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 results
John Riley
All Responded
2024-0637 18 Nov 2024 Norfolk
Manor House Care Home
Concerns summary (AI 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 (AI summary) The Manor House Care Home has implemented a new approach to two-hourly welfare observations, dividing the home into sections and assigning staff to specific areas, with electronic recording and daily auditing to ensure timeliness; these actions are embedded into practice.
Sylvia Prichard
All Responded
2024-0576 25 Oct 2024 Surrey
Avery Healthcare Group
Concerns summary (AI summary) The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.
Action Taken (AI summary) Avery Healthcare has appointed a new Regional Director and Home Manager, conducted a lessons learned workshop across the organisation, completed a full audit of care plans, introduced a care plan tracker, implemented a new internal audit framework, fully reviewed the RADAR incident reporting system, and scheduled weekly Regional Director visits.
Christiana Dawson
All Responded
2024-0557 16 Oct 2024 South Yorkshire (West)
Darnell Grange Nursing Home
Concerns summary (AI summary) Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.
Action Taken (AI summary) Darnell Grange Nursing Home has updated its agency nurse induction to include istumble and post fall protocol, reinforced the policy of not moving a service user post fall until clinical assessments have been done, informed the agency of the breach of company policy regarding moving a service user after a fall, and checked that there are no changes in medication.
Sally Mills
All Responded
2024-0556 14 Oct 2024 Berkshire
Caremark (Chiltern & Tree Rivers)
Concerns summary (AI summary) There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.
Action Taken (AI summary) Caremark has updated its basic life support training, medication policy and induction programme, emphasizing practical scenarios, communication, and clear recording of medication incidents.
Mia Gauci-Lamport
All Responded
2024-0545 14 Oct 2024 Surrey
Care Quality Commission Department of Health and Social Care NHS England +1 more
Concerns summary (AI summary) Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent specialist oversight were significant clinical governance concerns.
Noted (AI summary) NHS England acknowledges concerns and outlines existing oversight mechanisms, offering support to connect TCT's clinical team to specialists within the NHS and supporting TCT in connecting within the local integrated care system to improve flow to clinical appointments. CQC states that The Children's Trust (TCT) have strengthened their frequency of monitoring policy and increased their audits of the implementation of this policy; have a Frequency of Monitoring Policy in place since July 2022 which continues to be reviewed and updated. CQC have seen evidence of a strengthened learning culture at TCT through inspection and routine engagement conversations. The DHSC acknowledges the concerns raised in the report and states that they have sought assurances from the CQC and NHS England that responses are being prepared to address concerns respective to each organisation. They highlight ongoing monitoring by the CQC and clarify commissioning responsibilities. The Children's Trust has revised its Frequency of Monitoring Policy, enhanced clinical governance frameworks, and strengthened integration with NHS services following the death of Mia Gauci-Lamport.
Paul Batchelor
All Responded
2024-0494 13 Sep 2024 Surrey
Care Quality Commission Medicines and Healthcare Products Regul… Red House (Ashtead) Limited
Concerns summary (AI summary) A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.
Action Taken (AI summary) The MHRA highlights a National Patient Safety Alert published two months after the death with general requirements to prevent entrapment with beds and associated devices. They have also discussed with NAMDET the possibility of producing training materials for users of beds and bed rails, and the risks relating to entrapment, with a view to be available in the coming months. The care home has reinforced learnings, extended the Room Call Policy, implemented QR codes for night checks, and provided further training. The staff member involved is no longer working at the Red House. The CQC will continue to monitor the care home, utilising insight data and information from stakeholders. They have commenced an inspection of the service and have undertaken an initial assessment in respect of this death to determine whether criminal enforcement action should be considered and will take robust action as necessary.
James Astley
All Responded
2024-0486 10 Sep 2024 South Manchester
Care Quality Commission Downshaw Lodge
Concerns summary (AI summary) Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.
Noted (AI summary) CQC commenced an inspection of Downshaw Lodge on 16 October 2024 to review matters in relation to ongoing risk and to assess documentation; findings will be published on the CQC website. An initial assessment concluded there was no evidence of a registered provider level failure to meet the threshold at which criminal enforcement would be considered. No information provided.
John Howlett
All Responded
2024-0483 6 Sep 2024 Manchester South
Care Quality Commission Department of Health and Social Care Lakes Care Centre
Concerns summary (AI summary) Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.
