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 resultsSteven Jones
All Responded
2017-0357
14 Nov 2017
South Yorkshire (East)
Beech Cliffe Grange Care Homes
Concerns summary (AI summary)
Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred due to staff channelling medical issues through managers, who then underestimated the situation's seriousness.
Disputed
(AI summary)
Beech Cliffe disputes the coroner's conclusion that deficiencies in care may have contributed to the death, arguing that evidence presented at the inquest suggested otherwise. They state that the resident's GP was happy to proceed with an appointment and that staff considered the resident's needs when making decisions about attending appointments.
John Nichols
All Responded
2017-0344
2 Nov 2017
Norfolk
Eastgate Residential Care Homes
King's Lynn Residential Care Homes
Concerns summary (AI summary)
The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.
Action Taken
(AI summary)
Kings Lynn and Eastgate Residential Care Homes engaged a fire consultant to observe fire drills, amended the pre-assessment form to include questions on distress caused by fire alarms, and revised the PEEP form. They have also amended the Group's Fire Drill Procedure and implemented relevant training.
Ronald Brewer
All Responded
2017-0306
19 Oct 2017
Gloucestershire
Barchester Homes
Concerns summary (AI summary)
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Action Taken
(AI summary)
A Deputy Manager with palliative care experience was appointed to support training and practice, staff undertook competency assessments, further training was provided, medication fridges were replaced, and policies/procedures were updated. The facts of the case will form a case study for staff training.
Joseph Tarnowski
All Responded
2017-0247
24 Aug 2017
Manchester (South)
Hillbrook Grange Residential Care Home
Concerns summary (AI summary)
A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.
Action Taken
(AI summary)
Following the inquest, Hillbrook Grange Residential Care Home immediately provided residents with call bells to be worn around their necks.
Maureen Colclough
All Responded
2017-0318
27 Jul 2017
Cheshire
Care Agency
Care Quality Commission
Concerns summary (AI summary)
Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.
Action Taken
(AI summary)
CQC has raised the provider's failure to notify them of the death, conducted an inspection, found all staff received basic life support training in August/September 2017 with additional training in late September/early October, and is taking substantive enforcement action requiring an action plan to improve care. Unique Care Services has notified all employees and revised performance appraisals to include recognizing emergency situations, ensured new starters receive relevant information, and mandated extra Emergency First Aid training for all employees.
James Harris
All Responded
2017-0334
21 Jul 2017
Birmingham and Solihull
Care First Class UK Limited
Care Quality Commission
Concerns summary (AI summary)
Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.
Noted
(AI summary)
Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; management staff are also monitoring records to address any issues arising. CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for a registered manager and ongoing assessments.
Daphne Cherry
All Responded
2017-0080
13 Mar 2017
Gloucestershire
Care UK
Concerns summary (AI summary)
Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Action Taken
(AI summary)
Care UK has taken actions including training the home manager, deputy, and unit leaders in early recognition of deteriorating patients, delivering training to all staff, introducing daily meetings and walkarounds to discuss residents, and CQC has acknowledged the implemented changes.
Etheline De-Gale
All Responded
2017-0058
16 Feb 2017
Bedfordshire and Luton
Ambassador House Care Home
Concerns summary (AI summary)
Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Action Taken
(AI summary)
Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at all times.
Frederick Chisnall
All Responded
2017-0017
30 Jan 2017
Cheshire
Halton Clinical Commissioning Group
St Helens Clinical Commissioning Group
Concerns summary (AI summary)
Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.
Action Taken
(AI summary)
Following a safeguarding investigation, Reflex Agency provided further training to its staff, and disciplinary action was taken against a nurse by St Mary's Nursing Home, who also assured they would no longer use Reflex Agency for non-registered staff. The Team Manager for St Helens Contracts and Quality Monitoring service liaised with the agencies for assurance of actions taken.
Joyce Crompton
All Responded
2016-0434
6 Dec 2016
Manchester (West)
CLS Care Services
Concerns summary (AI summary)
The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.
Action Taken
(AI summary)
Belong has reminded managers and nurses of policy adherence, requested reassessment of residents' choking risk, updated staff training, and will review policies in a meeting with registered managers. Staff at Belong Atherton have received updated training about Dysphagia which will be cascaded throughout the organization.
Doris Clarkson
All Responded
2016-0423
29 Nov 2016
County Durham and Darlington
Lambton Care Home
Action Taken
(AI summary)
Lambton House is phasing in air flow mattresses compatible with bed sensors and installs bed sensors for users at risk of falls who do not require an air flow mattress. The home now has a standard practice for pressure mats to be installed in all cases where a mattress is used that is incompatible with bed sensors.
William Marson
All Responded
2016-0394
2 Nov 2016
Wiltshire and Swindon
Avon Care Home Limited
Concerns summary (AI summary)
Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.
Action Planned
(AI summary)
The care home outlines a process for managing residents requiring specialist equipment or interventions, including staff training, competency assessments, clear documentation, and reviews. This process will be communicated and implemented across all Avon Care Homes.
Robert Davidson
All Responded
2016-0363
13 Oct 2016
Birmingham and Solihull
Aran Court Care Centre
Care Quality Commission
Department of Health and Social Care
+2 more
Concerns summary (AI summary)
Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.
Noted
(AI summary)
Priory Group will raise the need for effective communication at resident transfer in their Safety 1st bulletin and highlight the requirement to complete Form AM32 Transfer/Discharge record. Avery acknowledges shortcomings at Aran Court under previous management and has implemented an additional action plan and timetable to fully embed Avery's policies and procedures. NHS England outlines its commissioning role and refers to the Care Certificate as a new minimum standard for care workers. They state that the commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs. The CQC details inspections carried out at Aran Court Care Centre and Jubilee Gardens, noting expectations around risk assessments and handover documents when patients transfer between services. The Department of Health acknowledges the importance of workforce skills development and highlights the introduction of the Care Certificate and funding for training.
