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
Clear
PFD Reports
98 results
John Lambton
Historic (No Identified Response)
2018-0046 14 Feb 2018 Sunderland
Dairy Lane Care Centre
Concerns summary Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.
Sandra Miller
Historic (No Identified Response)
2018-0037 25 Jan 2018 Avon
Milestones Trust
Concerns summary Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.
Sheila Ross
Historic (No Identified Response)
2017-0384 21 Dec 2017 Brighton and Hove
Carlton House Rest Home Compliance Manager
Concerns summary The provided concerns text for this report does not detail specific safety issues or systemic failures related to the deceased's care at Carlton House Rest Home.
Wycliffe Matthews
Historic (No Identified Response)
2017-0299 18 Oct 2017 Manchester (West)
Grange Care Home
Concerns summary Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.
Barbara Sturgess
Historic (No Identified Response)
2017-0209 21 Sep 2017 Derby and Derbyshire
Ashgate House Nursing Home Chesterfield Royal Hospital
Concerns summary The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.
Beryl Goode
Historic (No Identified Response)
2017-0246 29 Aug 2017 Bedfordshire and Luton
Abbotsbury Elderly Persons Home
Concerns summary Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a fall, indicating a need for improved awareness and assessment training.
Ida Toole
Historic (No Identified Response)
2017-0146 2 May 2017 Milton Keynes
Excel Care
Concerns summary A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially neglecting safety needs.
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.
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.
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.
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.
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.
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.
Doreen Mattinson
Historic (No Identified Response)
2016-0156 18 Apr 2016 London Inner North
Acorn Lodge Care Home
Concerns summary Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, lacked training in oxygen administration.
Vincent Smith
Historic (No Identified Response)
2016-0134 6 Apr 2016 Sunderland
Village Nursing and Care Home
Concerns summary The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, and associated staff training.
Betty Addison
Historic (No Identified Response)
2016-0071 25 Feb 2016 Manchester (West)
Cuerden care Homes
Concerns summary A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
James Robertson
Historic (No Identified Response)
2016-0053 15 Feb 2016 Portsmouth and South East Hampshire
Healthcare Management Solutions Ltd
Concerns summary Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and the emergency resuscitation pack lacked essential equipment.
Norman Dorn
Historic (No Identified Response)
2016-0006 8 Jan 2016 Cornwall
Care Quality Commission Cornwall and Isles of Scilly Safeguardi…
Concerns summary Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Marie Quinn
Historic (No Identified Response)
2015-0423 2 Nov 2015 Manchester (West)
HC-One Limited
Concerns summary Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.
Violet Cloudsdale
Historic (No Identified Response)
2015-0387 25 Sep 2015 Cumbria
Care Quality Commission Risedale Estates Limited
Concerns summary The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.
Thomas Farrell
Historic (No Identified Response)
2015-0273 14 Jul 2015 Nottinghamshire
Springfield Care Home
Concerns summary The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.
Dorothy McDermott
Historic (No Identified Response)
2015-0266 10 Jul 2015 Manchester (North)
Department of Health and Social Care Littleborough Care Home Pennine Care Trust +1 more
Concerns summary A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.
Kathleen Eaton
Historic (No Identified Response)
2015-0236 22 Jun 2015 Manchester (South)
Peaks and Plains Housing Trust
Concerns summary An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance for ambulance summoning, raising doubts about the adequacy of emergency response from a distant base.
Walter Willows
Historic (No Identified Response)
2015-0218 10 Jun 2015 Manchester (South)
Westwood Homecare Limited
Concerns summary Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.