Noted (AI summary) DHSC reports that Tameside and Glossop Integrated Care NHS Foundation Trust completed work on re-developing its urgent care and emergency departments in July 2024, including front-door streaming, an Urgent Care Transformation Programme, and a review of the emergency department to avoid hospital admissions for those patients living with frailty; The Lakes Care Centre is no longer registered for nursing, and is under new management. The CQC acknowledges concerns about care at The Lakes Care Centre. The provider has ceased to deliver the regulated activity of 'Treatment for Disease, Disorder or Injury' and the CQC will seek to register a suitable candidate for the registered manager role. Response consists of the text A1, A2, and A3. Unable to classify without further content.
Margaret Aitchison
All Responded
2024-0481 3 Sep 2024 South Yorkshire East
National Care Consortium Ltd Pristine Care Group Ltd
Concerns summary (AI summary) A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.
Noted (AI summary) The organisation acknowledges receipt of the letter and clarifies the relationship between National Care Consortium and Pristine Care Group Ltd. The care home has implemented processes and protocols to address identified shortfalls, with auditing duties carried out by the senior management team. A CQC inspector reviewed the protocols and was happy with the improvements.
Wendy Afford
No Identified Response
2024-0478 30 Aug 2024 Berkshire
Happy at Home Community Care Services L…
Concerns summary (AI summary) Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training on skin integrity.
Mavis Dewey
All Responded
2024-0435 7 Aug 2024 South Yorkshire West
Monarch Health Care C/O Heeley Bank Car…
Concerns summary (AI summary) Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Action Planned (AI summary) Monarch Healthcare is implementing a new clinical oversight form for moving and handling, monitoring staff via CCTV, auditing resident bedrooms for equipment, and requiring staff signatures at handover meetings, with implementation by August 31, 2024 and review by September 30, 2024.
Alfred Sparrow
All Responded
2025-0405 6 Aug 2024 Worcestershire
Cardinal Health
Concerns summary (AI summary) Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake as required by his care plan; a false entry in Mr. Sparrow's notes gave rise to concern that staff might have been completing care note entries which did not reflect their actions.
Action Taken (AI summary) Cardinal Healthcare has already implemented several actions, including a manual reminder system for documentation, monitoring via a 'Resident of the Day' system, reflective practice sessions for staff, and a mentorship program for new staff. They are also planning to introduce a multi-layered review process for investigations, train managers, and strengthen collaboration with external bodies.
James Capstick
All Responded
2024-0429 2 Aug 2024 Cumbria
Care Quality Commission Nursing and Midwifery Council Westmorland Court Care Home
Concerns summary (AI summary) Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR correctly highlighted training deficiencies and lack of defibrillator availability.
Noted (AI summary) The NMC acknowledges the concerns and states they have passed information to their Employer Link Service and New Referrals team to make enquiries and will investigate concerns within their remit. They have also referred the case to the Public Support Service to reach out to the family. Westmorland Court Care Home states that a number of improvements have taken place since the death, including implementing a Quality Improvement Plan with the ICB and Westmorland and Furness Council. Staff training has been refreshed and updated, and reflective accounts of the incident were completed. The CQC acknowledges the concerns raised and outlines actions taken following previous notifications, including a targeted inspection. They state that mandating defibrillators in care homes falls outside their remit but expect providers to have appropriate policies for resuscitation.
Shahida Khan
All Responded
2024-0398 24 Jul 2024 Hampshire, Portsmouth and Southampton
Voyage Care Cloverdale
Concerns summary (AI summary) A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication errors.
Action Taken (AI summary) Voyage Care describes actions taken including reviewing resident care plans, medication training for staff, and commissioning an independent pharmacist to review policies. They are also planning the implementation of an electronic Medication Administration System.
Richard Fitzgerald
All Responded
2024-0369 10 Jul 2024 East London
Serencroft
Concerns summary (AI summary) Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation was criticised for its lack of thoroughness.
Action Taken (AI summary) Gable Court immediately provided further First aid including Basic life support and Dysphasia, Dysphagia and IDDIS training to all staff. Following significant events, investigations will be allocated to at least two independent investigators, not from the Care Home involved in the incident, and will be scrutinised by at least two members of the Board of Directors.
Debra Bates
All Responded
2024-0350 28 Jun 2024 Derby and Derbyshire
Park Surgery
Concerns summary (AI summary) A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system safeguards.
Action Planned (AI summary) The surgery plans to discuss the SOP during an education session, undertake quality improvement work on opioid prescribing (including patient reviews), and review the SOP in July 2025.
Terrence Taylor
All Responded
2024-0336 21 Jun 2024 Cambridgeshire and Peterborough
British Standards Institute Care Quality Commission Department of Health and Social Care
Concerns summary (AI summary) Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators are unaware these standards may not provide sufficient security.
