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 resultsJanet 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.
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.
Carol Clements
All Responded
2023-0175
30 May 2023
Birmingham and Solihull
Birmingham Community Healthcare NHS Fou…
Concerns summary (AI summary)
Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. Audits of falls risk assessments only check compliance, not correctness, failing to identify errors or training gaps.
Action Planned
(AI summary)
An in-depth action plan is being created to improve falls assessment training, enhanced supervision training, and auditing of falls risk assessments, to be approved by the Chief of Nursing and Therapies by 25 July 2023. Spot check reviews of falls risk assessments will be undertaken as part of care rounding, and a quarterly falls prevention effectiveness audit will be developed.
Julie Nolan
All Responded
2023-0162
11 May 2023
North Northumberland and South Northumberland
Maria Mallaband Care Group and Countryw…
Concerns summary (AI summary)
Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive days.
Action Taken
(AI summary)
Maria Mallaband care home has retrained staff regarding wound management and documentation, reviewed staffing levels, and reinforced the importance of escalating concerns to Tissue Viability. A national webinar was also held to discuss the inquest findings and the importance of documentation.
Janet Smith
All Responded
2023-0136
26 Apr 2023
Leicester City and South Leicestershire
Silver Birches Care Home
Concerns summary (AI summary)
Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.
Action Taken
(AI summary)
The care home has installed stairgates and provided/continues to provide training to residents on how to use them, and is conducting regular training sessions for staff on the risks of leaving residents unmonitored.
Lugh Baker
All Responded
2023-0090Deceased
13 Mar 2023
Cornwall and the Isles of Scilly
Bowden Derra Park Ltd
Concerns summary (AI summary)
The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff to address residents with unusual presentations.
Action Taken
(AI summary)
The facility has updated its Nocturnal CCTV Monitoring Chart to include a comments box for explaining gaps in monitoring. They have also updated their Care Plan and Training policies, with staff notified and tracked via the BrightHR application.
Gunapathyammah Ragnanathan
All Responded
2023-0087Deceased
13 Mar 2023
West London
Lean on Me Care Agency
Concerns summary (AI summary)
An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and supervision to provide safe assistance.
Action Planned
(AI summary)
The agency has contracted training providers and a consulting agency to support ongoing training, including RQF courses for care workers. They are also recruiting more field care supervisors to improve shadowing and appraisal of new care workers.
Peter Seaby
All Responded
2023-0076Deceased
27 Feb 2023
Norfolk
Oaks and Woodcroft Care Home
Concerns summary (AI summary)
Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack of post-incident review and management oversight.
Action Planned
(AI summary)
The Priory's operational management team will review the findings of the inquest and other information related to the incident, to identify any remaining salient themes and trends. They are also recruiting an additional Investigations Officer and adopting the Patient Safety Incident Response Framework.
Evelyn Burcham
All Responded
2023-0421
31 Jan 2023
Somerset
Care Quality Commission
Department of Health and Social Care
Health and Safety Executive
Concerns summary (AI summary)
Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.
Noted
(AI summary)
Aria Care will direct all future requests for riser/recliner chairs to Shackleton's, ensuring lockable handsets, and inform newly admitted residents of this requirement from December 1st, 2023. They are also working to replace existing chairs without lockable handsets and will reduce the use of riser/recliner chairs across the organization. HSE outlines the regulatory regimes applicable to the circumstances. HSE has contacted CQC on the patient safety aspects and notified OPSS regarding consumer product safety. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs.
Derek Larkin
All Responded
2023-0018Deceased
19 Jan 2023
Dorset
Dorset Clinical Commissioning Group
Dorset Council
Concerns summary (AI summary)
Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.
Noted
(AI summary)
The ICB notes that patient information is accessible via the Dorset Care Record (DCR) and that this gentleman has had a DCR since February 2018, which has been accessed by health and social care staff. They have shared the findings with the relevant teams to inform any future improvements to the DCR. Dorset Council confirms that they ensure health is consulted on medication, its use, storage and any risks at assessment and review points. They also confirm written confirmation from Health in writing of any known risks linked to the use of specific medications for named individuals and how to safely manage these is obtained. The learning recommended from the action plan was shared with relevant managers in February 2023.
Beryl Ellison
All Responded
2023-0002Deceased
3 Jan 2023
Sefton, St Helens and Knowsley
CQC, Weightmans’s Solicitors and Four S…
Concerns summary (AI summary)
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Action Taken
(AI summary)
Four Seasons Health Care Group has implemented improved communication, incident escalation, and medication risk assessment processes to prevent future medication errors. These include notifying management of incidents promptly, regular clinical meetings, monthly meetings to review incident management and medication audits, and medication risk assessments shared with the nursing and care team.
Tina Allen
All Responded
2022-0391
5 Dec 2022
Cornwall and the Isles of Scilly
Home Farm Trust Limited
Concerns summary (AI summary)
Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective management oversight of care quality.
Action Taken
(AI summary)
HFT has made improvements to service provision at Valley View, commissioning an independent review and working with stakeholders. They have increased staffing levels, provided training on specific health conditions, implemented a new digital care planning system, and enhanced the Quality Assurance Framework.
Janice Hopper
All Responded
2022-0384
28 Nov 2022
Norfolk
Windmill House Care Home
Concerns summary (AI summary)
The care plan was inaccurate, not person-specific, and vital medical monitoring—including weight, blood sugar, and fluid intake—was neglected or poorly recorded. Additionally, medication was administered inappropriately and care plans lacked regular review or audit.
Action Taken
(AI summary)
Runwood Homes has implemented changes including a new pre-admission form, staff training on individualised care plans, improved medication management protocols, and monthly care plan audits by the senior team.
Frederick King
All Responded
2022-0363
15 Nov 2022
Berkshire
Care Quality Commission
Concerns summary (AI summary)
The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.
Action Taken
(AI summary)
CQC conducted follow-up inspections of Birchwood Care Home after concerns were raised and rated the home as 'requires improvement' or 'inadequate' in several domains. They are keeping the service under review and will conduct another comprehensive inspection by August 2023, and will consider enforcement action based on the circumstances leading to the death.
Ellen MacFarlane
All Responded
2022-0350
4 Nov 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests at district general hospitals delays urgent surgery, contradicting best practice.
Noted
(AI summary)
The Department of Health and Social Care notes the concerns regarding ambulance response times and access to hospital services and says that ambulance performance is reviewed regularly. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance
John Fallon
All Responded
2022-0348
4 Nov 2022
Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.
Action Planned
(AI summary)
NHS Greater Manchester Integrated Care will share learning from this case with the Greater Manchester System Quality Group and cascade it to professionals through relevant governance and learning forums. The Team are currently looking into any additional training in relation to obstructed airways that can be undertaken by care home staff.
Sylvia Gibson
All Responded
2022-0342
27 Oct 2022
County Durham and Darlington
Lambton House LTD
Concerns summary (AI summary)
Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing important patient details with healthcare professionals.
Action Taken
(AI summary)
Following a fall incident, Lambton House implemented immediate actions: mandatory full documentation of falls, visual checks by senior staff, recording of observations (O2 sats, pulse, BP, temp, resps), contacting appropriate medical personnel, and following documented advice. Senior staff received supervision on communication and documentation.
Hazel Mayho
All Responded
2022-0340
26 Oct 2022
Hampshire, Portsmouth and Southampton
Westlands Care Home
Concerns summary (AI summary)
Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.
Action Taken
(AI summary)
Westlands Care Home installed an additional beam to the garden doors to alert staff if a resident enters the garden without observation, addressing concerns about exit control.