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.

Response Status
Responded 299 No Response 2 Historic 106
AI Classification
Action Taken 62%
Action Planned 20%
Noted 16%
Disputed 2%
Based on 402 classified responses
Reports by Quarter
PFD Reports
407 results
Karen Redding
All Responded
2022-0133 18 Nov 2021 Black Country
Cherish Home Care
Concerns summary (AI summary) Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.
Action Taken (AI summary) Cherish Home Care now conducts spot checks with carers every 3 months (increased from annually) which will cover medication. During double up calls, carers are required to work together when administering medication to ensure it is done correctly, and the second carer is required to record and sign to verify the actions taken.
Dorothy Pegg
All Responded
2021-0358 22 Oct 2021 North Yorkshire Western District
Abbeyfields the Dales Ltd and North Yor…
Concerns summary (AI summary) A resident was hoisted from her bed to a shower chair with a slip left underneath, then wheeled to the living room; prior to being hoisted to her living room chair, she slipped and suffered bilateral leg fractures that contributed to her death.
Action Planned (AI summary) NYCC has requested ICES to provide instruction leaflets for equipment and will include a dedicated module with examples and scenarios for completing moving and handling risk assessments and plans in future training for new or existing OTs (February/March 2022); a specialist moving and handling training event for NYCC OTs is scheduled for February and March 2022 and will incorporate a specific focus on instructions as to the purpose of equipment and moving and handling plans. Abbeyfield The Dales Ltd has introduced a new care plan format with images of mobility equipment and updated systems of work, launched a service delivery audit to check care delivery against the care plan, and plans to implement a new equipment process in January 2022 to ensure staff competency with new equipment.
Henry Doll
Historic (No Identified Response)
2021-0351 20 Oct 2021 Surrey
Avenues Trust Group
Concerns summary (AI summary) Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.
Murray Hyslop
Historic (No Identified Response)
2021-0339 14 Oct 2021 Nottinghamshire
My Care Ltd My The Orchards Ltd Nottinghamshire County Council +2 more
Concerns summary (AI summary) The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. Frontline staff lacked crucial training, and senior management showed a culture of obfuscation.
Stephen Verrall
All Responded
2021-0336 1 Oct 2021 South London
Care Quality Commission St John’s Nursing Home
Concerns summary (AI summary) The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents without capacity to leave unaccompanied, posing a significant risk.
Action Taken (AI summary) St Johns Nursing Home has implemented several measures, including advising all staff of the potential problem of residents leaving through the front door, ensuring all staff securely closes the door behind them, fitting all windows in the building with window restrictors in line with guidance, and introducing a 'Herbert Protocol' for any resident that poses a risk of absconding. Following the inquest, the CQC carried out a responsive “targeted” inspection of St John’s Nursing Home on 13 October 2021 and are progressing regulatory action in relation to their concerns.
Tripta Bhanote
Historic (No Identified Response)
2021-0347 16 Sep 2021 Black Country
Manor Court Healthcare on behalf of Ans…
Concerns summary (AI summary) Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.
Eldine Lashley
Historic (No Identified Response)
2021-0308 16 Sep 2021 East London
Cherry Orchard Nursing Home
Concerns summary (AI summary) The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
James Golds
All Responded
2021-0284 26 Aug 2021 Greater Manchester South
Ministry of Communities, Housing and Lo…
Concerns summary (AI summary) Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler requirement and ineffective smoke detector placement.
Noted (AI summary) The Department for Levelling Up, Housing & Communities references existing building regulations, guidance, and the role of fire and rescue authorities, but does not commit to further action.
Peter Harte
All Responded
2021-0283 24 Aug 2021 Birmingham and Solihull
Bromford Lane Nursing Home
Concerns summary (AI summary) Proper skin inspections and monitoring were not consistently carried out or adequately recorded, indicating a possible systemic issue with record-keeping that could pose a risk to frail and vulnerable residents.
Action Taken (AI summary) Bromford Lane Care Centre reports that all staff have been spoken to and have received feedback and support to improve the service provided. Following this review, they have had an external auditor come and audit their body maps to ensure that they are being completed accurately.