Action Planned (AI summary) BSI has passed the coroner's report to the responsible expert committees, who are considering amending the existing standard to include the recommendations that restrictors should withstand forces greater than the current British Standard and be tested to demonstrate this. The CQC has updated their ‘Learning From Safety Incidents’ webpage with a link directing providers to the Health Building Note 00-10 Part D: Windows and associated hardware. They have also committed to publish a note in their bulletin to providers in August 2024 to remind providers of the CQC’s ‘Learning From Safety Incidents’ webpage. The CQC has published a note in its bulletin to providers highlighting the tragic loss of life following a deliberate attempt to bypass a window restrictor and reminding providers of the CQC’s ‘Learning From Safety Incidents’ webpage and updated the CQC website to reflect the Health Building Note published by NHS England.
Maureen Woollen
All Responded
2024-0335 19 Jun 2024 South Yorkshire West
Deerlands Residential Home
Concerns summary (AI summary) The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately used to record incidents or monitor injury progression.
Action Taken (AI summary) Sheffcare has implemented a new Person-Centred Care system, provided refresher training to staff, updated policies, and performs audits, with oversight from the new Director of Quality and Care.
Alan Lee
Partially Responded
2024-0308 6 Jun 2024 West Sussex, Brighton and Hove
Abbotswood Care Outlook Ltd
Concerns summary (AI summary) Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt life-saving techniques.
Action Taken (AI summary) Care Outlook has implemented mandatory Basic Life Support training with a choking vest, expanded their nutrition and hydration assessment to include an 'Eating and Drinking Checklist' highlighting choking risk, and increased the frequency of e-learning on Dysphagia and Modified Diets to annually.
Terence Manning
All Responded
2024-0495 10 May 2024 Blackpool & Fylde
HADDON COURT REST HOME, BLACKPOOL
Concerns summary (AI summary) Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, posing a risk to future patient safety.
Action Taken (AI summary) Haddon Court Rest Home has reminded staff about the importance of accurate record keeping and the risks of using the "repeat functionality" of their software; the software provider is reviewing the functionality.
Frederick Boyd
All Responded
2024-0240 2 May 2024 Manchester South
Care Quality Commission Lakes Care Centre
Concerns summary (AI summary) Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.
Action Taken (AI summary) The Lakes Care Centre has ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. The CQC is following up with the manager to register them as soon as possible.
Edith Alden
All Responded
2024-0196 16 Apr 2024 Norfolk
Limes Care Home
Concerns summary (AI summary) Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, leading to preventable falls.
Action Taken (AI summary) The Limes Care Home outlines actions taken both before and after the inquest, including reviewing and updating care plans/risk assessments, increasing staff presence in communal areas, and utilizing assistive technology like sensor mats in bedrooms. They also plan to develop guidance resources for families.
Rose Hollingworth
All Responded
2024-0150 Inner North London
Care Quality Commission Home Dot Care Limited Islington Social Services
Concerns summary (AI 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.
Disputed (AI summary) HomeDot Care has implemented a sleeping protocol, enhanced staff training, fully transitioned to an electronic care recording system, and revised call management procedures. They also introduced a new daily communication system, mandated staff shadowing, updated policies, and committed to annual mock inspections. The CQC conducted a comprehensive inspection of HomeDotCare Limited, finding that the service had already implemented several risk mitigation actions, including individual fire risk assessments, a 'sleep protocol,' updated next-of-kin notification policies, and comprehensive staff training. First aid training was also arranged immediately after the inspection. Islington Council has submitted a 'Letter Before Claim for Judicial Review' challenging the coroner's decision to issue a PFD report against them, arguing procedural irregularity and seeking to have the report quashed against the Council. Islington Council describes its robust processes for monitoring care agency performance, including a dedicated contract management team and a recently updated provider audit approach to include resident and staff feedback. They also undertook a procurement exercise to reduce provider numbers to enhance quality and safety.
Victor Costello
All Responded
2024-0141 14 Mar 2024 Teesside and Hartlepool
Stockton Care Limited
Concerns summary (AI summary) Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.
Action Planned (AI summary) The care home communicated the coroner's concerns to all staff and is implementing an upgraded cloud-based electronic documentation system by June 1, 2024. They are also ensuring effective handovers between staff and that risk assessments and care plans are detailed and shared with next of kin.
Ronald Jepson
All Responded
2024-0200 11 Mar 2024 Coventry and Warwickshire
Meadow House
Concerns summary (AI summary) Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.
Action Taken (AI summary) Meadow House has implemented face-to-face 1st aid training for staff, reviewed systems and processes to minimize risk of human error, reoriented staff to the escalation guidance for care homes, and provided ongoing supervision. The Provider has recirculated the International Dysphagia Diet Standardized Descriptors to staff team, and notified relevant statutory bodies of the incident, findings, and improvement actions.