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.

Response Status
Responded 295 No Response 3 Historic 98
AI Classification
Action Taken 70%
Action Planned 13%
Noted 9%
Disputed 9%
Based on 141 classified responses
Reports by Quarter
PFD Reports
407 results
Donald Berry
All Responded
2018-0324 28 Sep 2018 Manchester (South)
Kendal Calling Health and Safety Executive Department of Health and Social Care
Concerns summary The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.
Doris Douthwaite
Historic (No Identified Response)
2018-0294 3 Sep 2018 Manchester (South)
HC-One
Concerns summary Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.
Kenneth Brincombe
Unknown
25 Aug 2018 Plymouth Torbay and South Devon
Concerns summary Carers facilitated smoking for a high-risk patient without supervision, lacked training in fire safety assessment, and smoke detectors were not linked to emergency services, increasing fire risk.
Flora Baber
All Responded
2018-0229-wp26369 13 Aug 2018 London Inner (North)
Adelaide Medical Centre Compton Lodge Care Home Royal Free Hospital NHS Trust
Concerns summary Inadequate patient care involved poor assistance with food/drink, delayed referrals, staff neglect, incorrect incontinence assessment, and a critical failure to record opioid sensitivity across healthcare providers.
Phylliss Letcher
All Responded
2018-0276 6 Aug 2018 Isles of Scilly
Crossroads House Care Home
Concerns summary The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was left open, creating unrestricted access to dangerous areas.
Stanford Bell
Unknown
30 Jul 2018 West Yorkshire (West)
Concerns summary Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's referral procedures for patients experiencing post-trauma seizures.
Jane Parker
Historic (No Identified Response)
2018-0243 25 Jul 2018 Manchester (South)
Care Quality Commission
Concerns summary Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited understanding of escalating choking episodes to speech and language therapy.
Ruth Perkins
Historic (No Identified Response)
2018-0236 20 Jul 2018 Coventry
Department for Health
Concerns summary A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.
Robert Power
All Responded
2018-0221 9 Jul 2018 Gloucestershire
North Bristol NHS Trust
Concerns summary A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.
Doris McCarthy
Historic (No Identified Response)
2018-0222 9 Jul 2018 London (South)
Baycroft Care Homes
Concerns summary Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.
Derek Smith
Historic (No Identified Response)
2018-0186 19 Jun 2018 Staffordshire (South)
Virgin Care Services Limited
Concerns summary Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.
Joan Lunt
Historic (No Identified Response)
2018-0164 29 May 2018 Manchester (South)
Harbour Healthcare Limited
Concerns summary Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite prior assurances of resolution.
Philip Ashton
Historic (No Identified Response)
2018-0146 14 May 2018 Milton Keynes
PJ Care
Concerns summary Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.
Gladys Rich
Partially Responded
2018-0149 14 May 2018 Northamptonshire
Avenue House Nursing and Care Home Care Quality Commission Kettering General Hospital +1 more
Concerns summary The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.
Charles Grainger
Historic (No Identified Response)
2018-0353 12 May 2018 Derby and Derbyshire
NHS Southern Derbyshire Clinical Commis… Milford House Care Home Derbyshire County Council
Concerns summary Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.
Ahmed Tabeche
All Responded
2018-0143 11 May 2018 London (East)
Twinglobe Care Homes Limited
Concerns summary Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.
Thomas Ratchford
Historic (No Identified Response)
2018-0147 11 May 2018 Manchester (North)
Elizabeth House (Oldham) Limited
Concerns summary Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure relief for staff and management.
Patricia Heslop
All Responded
2018-0102 12 Apr 2018 Sunderland
Department of Health and Social Care HC-One
Concerns summary Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.
William Callis
Historic (No Identified Response)
2018-0105 12 Apr 2018 Northamptonshire
St Lukes Primary Care Centre
Concerns summary A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and Assessment team was identified.
George Goldby
All Responded
2018-0104 11 Apr 2018 Nottinghamshire
HC-One
Concerns summary Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.
Barbara Haley
Historic (No Identified Response)
2018-0095 3 Apr 2018 Manchester (South)
Harbour Health Care Limited
Concerns summary Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
Donald Martin
All Responded
2018-0166 28 Mar 2018 Derby and Derbyshire
New Lodge Nursing Home
Concerns summary A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.
Joan Osborne
All Responded
2018-0091 26 Mar 2018 Nottinghamshire
Adbolton Hall Nursing Home
Concerns summary Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.
Sheila Ross
Historic (No Identified Response)
2018-0081 19 Mar 2018 Sunderland
Hylton View Care Home
Concerns summary The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.
David Sketchley
All Responded
2018-0069 9 Mar 2018 Gloucestershire
BUPA UK
Concerns summary The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.