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 12%
Noted 10%
Disputed 9%
Based on 104 classified responses
Reports by Quarter
PFD Reports
407 results
Sonia Sore
All Responded
2025-0305 17 Jun 2025 Suffolk
North Court Care Home – Maven Healthcare
Concerns 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 summary Maven Healthcare has restructured its clinical governance framework, established a corporate committee, and implemented a new audit program with weekly falls audit tools. They have delivered staff tra
Valerie Hill
All Responded
2025-0301 13 Jun 2025 South Wales Central
Merthyr Tydfil County Borough Council
Concerns 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 summary The Council has revised its falls incident reporting process, requiring more detailed staff reports to be reviewed by the Health and Safety Department for environmental factors and trends, with invest
Maureen Powell
All Responded
2025-0293 11 Jun 2025 Nottingham City and Nottinghamshire
Red Oaks Care Community
Concerns 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 summary Red Oaks Care Home has introduced a new Skin Care Assessment and Audit Form, provided refresher training on pressure care and skin inspections, and implemented weekly care plan reviews and daily 'walk
Esther Byrne
All Responded
2025-0272 3 Jun 2025 Durham and Darlington
REDACTED
Concerns 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 summary The Trust has introduced a new Discharge Care bundle with a family communication script, updated discharge letter templates to record mobility status, and circulated a flowchart for contacting out-of-
Keith Inseon
All Responded
2025-0243 27 May 2025 Blackpool & Fylde
BARCHESTER HEALTHCARE LIMITED
Concerns 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 summary Barchester Healthcare has reviewed its falls policy and processes, provided staff with further training on observation record keeping, and refreshed its digital care planning system to incorporate NEW
Ian Simpson
All Responded
2025-0226 12 May 2025 Inner North London
Barchester Healthcare Ltd
Concerns 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 taken summary Barchester Healthcare disputed the coroner's finding of a 49-minute delay in calling an ambulance, stating their investigation found the deterioration likely occurred later and staff did not recall su
Raihana Oluwadamilola Awolaja
All Responded
2025-0212 2 May 2025 Inner West London
Children’s Trust
Concerns 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 summary The Children's Trust has implemented mandatory training on monitoring and observation, introduced a floating staff role, and allocated dedicated administrative support. They also thoroughly reviewed i
Patricia Catterall
All Responded
2025-0189 11 Apr 2025 North Wales (East and Central)
Pendine Park Care Organisation Betsi Cadwaladr University Health Board
Concerns 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 taken summary The Health Board has established a Task and Finish Group to review and update its standardized discharge form for care homes, aiming to ensure clear definition of observations and medication. The revi
Ivy Dixon
All Responded
2025-0186 10 Apr 2025 Inner North London
Lukka Care Homes Limited
Concerns 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.
Action taken summary The London Ambulance Service clarifies that their paramedic assessed the patient's airway as clear, with no food or secretions, and therefore had a low clinical suspicion of choking. They justified no
Bernard Lyon
All Responded
2025-0179 9 Apr 2025 Manchester South
Department of Health and Social Care Care Quality Commission Tameside Metropolitan Borough Council
Concerns 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.
Action taken summary The CQC disputes concerns regarding the care home's reliance on agency staff with communication issues and their attendance at Multi-Agency Concern meetings, stating inspections found no such evidence
Raymond Jennings
All Responded
2025-0125 6 Mar 2025 West Yorkshire Western
Abbey Place Nursing Home
Concerns 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 summary Abbey Place Nursing Home has updated its medication policy, implemented electronic medication and digital care planning systems, standardized GP and pharmacy use for residents, and completed documenta
June Phillips
All Responded
2025-0112 28 Feb 2025 Birmingham and Solihull
Willow Grange Care Home
Concerns 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 summary Willow Grange Care Home has implemented new procedures for updating falls risk assessments within 24 hours, new root analysis tools, and incident investigation forms. Policies for calling 999 for resi
James Siddons
All Responded
2025-0051 30 Jan 2025 London Inner (South)
Mills Family Ltd London Borough of Bromley
Concerns 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 summary The Council has held discussions with staff regarding timely sharing of safeguarding concerns and put processes in place, including Consultant Lead Practitioners for practice support. They also plan t
Neville McKenzie
All Responded
2025-0044 24 Jan 2025 Birmingham and Solihull Districts
Birmingham and Solihull Integrated Care… Health and Safety Executive
Concerns 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.