Steven Kirkham
All Responded
2021-0280 18 Aug 2021 South Yorkshire (East)
Instastop Ltd
Concerns summary (AI summary) A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may be unaware of this significant safety flaw.
Action Planned (AI summary) Intastop identified a 'blind spot' on the door mechanism, confirmed timing delay was between 5-6 seconds, recommends checking thoroughly all alarms and re-setting the sensors and to inspect their testing protocol prior to dispatch.
Roland Stannard
All Responded
2021-0274 17 Aug 2021 Suffolk
Department of Health and Social Care
Concerns summary (AI summary) Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This highlights a broader concern regarding the appropriate assessment for nursing care needs.
Noted (AI summary) The Minister acknowledges the concerns and outlines the responsibilities of CQC registered providers regarding staff training and care delivery. It also mentions NHS England support for care homes and the upcoming statutory inquiry into the Government’s response to the Covid-19 pandemic.
Kumbulani Mtombeni
All Responded
2021-0272 16 Aug 2021 West London
Grassy Meadow Care Centre
Concerns summary (AI summary) Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.
Action Taken (AI summary) Care Outlook has implemented a digital care planning and monitoring system, will ensure all medication auditors and managers understand their obligation and have introduced a training program.
Albert Rowlands
All Responded
2021-0253 26 Jul 2021 North Wales (East & Central)
Gwern Alyn House Residential Home
Concerns summary (AI summary) Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during toilet access.
Action Planned (AI summary) Pendine Park will introduce a programme of testing door pressures where mobile residents encounter doors and will continue to work with GPs and other health professionals to support any resident that has a history of falls using the North Wales Prevention and Management of Falls in Care Homes Pathway. They also aim to continue to be suitably staffed.
John Dickinson
All Responded
2021-0310 22 Jul 2021 West Yorkshire Eastern
Care Quality Commission Sunnyside Nursing Home
Concerns summary (AI summary) Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and delayed the recognition of deterioration.
Action Planned (AI summary) Sunnyside Nursing Home attached an action plan to the response and has shared the action plan with the Care Quality Commission. The CQC contacted Bluebell Care Services Limited to request written confirmation and evidence of the action they have taken to date following this death and any additional action they intend to take in response to the prevention of future death report; they are assured with the actions taken by the registered provider to address the specific concerns found during the inquest.
Ben King
All Responded
2021-0250 20 Jul 2021 Norfolk
Jeesal Akman Care Corporation Ltd Jeesal Holdings Ltd Jeesal Residential Care Services +1 more
Concerns summary (AI summary) The provided text is a generic statement of concern, without specifying the particular matters that led to the risk of future deaths.
Action Taken (AI summary) Jeesal Residential Care Services has made changes to its board membership and oversight, including independent verification of reports, commissioning staff and family surveys, and a decision not to run hospital services in the future. They are also reviewing residents' placements and care packages to ensure appropriateness. The Norfolk and Norwich University Hospitals have discussed Mr King's case and raised awareness generally of the importance of obtaining tests when they are needed to inform the management and next stage of a patient's treatment. It was acknowledged by HM Coroner's expert that there was a spectrum of decision making available in this case, with admitting Mr King at one end of the range and sending him home at the other end.
Dorothy Seekings
All Responded
2021-0230 7 Jul 2021 Warwickshire
Clifton Court Nursing Home
Concerns summary (AI summary) Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.
Action Taken (AI summary) Crosscrown Ltd has implemented the CareDocs digital care management system, introduced "Understanding Challenging Behaviour and Dementia Training” and “Safeguarding Training", and enhanced the agenda for staff meetings to include behavioral issues and safeguarding.
William Rutherford
Partially Responded
2022-0118 16 Jun 2021 North Northumberland and South Northumberland
Alcyone Healthcare Baedling Manor Care Home
Concerns summary (AI summary) Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate and inaccurate, despite prior concerns.
Action Planned (AI summary) Due to significant failures, the provider is selling the business to an established provider and the home is currently going through transition, with a new management team. Efforts are being made to significantly develop the safe operation of the home during the transition, including reviews, training, audits and revised processes.
Clive Rivers
All Responded
2021-0199 10 Jun 2021 Manchester South
Department of Health and Social Care NHS England
Concerns summary (AI summary) Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting in an unsafe return to isolated accommodation.
