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 resultsJohn 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.
Blanche Knowles
Partially Responded
2024-0078
13 Feb 2024
West Yorkshire (Eastern)
Care Quality Commission
Colton Lodges Nursing Home
HC-One Healthcare Company
Concerns summary (AI summary)
Staff lacked adequate training and clear operational communication regarding the critical importance of immediate 'cooling by running water' for burn injuries.
Action Planned
(AI summary)
The CQC requested information from the provider regarding their actions following the death and any additional actions planned. CQC plans to complete an assessment within the new Single Assessment Framework, focusing on relevant Quality Statements, within the next 3 months. HC-One has developed a 'Here's How To' guide for staff on first aid management of burns and scalds, issued a Safety Management Alert reiterating risk assessments for residents eating/drinking in bed, and developed training on the management of burns and scalds, available on their staff training site. They are also developing procedural guidance on common injury types, including burns and scalds.
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 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. 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.
David Hemmings
Historic (No Identified Response)
2023-0529
18 Dec 2023
Inner West London
Choice Support
Concerns summary (AI summary)
Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.
Julia Murphy
Historic (No Identified Response)
2023-0490
30 Nov 2023
Sefton, St Helens and Knowsley
Abbey Wood Lodge Care Home
Concerns summary (AI summary)
The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.
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.
Barbara Rymell
Partially Responded
2023-0482
27 Nov 2023
Somerset
Department of Health and Social Care
Home Office
Concerns summary (AI summary)
Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency services, potentially delaying urgent medical attention.
Noted
(AI summary)
The Home Office expresses condolences and explains the English language requirements for various immigration routes. They will tighten requirements for care workers coming to the UK on the Health and Care visa and will keep immigration requirements under review as part of this work, but does not believe raising the level of the English language requirements for Skilled Workers would be appropriate.
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.
Irene White
Historic (No Identified Response)
2023-0430
7 Nov 2023
Somerset
Frome Nursing Home
Concerns summary (AI summary)
Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative measures like TED stockings, and inadequately mobilized her post-discharge.
Geoffrey Whatling
Historic (No Identified Response)
2023-0418
27 Oct 2023
Norfolk
Amberley Hall Care Home
Athena Care Homes (UK) Limited
Concerns summary (AI summary)
A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.
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.
Norma Kyte
Partially Responded
2023-0398
12 Oct 2023
South Yorkshire (Western)
Broomcroft House Nursing Home
BUPA
Concerns summary (AI summary)
Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential non-compliance with manufacturer instructions.
Action Taken
(AI summary)
Bupa has taken several actions including reviewing the falls prevention policy, implementing mandatory sensor mat training, adding sensor mats to the equipment catalogue with recommended uses, ensuring sensor mat use is clearly recorded in care plans and providing 1:1 sessions with staff to reinforce the importance and correct use of the equipment.
Janet Spencer
All Responded
2023-0541
4 Oct 2023
Nottingham City and Nottinghamshire
Nottinghamshire County Council
Concerns summary (AI summary)
Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving care home also lacked the authority to refuse referrals despite insufficient information.
Action Taken
(AI summary)
Nottinghamshire County Council has implemented a new process and referral/assessment form for hospital and community admissions into Assessment Flat accommodation at Gladstone Court to outline a person's care and support needs, any risks, and updated medical information. They also hold weekly meetings for the Discharge to Assessment Team Managers to review practice and share improvements.
Douglas Nickols
Historic (No Identified Response)
2023-0354
29 Sep 2023
Surrey
Surrey and Sussex Healthcare NHS Trust
Concerns summary (AI summary)
The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early mobilisation and increasing patients' risk of complications like pneumonia.
Stephen Cassidy
All Responded
2023-0337
19 Sep 2023
Avon
North Bristol NHS Trust
Concerns summary (AI summary)
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
Noted
(AI summary)
NHS England acknowledges concerns about accessing Summary Care Records and allergy information but primarily describes existing requirements and procedures. They highlight national work to share learnings from PFD reports. The trust is exploring non-smartcard-based access to NCRS, with access planned for all staff in Q1 2024. They are also commissioning EPMA (Electronic Prescribing and Medicines Administration) for deployment in Q3 2024 and planning to implement 'Red Wrist Bands' for patients with allergy alerts by Q3 2024.
Anthony Friend
All Responded
2023-0336
18 Sep 2023
Worcestershire
Bluebird Care
Divine Health Services
Herefordshire and Worcestershire Health…
Concerns summary (AI summary)
A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of patient needs and critical equipment concerns.
Action Planned
(AI summary)
Bluebird Care will now contact the incoming care provider directly to discuss handover, provide customer information sheets to all new customers that can be shared with new providers, and offer/request information on existing appointments. Herefordshire and Worcestershire Health and Care NHS Trust has designed and introduced a leaflet with contact details for patients on initial assessment. They have also introduced a new role to improve communication with external agencies.
Sheila Johnson
All Responded
2023-0319
6 Sep 2023
Lincolnshire
Phoenix Care Centre
Concerns summary (AI summary)
Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe environment.
Action Planned
(AI summary)
The care home manager will personalise existing generic policies. The care home manager will personalise existing generic policies.
Linda Oldland
All Responded
2023-0293
14 Aug 2023
Surrey
Leonard Cheshire
Concerns summary (AI summary)
Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.
Action Planned
(AI summary)
Leonard Cheshire has implemented measures including manager's daily walkarounds, Sepsis training, and is reviewing their training program, service manager/staff induction, and implementing a quality audit plan, with plans to implement electronic care plans by March 2025.
Doris Urch
All Responded
2023-0302
11 Aug 2023
Inner North London
Globe Court Care Home
Concerns summary (AI summary)
The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system failed to preserve historical records.
Action Taken
(AI summary)
Staff training on PCS handheld devices has been implemented during induction, and a list of residents at high risk of falls is maintained to inform staff, with documentation being regularly checked for accuracy. They state that all staff are up to date with training except new employee's.
Eileen Walsh
All Responded
2023-0278
31 Jul 2023
Norfolk
Broadlane View Care Home
Concerns summary (AI summary)
The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an internal investigation that missed key facts, mirroring CQC concerns.
Action Taken
(AI summary)
The Night Work policy, incorporating a successful daily notes audit to prevent pre-recording of observations, was uploaded to the QCS system and added to the staff reading list on 01/08/2023. They have also engaged an external compliance company for more thorough inspections and monthly visits to assist with continuous improvement.
Terence Burns
All Responded
2023-0243
14 Jul 2023
Blackpool & Fylde
Highgrove Rest Home
Concerns summary (AI summary)
A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking appropriate care.
Action Taken
(AI summary)
Hospital passports are checked by two members of senior staff weekly, and Care Plans updated monthly or when any changes to care are required by a senior member of management. A hospital passport checklist has been implemented, and the provider contacted North West Ambulance Service to discuss the checklist.
June Peel
All Responded
2025-0403
11 Jul 2023
South Yorkshire (West District)
Belle Green Court Care Home
Concerns summary (AI summary)
Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate care without timely medical attention.
Action Taken
(AI summary)
Staff at Belle Green Court Care Home have received updated training on care planning and record keeping, and reviewed key policies and procedures. The Manager has commenced a tracker of all accidents and incidents to assist identifying any patterns or concerns.