Winston Harris
All Responded
2016-wp25349
3 Aug 2016
Birmingham and Solihull
Birmingham City Council
Kerria Court residential home
Sandwell and West Birmingham Hospitals …
Concerns summary (AI summary)
The care plan for Mr Harris did not address his risk of absconding, and hospital staff did not consider an emergency DOLS despite his dementia and previous attempts to leave; the DOLS application was not processed before his death.
2 responses
from Birmingham City Council, Sandwell and West Birmingham NHS Trust
Rebecca Gilbank
All Responded
2016-wp25329
26 Jul 2016
Surrey
Independence Homes Limited
Concerns summary (AI summary)
A check was missed because staff were busy with other service users, and staff lacked knowledge about how to obtain an outside telephone line to call emergency services; the coroner suggests providing sufficient staffing resources and clear guidance on obtaining an outside line.
Action Taken
(AI summary)
The organisation has changed its telephone system so staff no longer need to dial 9 for an outside line when calling emergency services. This change was communicated to staff verbally, by email, and in the Clareville Lodge Communications Book.
Harold Goulding
All Responded
2016-0248
14 Jul 2016
London (East)
Alexander Court Care Central
Concerns summary (AI summary)
Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.
Action Taken
(AI summary)
The care home created a handover document for sharing new resident information with GPs, and implemented protocols to ensure nurses accompany GPs on rounds to discuss medication charts and care plans.
Malcolm Bennett
All Responded
2016-0232
22 Jun 2016
Manchester (South)
Borough Care Ltd
Concerns summary (AI summary)
Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.
Action Taken
(AI summary)
Borough Care has updated risk management plans for residents on Warfarin, placed anti-coagulant warnings on care plans and MAR sheets, discusses medication at handovers, reviewed medication training to include anticoagulant use, and will review the 'Falls Prevention' and medication audit procedures by the end of September 2016.
Lillian Hursell
All Responded
2016-0129
1 Apr 2016
Mid Kent and Medway
Ranc Care Home Ltd
Concerns summary (AI summary)
Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck injuries.
Action Taken
(AI summary)
The care home has commenced retraining in first aid, moving and handling, and health and safety. They have introduced bedrail audits, re-educated staff in bed rail use, and advised staff not to move a person following a fall until assessed.
Margaret Metcalfe
All Responded
2016-0107
14 Mar 2016
Teesside
Rosedale Care Home
Concerns summary (AI summary)
Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.
Action Taken
(AI summary)
Rosedale Centre implemented a new policy regarding Care Assist pagers, including staff responsibilities for checking equipment, documenting its use, responding to alerts, and reporting problems, with monthly audits by the manager.
Elsie Raper
All Responded
2016-0090
4 Mar 2016
County Durham and Darlington
County Durham and Darlington NHS Trust,…
Neasham Road Surgery
Concerns summary (AI summary)
A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
Action Planned
(AI summary)
The surgery will implement several actions, including investigation of falls in elderly patients and prompt referral for x-rays, as well as regular reviews of factors contributing to falls and discussion of the issues with the staff at Grosvenor Park Care Home. Four Seasons Health Care has initiated 24-hour falls observation charts, completed a list of all residents with a confirmed diagnosis of osteoporosis, reviewed and rewritten residents' care plans to incorporate details associated with a diagnosis of osteoporosis and increased risk of fracture, and now refers residents to the Community Matron for review after low impact falls.
Jean Gillespie
All Responded
2015-0419
2 Nov 2015
Blackpool and Fylde
Alexandra Court Care Home
Concerns summary (AI summary)
Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Action Taken
(AI summary)
Senior Care Assistants received further medication training and competency assessments, including a supervision after the inquest. The new manager introduced handover and medication count down sheets for improved communication and stock control.
William Tolen
All Responded
2015-0407
15 Oct 2015
Manchester (South)
Shawe Lodge
Concerns summary (AI summary)
Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.
Action Taken
(AI summary)
Staff have received further supervision and training in relation to documentation, and instructions have been added to staff diaries. Staff have been requested that requests are stated clearly and that progress is recorded, and all nurses have discussed the need to enter details fully in the daily notes.
Peter Furness
All Responded
2015-0398
5 Oct 2015
North Wales (East and Central)
Nant y Gaer Hall Nursing Home
Concerns summary (AI summary)
The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Action Taken
(AI summary)
Nant Y Gaer Hall has implemented a new alert system for changes in residents' conditions, with training and supervision for staff. The new system includes forms, flow charts, and posters, and is supported by red alert files.
Phyllis Broomhead
All Responded
2015-0290
6 Jul 2015
South Yorkshire (East)
Rotherham Metropolitan Borough Council
Concerns summary (AI summary)
Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.
Action Planned
(AI summary)
Rotherham Metropolitan Borough Council will provide a detailed action plan regarding recommendations made under Regulation 28, outlining actions taken, actions to be achieved, and timescales to conclude any uncompleted actions.
Michael Lyons
All Responded
2015-0067
20 Feb 2015
London (East)
John Stanley Agency
Concerns summary (AI summary)
The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention measures, and staff lacked crucial awareness regarding food preparation.
Disputed
(AI summary)
The care agency disputes responsibility, stating that they were not informed of Mr. Lyons' swallowing difficulties or risk of choking by social services or family, and therefore could not supervise him adequately during mealtimes.