vivisol
Invacare Rehabilitation
Concerns summary
Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator and insufficient training regarding equipment setup.
Marjorie Phillips
All Responded
2014-0413
18 Sep 2014
Manchester (South)
Sunrise Medical Limited
Concerns summary
The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted their weight.
Christopher Royal
All Responded
2014-0354
30 Jul 2014
Leicester City & South Leicestershire
Baron’s Park Nursing Home
Concerns summary
The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively long shifts.
Charles Lawrence
All Responded
2014-0342
25 Jul 2014
Portsmouth & South East Hampshire
Alexandra Rose Care Home
Concerns summary
The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.
Michaela Christoforou
All Responded
2014-0285
25 May 2014
London (North)
Care UK
Concerns summary
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Ross Boyd
All Responded
2014-0313
23 May 2014
Milton Keynes
REDACTED
Concerns summary
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Margaret Connor
All Responded
2014-0215
9 May 2014
Norfolk
Heathers Nursing Home
Concerns summary
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.
Beryl French
All Responded
2014-0198
30 Apr 2014
Nottinghamshire
Lifestyle Care PLC
Concerns summary
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Peter Norman Nott
All Responded
2014-0229
28 Feb 2014
Oxfordshire
Rush Court Nursing Home
Concerns summary
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Sandra Wordingham
All Responded
2013-0373
17 Dec 2013
Cardiff & the Vale of Glamorgan
Springbank Care Home Limited
Concerns summary
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early intervention was possible.
Action taken summary
Springbank Nursing Home has developed and implemented new policies and protocols for managing residents who become unconscious, including a strict protocol for summoning emergency services and clear g
John Gwynfryn Morris
All Responded
2013-0295
11 Nov 2013
Hertfordshire
Care Quality Commission
Concerns summary
Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous escape incidents.
Action taken summary
The CQC acknowledges concerns about dementia care staffing and underestimation of needs, clarifying their existing inspection methods. They plan to publish a thematic report on good practice in dement
Walter Gordon Powley
All Responded
2013-0251
4 Oct 2013
Leicester City & South Leicestershire
Health and Safety Executive
Care Quality Commission
Registered Nursing Home Association
Concerns summary
Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Action taken summary
The CQC acknowledges its inspector did not assess against relevant regulations for premises safety in this case. They are piloting a new inspection methodology that will focus on safety and ensure ins
Joan Mary Jones
All Responded
2013-0234
20 Sep 2013
Leicester City and South Leicestershire
Manor Residential and Nursing Care Home
Concerns summary
Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Action taken summary
The Manor has issued a memo to all unit leads to ensure families are contacted after health professional visits, communication sheets are completed and shared, and visits are communicated to families.
Peter Pattinson
All Responded
2013-0250
6 Sep 2013
Sunderland
European Care group
Concerns summary
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Action taken summary
European Care Group has implemented new procedures for bed rail risk assessments (within 24 hours of admission and monthly review), a daily checking system for bed rail condition, and staff training o
Mark Sumnall
All Responded
2022-0160
Derby and Derbyshire
Derbyshire County Council and NHS Derby…
Concerns summary
The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital staff are unaware of its purpose, leading to critical care plans not being accessed.
Action taken summary
NHS Derby and Derbyshire has refreshed and re-issued Red Bag Guidance, updated the transfer checklist, delivered training in care homes, and issued urgent communications to Ambulance and Hospital Trus
Lilian Behrendt
All Responded
2022-0169
Norfolk
Downham Grange Care Home
Concerns summary
The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile recording devices, lack of staff accountability, and unclear DNACPR status.
Action taken summary
Kingsley Healthcare has removed pre-loaded, emotionally charged words like 'content' from its electronic care management software across all homes. Staff are now required to manually describe resident
Rose Hollingworth
All Responded
2024-0150
Inner North London
Home Dot Care Limited
Islington Social Services
Care Quality Commission
Concerns summary
The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan and inadequate monitoring of service performance for a vulnerable person.
Action taken summary
Islington Council is disputing the Prevention of Future Death report issued against them, arguing procedural irregularity as they were not given the opportunity to provide submissions. They are seekin
John Alston
All Responded
2025-0616
Lancashire and Blackburn with Darwen
NHS England
Concerns 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 summary
NHS England reported that Greater Manchester ICB updated processes for out-of-area placements, developed a discharge protocol, and implemented specific training for commissioners. Lancashire and South