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
244 results
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.
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) 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 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. 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.
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.
John MacGregor
All Responded
2024-0129 6 Mar 2024 Herefordshire
Credenhill Court Rest Home
Concerns summary (AI summary) Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or not escalating care following a fall.
Action Taken (AI summary) The care home has stopped offering respite care, enhanced documentation procedures for senior staff, reviewed and reinforced the falls protocol, improved communication during weekly ward rounds, added safeguards to medication processes for residents on blood thinners, implemented a written daily handover sheet, and increased care plan audits.
Susan Bracegirdle
All Responded
2024-0052 2 Feb 2024 Manchester South
Care Quality Commission
Concerns summary (AI summary) Poor communication and information sharing between District Nurses, care home, GP, and family hindered effective joint care for pressure ulcers. Inadequate internal reviews and remote expert input further compromised timely intervention for a deteriorating patient.
Noted (AI summary) The Integrated Care Partnership states that District Nurses share advice via a Communication Book and that the Trust has provided a timeline of communication with the care home. They describe the process for Tissue Viability Nurses to review and provide advice, including the use of wound photography and communication with the nursing service. CQC will follow up with Stockport NHS Foundation Trust at future engagement meetings to ensure that appropriate reflection has taken place and learning from this incident disseminated. CQC are continually monitoring the service and liaising with the Integrated Care Board to review any ongoing risks and feedback.
Sylvia Nash
All Responded
2024-0003 2 Jan 2024 Birmingham and Solihull
Birmingham City Council Connaught House Care Home
Concerns summary (AI summary) Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.
Noted (AI summary) BCC has conducted staff engagement sessions and provided a template for recording multi-disciplinary decision making. The ICB is leading on developing procedures around 1 to 1 support in P2 beds, stating that it can only be removed following an MDT decision. Connaught House states they assessed Sylvia required 1:1 supervision and communicated this, but that funding for 1:1 observations is a wider issue. They claim the Regulation 28 order is unfair and not factual against them. Connaught House has cascaded information about a new ICB process for removing 1:1 support to their staff and placed posters in each nursing station to ensure awareness.
Margaret Austin
All Responded
2024-0065 27 Nov 2023 County Durham and Darlington
Stanley Park Care Centre
Concerns summary (AI summary) The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls training.
Action Taken (AI summary) Stanley Park care home has taken steps to improve documentation around assessment and management of falls, including documentation to reflect the rationale sitting behind clinical decision making, and has incorporated a falls specific package into the mandatory training programme.
Hazel Pearson
All Responded
2023-0471 24 Nov 2023 North Wales East and Central
Betsi Cadwaladr University Health Board
Concerns summary (AI summary) Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a serious risk.
Action Planned (AI summary) The Health Board is exploring how to access expert advice in relation to compliance. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet and a new incident process will be introduced in April 2024.
Leya Adris
All Responded
2023-0433 8 Nov 2023 Birmingham and Solihull
Birmingham and Solihull Integrated Care… Birmingham and Solihull Mental Health N…
Concerns summary (AI summary) A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the GP's urgent referral was incorrectly diverted by the single point of access system.
Action Planned (AI summary) Birmingham and Solihull Mental Health NHS Foundation Trust have made alterations to their referral form making it explicitly clear that the Community Mental Health and Wellbeing Service will review the referral and determine where the patients’ needs can be best met, while also removing reference to referral to ‘secondary care services’. Birmingham and Solihull ICB will ensure effective working relationships between BSMHFT and General Practice, particularly regarding referral processes for the Community Mental Health and Wellbeing Service. They will also ensure mental health referral protocols are included in a central portal for General Practice.
Jacqueline Carrey
All Responded
2023-0411 26 Oct 2023 Milton Keynes
Milton Keynes University Hospital
Concerns summary (AI summary) The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged to staff before discharge, highlighting failures in record-keeping and communication.
Action Taken (AI summary) Milton Keynes University Hospital has incorporated new measures into their EHR that codify information regarding restrictions on medicines supplied at discharge, including alerts for both doctors and pharmacists.
Terence Davenport
All Responded
2023-0389 17 Oct 2023 Manchester South
Greater Manchester Integrated Care
Concerns summary (AI summary) A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing between authorities also failed to recognize a safeguarding risk, endangering residents and staff.
Action Planned (AI summary) Learning from the report will be presented to Tameside Care Home Managers in December 2023 and ICFT Trust Colleagues in February 2024, focusing on sharing risk information and discharge issues. The learning will also be taken via the Tameside System Quality Group and shared via the GM System Quality to ensure robust information sharing across settings.