- Staff at Bowood Court did not understand importance of updating residents' care plans and behavioural support plans.
- Management had not instituted a system to check and ensure care and behavioural support plans were updated, leaving risks unmanaged.
- The home's internal investigation failed to identify plan deficiencies or implement measures to prevent recurrence, increasing risk of future deaths.
Date of report: 02/06/2026
Ref: 2026-0298
Deceased name: Francis Leech
Coroner name: David Reid
Coroner Area: Worcestershire
This report is being sent to: Adept Care Homes
| REGULATION 28: REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| 1 | CORONER I am David REID, HM Senior Coroner, for the coroner area of Worcestershire. |
| 2 | DATE OF REPORT 02 June 2026 |
| 3 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners Investigations) Regulations 2013. |
| 4 | THIS REPORT IS BEING SENT TO 1. The Managing Director, Adept Care Homes, 1 Lutterworth Road, Burbage, Hinckley LE10 2DJ You are under a duty to respond to this report within 56 days of the date of this report, namely by July 28, 2026. I, the coroner, may extend the period if an appropriate application is made. |
| 5 | YOUR RESPONSE Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. I will pass any representations received to the Chief Coroner for a decision. The names of those who do not respond to PFD reports are regularly |
| 6 | SUMMARY OF CORONER’S CONCERN (a) staff at Bowood Court Care Home, Redditch did not understand the importance of updating residents’ care plans and behavioural support plans; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) a subsequent internal investigation carried out by the care home failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated. |
| 7 | ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe you, as the Managing Director of the company which owns and runs Bowood Court Care Home, Redditch have the power to take such action. |
| 8 | INVESTIGATION AND INQUEST On 05 September 2024 I commenced an investigation and opened an inquest into the death of Francis Phillip LEECH aged 80. The investigation concluded at the end of the inquest on 02 June 2026. The conclusion of the inquest was that Mr. Leech “died from natural causes, to which traumatic facial injuries inflicted by a fellow care home resident and a resulting lengthy hospital admission contributed.” |
| 9 | CIRCUMSTANCES OF DEATH In February 2024 Francis Leech, who lived with advanced dementia and a number of other significant medical conditions, was admitted to Moundsley Hall Nursing Home, King’s Norton having spent the previous four months in hospital recovering from severe traumatic facial injuries sustained when he was struck repeatedly by a fellow resident at Bowood Court Care Home, Redditch. Over the next few months, he continued steadily to decline and died there on 26.8.24. His final decline was contributed to by the injuries which he had sustained and by the functional decline associated with the resulting lengthy hospital admission. |
| 10 | CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: |
| 11 | COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] I also have a duty to send a copy of the report to the Chief Coroner. |
| 12 | David REID HM Senior Coroner for Worcestershire |
published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.The post Francis Leech: Prevention of future deaths report appeared first on Courts and Tribunals Judiciary.
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