Action taken summary The HSE states that the regulation of anti-choking devices and care providers falls outside their remit, directing the Coroner to the Care Quality Commission (CQC), the Medicines and Healthcare produc
Diane Poole
All Responded
2025-0020 13 Jan 2025 Liverpool and Wirral
Victoria Residential Home
Concerns 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 summary Victoria Residential Home has implemented several measures, including daily rigorous alarm checks, increasing staff numbers by two per shift, improving shift handover procedures, and restructuring the
Sheila Nicholls
All Responded
2025-0009 7 Jan 2025 Buckinghamshire
Mandeville Grange Nursing Home
Concerns 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 summary Mandeville Grange Nursing Home has engaged Care4Quality to rewrite all policies, implementing a new process for drafting, reviewing, and distributing policies via Bright HR. They have moved staff trai
Victor Knowles
Partially Responded
2025-0002 2 Jan 2025 Cheshire
Springcare Care Homes Ltd Henning Hall Nursing Home
Concerns 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.
Action taken summary Springcare Care Homes Ltd disputes the necessity of the report, stating their existing internal investigation policies are comprehensive and appropriate. They assert that no further changes are requir
Peter Good
All Responded
2025-0003 2 Jan 2025 Manchester South
Harbour Healthcare Ltd
Concerns 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 summary Harbour Healthcare Ltd has revised its Safeguarding and Whistleblowing Policy and Serious Incident Reporting Policy to mandate comprehensive internal investigations following serious incidents. These
Edith Pye
All Responded
2024-0706 20 Dec 2024 Worcestershire
Care UK Ltd
Concerns 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 summary Care UK has revised its care plan policy to ensure clarity, introduced quarterly reviews, and implemented a new Safety Incident Response Framework policy (September 2024). This new policy mandates tha
Sylvia Savage
All Responded
2025-0010 18 Dec 2024 Durham and Darlington
Four Seasons Healthcare
Concerns 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 summary Four Seasons Healthcare states that staff training in record-keeping and archiving has been undertaken, and actions have been implemented to address concerns. This includes policies ensuring all care
Craig Spiby
All Responded
2024-0694 10 Dec 2024 Manchester West
Bolton Cares
Concerns 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 summary Bolton Cares has provided new guidance to staff on the distinction between 'monitoring' and 'supervision' at mealtimes. They have also implemented an electronic 'Read and Sign' record for SALT guideli
Gloria Linton
All Responded
2024-0661 2 Dec 2024 West Yorkshire East
Lifeway Care Ltd
Concerns 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 summary Lifeway Care has provided all staff with further training in Moving and Handling, including refresher training on safeguarding and reporting concerns, with a signed 'Staff Declaration of Compliance'.
Susan Paley
All Responded
2024-0647 26 Nov 2024 Manchester South
Harbour Healthcare Ltd
Concerns 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 summary Harbour Healthcare has implemented a new process to ensure call bells are readily accessible after care delivery, reinforced with staff communication, and has upgraded its call bell system. They clari
Elan Adams
All Responded
2024-0655 26 Nov 2024 East London
Abbey Healthcare
Concerns 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 summary Abbey Healthcare has implemented a new app on staff handsets allowing direct 999 calls via Wi-Fi, updated their Emergency Ambulance Protocol, and is replacing Wi-Fi hotspots. They have also created a
John Riley
All Responded
2024-0637 18 Nov 2024 Norfolk
Manor House Care Home
Concerns summary Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient monitoring protocols in the care home.
Action taken summary Manor House Care Home has implemented new procedures for night staff, effective since March 2024, to ensure two-hourly welfare observations are consistently completed for residents. These actions incl