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.
PFD Reports
407 resultsMargaret Douglas
Partially Responded
2025-0309
18 Jun 2025
Cheshire
1st Care 4U
Holcroft Grange
Minster Care Group
Concerns summary (AI summary)
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding of patient requirements.
Action Taken
(AI summary)
The care group will ensure overseas workers have a competent understanding of English and that the agency worker induction policy will now form part of the compliance test undertaken by routine internal monitoring teams. Handover of care between staff will be enhanced to ensure that any irregular staff have a written description of the issues and conditions that a person may exhibit.
Sonia Sore
All Responded
2025-0305
17 Jun 2025
Suffolk
North Court Care Home – Maven Healthcare
Concerns summary (AI summary)
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.
Action Taken
(AI summary)
Maven Healthcare has implemented mandatory post-incident debriefing, created an organizational lesson learned document, and reviewed policies/procedures for bed rails and falls risk management, and implemented an electronic care planning system. Staff refresher training on falls prevention was completed in January 2025, and electronic care planning was implemented in January 2025 and fully embedded by the end of March 2025.
Valerie Hill
All Responded
2025-0301
13 Jun 2025
South Wales Central
Merthyr Tydfil County Borough Council
Concerns summary (AI summary)
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.
Action Taken
(AI summary)
The council's Health and Safety team reviews incident reports for environmental factors contributing to falls, contacts care homes to investigate and make recommendations, and reports trends to the Adult Social Care Management Team. They also ensure that environmental risks are addressed alongside individual care plans.
Maureen Powell
All Responded
2025-0293
11 Jun 2025
Nottingham City and Nottinghamshire
Red Oaks Care Community
Concerns summary (AI summary)
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.
Action Taken
(AI summary)
Red Oaks Care Home has strengthened processes for pressure management care, including additional training, increased monitoring by senior staff, and alterations to the notification process for serious injuries to involve the Operations Manager.
Esther Byrne
All Responded
2025-0272
3 Jun 2025
Durham and Darlington
Concerns summary (AI summary)
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.
Action Taken
(AI summary)
The Trust will include mobility status in discharge letters, conduct regular ward audits to ensure follow-up appointments are scheduled, and has circulated a flowchart detailing the process for contacting the on-call radiologist, sharing it with orthopaedic consultants.
Keith Inseon
All Responded
2025-0243
27 May 2025
Blackpool & Fylde
BARCHESTER HEALTHCARE LIMITED
Concerns summary (AI summary)
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.
Action Taken
(AI summary)
Barchester Healthcare has taken several actions including a review of training, refresher training on NEWS2, a new care planning digital system with guidance sheets, and themed supervision for staff. The falls policy has been reviewed and prompt sheets and guides have been created.
Ian Simpson
All Responded
2025-0226
12 May 2025
Inner North London
Barchester Healthcare Ltd
Concerns summary (AI summary)
The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, compromising patient safety.
Action Planned
(AI summary)
Barchester Healthcare completed themed supervisions with staff, supported by clinical leads, covering RESTORE2 and managing resident deterioration. They also provided staff with 'Clinical Shots' guidance and are reviewing the Appropriate Admission Policy, with a workshop planned for General Managers. NICE will amend its guideline NG89 to recommend VTE and bleeding risk assessment after a decision to admit to hospital, or after 12 hours in ED, or by the first consultant review, whichever is sooner. Recommendations on pharmacological VTE prophylaxis will also be amended to state it should be started as soon as possible and within 14 hours of the decision to admit, rather than within 14 hours of admission.
Raihana Oluwadamilola Awolaja
All Responded
2025-0212
2 May 2025
Inner West London
Children’s Trust
Concerns summary (AI summary)
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.
Action Taken
(AI summary)
The Children's Trust has implemented mandatory training on monitoring and observation, introduced a "floating" staff role for additional support, allocated dedicated administrative support to each house, and clarified staff roles to prioritize caregiving. They have also enhanced incident reporting procedures, strengthened risk assessment processes, and improved communication with families and professionals.
Patricia Catterall
All Responded
2025-0189
11 Apr 2025
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Pendine Park Care Organisation
Concerns summary (AI summary)
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Action Planned
(AI summary)
A task and finish group has been set up to review the current discharge form for suitability to ensure that frequency of observations and medication is clearly defined within the document. Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team. Pendine Park Care Organisation now conducts all pre-admission assessments in person (except emergency admissions) and has updated the pre-admission assessment document to include prompts to ensure all information is requested prior to admission, including a section for diabetes.
