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
Terence White
All Responded
2017-0078 16 Mar 2017 Gloucestershire
Grange Care Centre
Concerns summary The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.
Daphne Cherry
All Responded
2017-0080 13 Mar 2017 Gloucestershire
Care UK
Concerns summary Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Frederick Bevan
Historic (No Identified Response)
2017-0060 9 Mar 2017 Birmingham and Solihull
Bondcare Limited
Concerns summary A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of the witnessing carer, risking detrimental effects on treatment.
Joan Rimmer
Historic (No Identified Response)
2017-0036 3 Mar 2017 Liverpool and Wirral
Liverpool Community Health NHS Trust
Concerns summary A Community Matron's failure to take physiological readings and incorrectly assess consent for an X-ray in a patient with severe dementia led to a two-week delay in diagnosing a fractured hip.
Etheline De-Gale
All Responded
2017-0058 16 Feb 2017 Bedfordshire and Luton
Ambassador House Care Home
Concerns summary Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Roger Tombs
All Responded
2017-0027 13 Feb 2017 Birmingham and Solihull
Care Quality Commission Sunrise Senior Living
Concerns summary Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Frederick Chisnall
All Responded
2017-0017 30 Jan 2017 Cheshire
Halton Clinical Commissioning Group St Helens Clinical Commissioning Group
Concerns summary Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.
Geraldine Butterfield
Historic (No Identified Response)
2017-0022 25 Jan 2017 Surrey
Collingwood Nursing Home
Concerns summary Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.
Winifred Elliott
Partially Responded
2016-0448 15 Dec 2016 London Inner (West)
Care Quality Commission Meadbank Care Home
Concerns summary The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.
Joyce Crompton
All Responded
2016-0434 6 Dec 2016 Manchester (West)
CLS Care Services
Concerns summary The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.
Marjorie Bassendine
Partially Responded
2016-0424 30 Nov 2016 Surrey
Department of Health and Social Care Medicines and Healthcare products Regul… Royal College of Psychiatrists
Concerns summary Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for potential QT interval prolongation.
Doris Clarkson
All Responded
2016-0423 29 Nov 2016 County Durham and Darlington
Lambton Care Home
William Marson
All Responded
2016-0394 2 Nov 2016 Wiltshire and Swindon
Avon Care Home Limited
Concerns summary Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.
Ivy Atkin
All Responded
2016-0379 25 Oct 2016 Nottinghamshire
Care Quality Commission Department of Health and Social Care
Concerns summary A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability assessment, particularly in small, family-owned companies.
Robert Davidson
All Responded
2016-0363 13 Oct 2016 Birmingham and Solihull
Aran Court Care Centre Care Quality Commission Department of Health and Social Care +2 more
Concerns summary Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.
Norman Beard
Historic (No Identified Response)
2016-0438 7 Oct 2016 Stoke-on-Trent and North Staffordshire
Care First Homes
Concerns summary Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Winston Harris
All Responded
2016-wp25349 3 Aug 2016 Birmingham and Solihull
Birmingham City Council Sandwell and West Birmingham Hospitals …
Rebecca Gilbank
All Responded
2016-wp25329 26 Jul 2016 Surrey
Independence Homes Limited
Harold Goulding
All Responded
2016-0248 14 Jul 2016 London (East)
Alexander Court Care Central
Concerns summary Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.
Malcolm Bennett
All Responded
2016-0232 22 Jun 2016 Manchester (South)
Borough Care Ltd
Concerns summary Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.
Olive Wilmott
Historic (No Identified Response)
2016-0231 21 Jun 2016 Nottingham
Ideal Care Home Ltd
Concerns summary An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night staff for residents' needs.
Gwendoline Clarke
Partially Responded
2016-0218 8 Jun 2016 Gloucestershire
ADL PLC Care Quality Commission
Concerns summary Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
Freda Cordy
Historic (No Identified Response)
2016-0190 17 May 2016 Northamptonshire
Northampton General Hospital Templemore Care Home
Concerns summary A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Marjorie Wood
Partially Responded
2016-0161 25 Apr 2016 Manchester South
Kingsley Care Home Timperley Care Home
Concerns summary There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care and treatment.
Margaret Rogerson
Historic (No Identified Response)
2016-0155 21 Apr 2016 Manchester West
BUPA Mill View Nursing Home Right Honourable Jeremy Hunt MP
Concerns summary Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. Family members also lacked access to essential feeding training.