Noted (AI summary) NHS England explains that vaccinations were initially prioritized for staff, discusses discharge policies aligned with national guidance, and highlights the use of Criteria to Reside for discharge decisions, with efforts to expedite discharges where possible. The Department of Health and Social Care extends condolences and explains the JCVI's role in vaccine prioritisation, highlighting the initial focus on reducing mortality and protecting healthcare staff. It also mentions support for hospital discharge pathways and ongoing reviews of COVID-19 deaths.
Catherine Jux
Partially Responded
2021-0188 2 Jun 2021 Mid Kent and Medway
Avery Healthcare Elvy Court Nursing Home
Concerns summary (AI summary) A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an inadequate auditing process.
Action Taken (AI summary) The home has revamped its first aid training to include suicide, self-harm, and overdose response, and is providing ligature cutting kits in every office by the end of July 2021. They have also added preventative training around suicide awareness and conversations for all front-line staff.
Kesia Waller
All Responded
2021-0187 1 Jun 2021 Hampshire, Portsmouth and Southampton
A2Dominion of The Point
Concerns summary (AI summary) Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure staff understanding and practical application.
Action Taken (AI summary) The organisation has revamped first aid training to include suicide, self-harm and overdose, is providing ligature cutting kits in every office by the end of July 2021 and has implemented an interim solution to confirm staff have read and understood policy changes.
Kenneth Smith
Historic (No Identified Response)
2021-0170 24 May 2021 Manchester West
Bolton Council Commissioning Services NHS Bolton Clinical Commissioning Group Shannon Court Care Centre
Liam Kenyon
Historic (No Identified Response)
2021-0161 19 May 2021 Manchester North
Adullam Homes Housing Association
Concerns summary (AI summary) Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, and did not follow procedures for drug checks or risk assessment updates. Welfare checks were inadequate due to staff shortages and poor escalation.
Glenn Macmartin
All Responded
2021-0142 7 May 2021 Plymouth Torbay and South Devon
Care Quality Commission, Devon Partners…
Concerns summary (AI summary) No specific concerns were detailed in the provided text.
Noted (AI summary) The Trust has strengthened links between community and forensic social work teams, secured funding for a Local Authority assigned social worker to join the community forensic team, and developed a protocol to address placing people outside of the Trust’s geographical area. CQC describes enforcement action taken culminating in the closure of Annette's Care. It states that an internal review found no gaps or areas for improvement in CQC's processes and that the CQC will participate in a 'learning event' with the local authority and Devon Partnership Trust. The PSAP will commission a multi-agency learning review, independently facilitated, to identify multi-agency learning in terms of strengths and weaknesses related to the case. This review will involve the engagement and participation of the family.
Stephen MAGUIRE
All Responded
2021-0138 5 May 2021 Birmingham and Solihull
Options for Care Ltd
Concerns summary (AI summary) A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking system for staff, which poses a significant risk if alarms are unusable during emergencies.
Action Taken (AI summary) Dartmouth House has introduced a 'security lead' role to check PIT alarms at the beginning of each shift and ensure they are working correctly. They will reinforce training through supervision sessions and staff meetings, and agency staff will receive training on PIT alarm use.
Alan Massam
All Responded
2021-0120 26 Apr 2021 Manchester South
SoS of Health and Social Care, Greater …
Concerns summary (AI summary) Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to an unsuitable care home. There was also no escalation process for medication refusal, exacerbated by a national bed shortage.
Action Planned (AI summary) CQC will undertake a focused inspection of Lisburne Court, including staffing levels, training, and infection control, and meet with the Chief Executive and new Nominated Individual of Borough Care Limited to discuss the issues raised and seek assurances. Stockport CCG has improved communication between hospital, GP and community services via a common system. GMHSCP is working across the system to look at safe discharges for people with complex needs and has a Learning Disabilities Complex Needs programme underway. The Department of Health and Social Care is preparing a new Dementia Strategy. NHS England and NHS Improvement are working with regional and local partners and the CQC. The CQC are to meet with the Chief Executive of Borough Care Ltd in the interim, to discuss these matters and to seek assurances around the lessons learned from this incident.