Ivy Dixon
All Responded
2025-0186
10 Apr 2025
Inner North London
Lukka Care Homes Limited
Concerns summary (AI summary)
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and integrity issues.
Noted
(AI summary)
The London Ambulance Service provides a statement regarding the clinical review of the incident and details the assessment and actions taken by the paramedic at the scene, including confirming a valid DNACPR and finding no evidence of airway obstruction.
Bernard Lyon
All Responded
2025-0179
9 Apr 2025
Manchester South
Care Quality Commission
Department of Health and Social Care
Tameside Metropolitan Borough Council
Concerns summary (AI summary)
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment delays.
Noted
(AI summary)
The CQC acknowledges the concerns, noting that the care home in question is now dormant and outlining CQC's role and inspection methodology. They state that the Secretary of State for Health and Social Care is better placed to address concerns about pressures on the ED. Tameside Metropolitan Borough Council has revised its Multi Agency Concern (MAC) process to ensure providers notify families of concerns and has increased the number of quality monitoring officers to conduct more robust contract monitoring. The Department of Health and Social Care highlights the opening of an additional ward at Tameside General Hospital in November 2024 to provide additional capacity and support patient flow, as well as the £9 billion committed to the Better Care Fund to tackle delayed discharges.
Raymond Jennings
All Responded
2025-0125
6 Mar 2025
West Yorkshire Western
Abbey Place Nursing Home
Concerns summary (AI summary)
The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved systems to prevent reoccurrence of this significant failing.
Action Taken
(AI summary)
The nursing home has updated its medication policy, implemented an electronic medication system and digital care planning system, changed GP and pharmacy providers, and completed documentation training with all staff.
June Phillips
All Responded
2025-0112
28 Feb 2025
Birmingham and Solihull
Willow Grange Care Home
Concerns summary (AI summary)
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor patient deterioration.
Action Taken
(AI summary)
The care home has implemented a root cause analysis tool, uses body maps and photos for injuries, calls 999 in specific fall scenarios, implemented weekly GP ward rounds with detailed summaries, requires professional documentation on care plans, provided staff supervision and meetings on accurate reporting, updated the head injury policy, reports falls to safeguarding and CQC, refers residents with multiple falls to falls clinic, provides refresher first aid and manual handling training, implemented a documentation lead for oversight, and the manager has joined support groups.
James Siddons
All Responded
2025-0051
30 Jan 2025
London Inner (South)
London Borough of Bromley
Mills Family Ltd
Concerns summary (AI summary)
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.
Action Taken
(AI summary)
The London Borough of Bromley addressed delays in sharing PLE forms by reiterating the importance of timely safeguarding actions with the social worker involved. They are launching a Prevention and Intervention Service with a Safeguarding Hub on April 14, 2025, and will review the contents of the PLE form. Mills Family Ltd has re-emphasized notification and escalation procedures for serious incidents to senior management and implemented a Root Cause Analysis policy. Managers will receive training on updated Accident & Incident Reporting, Serious Incident Notification, and Root Cause Analysis policies, with Croner training completed and Bromley Adult Safeguarding training scheduled.
Neville McKenzie
All Responded
2025-0044
24 Jan 2025
Birmingham and Solihull Districts
Birmingham and Solihull Integrated Care…
Health and Safety Executive
Concerns summary (AI summary)
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.
Noted
(AI summary)
HSE states it is not the appropriate regulator to address concerns about anti-choking devices in care settings, deferring to the CQC for registered providers and the MHRA for medical device regulation. The ICB commissioned training for nursing homes, including a guest speaker on choking prevention and provided free training on modified diets and choking risk. The ICB also shared resources from the RCUK, MHRA and DSI.
Diane Poole
All Responded
2025-0020
13 Jan 2025
Liverpool and Wirral
Victoria Residential Home
Concerns summary (AI summary)
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Action Taken
(AI summary)
Victoria Residential Home has already closed off the front lounge area where the escape door was located, secured the outside front door with electronic fob access, and made the conservatory door permanently inaccessible. They have also improved shift handover procedures with a senior WhatsApp group, completed new paperwork to evidence refreshments for residents, and staff have been re-enrolled on Safeguarding, Nutrition, DOLS and Communication training.
