Care Home Health related deaths
PFD Category
Reports: 407
Areas: 66
Earliest: Aug 2013
Latest: 15 Jan 2026
73% response rate (above 62% average). 70% of classified responses show concrete action taken.
PFD Reports
407 resultsGeorge Renshaw Brown
Historic (No Identified Response)
2013-0230
16 Sep 2013
Manchester South
Trafford Borough Council
Manchester Clinical Commissioning Group
Fentons Solicitors
+3 more
Concerns summary
A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to more suitable accommodation.
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
Vera Lillian Steel
Historic (No Identified Response)
2013-0185
13 Aug 2013
Surrey
Care Quality Commission
South East England Fire and Rescue Serv…
Concerns summary
A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.
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
Care Quality Commission
Islington Social Services
Home Dot Care Limited
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
HomeDot Care has implemented a new sleeping protocol, integrated it into staff induction and orientation training, and established regular supervision cycles. They have also updated all care and suppo
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