Sheila Nicholls
All Responded
2025-0009
7 Jan 2025
Buckinghamshire
Mandeville Grange Nursing Home
Concerns summary (AI summary)
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.
Action Taken
(AI summary)
Mandeville Grange Nursing Home has engaged Care4Quality to rewrite its policies, implemented Bright HR for policy distribution, transitioned training to Access Learning for Care, engaged four additional trainers, and ordered a CPR training manikin; emergency CPR drills will start within 1 month pending staff competency assessment.
Peter Good
All Responded
2025-0003
2 Jan 2025
Manchester South
Harbour Healthcare Ltd
Concerns summary (AI summary)
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify learning or assess ongoing risks to other residents.
Action Taken
(AI summary)
Harbour Healthcare disseminated lessons learned regarding patient hygiene and safeguarding across the company via a bulletin to management, regional support teams and the senior leadership team and shared the Regulation 28 notice and responses across Harbour Healthcare Care Homes to ensure each of our homes benchmark themselves against the actions identified.
Victor Knowles
Partially Responded
2025-0002
2 Jan 2025
Cheshire
Henning Hall Nursing Home
Springcare Care Homes Ltd
Concerns summary (AI summary)
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed opportunities or improve care for residents.
Disputed
(AI summary)
Springcare believes their existing investigation procedures are appropriate and aligned with industry standards, therefore no further changes are needed beyond those already discussed at the inquest regarding admission of pathway for residents under the discharge to assess contract beds and the arrangements for food and fluid monitoring for residents.
Edith Pye
All Responded
2024-0706
20 Dec 2024
Worcestershire
Care UK Ltd
Concerns summary (AI summary)
The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating systemic failures in ensuring resident safety.
Action Taken
(AI summary)
Care UK has implemented a revised Safety Incident Response Framework (SIRF) policy based on the NHS framework, introduced in September 2024, to place responsibility for investigating serious incidents on independent Home Managers. They have also improved the process for updating care plans and handover sheets and ensured regular monitoring by the Home Manager.
Sylvia Savage
All Responded
2025-0010
18 Dec 2024
Durham and Darlington
Four Seasons Healthcare
Concerns summary (AI summary)
The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering proper resident care and risk assessment.
Action Taken
(AI summary)
Four Seasons Health Care Group has implemented further steps and actions to address record-keeping, falls policy, and care plan re-evaluation, incorporated into ongoing care at Redwell Hills Care Home and shared across the business. All care plans and risk assessments are reviewed monthly as a minimum, with mobility care plans evaluated following any fall or near miss.
Craig Spiby
All Responded
2024-0694
10 Dec 2024
Manchester West
Bolton Cares
Concerns summary (AI summary)
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.
Action Taken
(AI summary)
Bolton Cares has retrained staff on modified diets and choking risks, including practical training and competency assessments. They have implemented electronic 'Read and Sign' records for SALT guidelines and included SALT guidelines on manager audits and team meeting agendas.
Gloria Linton
All Responded
2024-0661
2 Dec 2024
West Yorkshire East
Lifeway Care Ltd
Concerns summary (AI summary)
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and injury.
Action Taken
(AI summary)
Lifeway Care provided additional training to staff on adhering to care plans and using prescribed equipment, and implemented a banner on their online app reminding carers to follow care plans and use prescribed equipment. They also stated that spot checks and refresher training will continue.
Elan Adams
All Responded
2024-0655
26 Nov 2024
East London
Abbey Healthcare
Concerns summary (AI summary)
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, posing a significant safety risk.
Action Taken
(AI summary)
Abbey Healthcare has installed an app on handsets connected to Wi-Fi for direct 999 calls, is replacing Wi-Fi hotspots, and has updated the Manager Daily Walk Round Checklist to include call bell checks; also updated the Call Bell Policy to specify actions when call bells fail.
Susan Paley
All Responded
2024-0647
26 Nov 2024
Manchester South
Harbour Healthcare Ltd
Concerns summary (AI summary)
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place for residents.
Action Taken
(AI summary)
Harbour Healthcare upgraded the call bell system to enable the use of more advanced, infra-red assistive technology. They also use the digital care planning system PCS and have strengthened it by the addition of a PCS training module completed by all staff using this system.