Recurring concern

Inadequate training and competence assurance for carers providing care

First to latest report 10 Sep 2014 — 8 Jan 2026

Reports that mention this concern
16
Times this concern has been raised
17
Stated actions linked to this concern
42

What this concern includes

Includes failures of training, practical preparation, shadowing, competence assessment, currency monitoring or role-specific competence assurance for carers providing care, including the anchor's lack of monitored training and comparable failures concerning practical care, repositioning, hoist operation or scope-of-care limits.

What is not included
  • Excludes failures limited to staffing numbers, availability or scheduling where carer competence is not the unsafe condition.
  • Excludes generic training or supervision deficiencies unrelated to carers providing care.
  • Excludes competence concerns for clinicians, emergency responders or other professional groups unless the assertion specifically concerns carers providing care.
  • Excludes failures of a separately named safety system or hazard where that system or hazard supplies the more specific parent boundary.
  • Excludes isolated poor performance where no deficiency in the carer training or competence-assurance process is identified.

Reports and published responses 16 reports

See individual reports that have raised this concern, and the actions taken in response

  1. South Yorkshire (Western)

    AI-generated summary

    Marjorie Nesbitt · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marjorie Nesbitt, who was bedbound and living alone with carers attending four times a day, died after a fan heater was turned up and left on overnight, making the room extremely hot. The inquest found that she died from hyperthermia in the presence of ischaemic heart disease and pulmonary emphysema, with old age and frailty as contributing factors. The principal concern was whether carers should receive training on managing similar situations involving heating and no overnight review.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of carer training for responding to similar situations

    Wider context from the report

    “(1) It is accepted that the circumstances were unusual and none of the carers were likely to have been trained what to do in such a situation. Indeed, it is accepted that they were placed in a difficult position, not turning the heater up would lead to the client being cold during the night, turning it up with no one due in to review the situation led to an uncomfortable and ultimately fatal situation for Mrs Nesbitt. (2) Nonetheless, it is difficult to say that this would be a completely unique situation and it is not impossible that other carers will be faced with similar situations in the future. What is a carer supposed to do in that situation? One supposes that the only potential remedy might be to include the circumstances of this case as a discussion in training of carers. ”

    Source location

    Marjorie Nesbitt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Prepare a case-study document and practical advice for carers and others with caring responsibilities.

    Verbatim wording from the response

    “You noted a potential remedy was to include the circumstances of this case as a discussion in the training of carers. To facilitate these discussions documents have been prepared and are included with this letter for your information.”

    Source location

    2016-0263-Response-by-Sheffield-City-Council
    Page 1 · response
    Published 25 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Recommend that recipient organisations use the documents as training tools and information to inform health and social care staff about relevant risks.

    Verbatim wording from the response

    “Sheffield City Council is making a recommendation that the above parties use the documents as a training tool and to provide information which informs those working in health and social care professions of the risks which are related to the content of the case.”

    Source location

    2016-0263-Response-by-Sheffield-City-Council
    Page 2 · response
    Published 25 July 2016

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Christine Valerie STREET · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of assurance that bank staff are trained to Trust standards

    Wider context from the report

    “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed. The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA. The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all. This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy. There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust. The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately. ”

    Source location

    Christine Valerie STREET · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Inform bank staff about observation policy and documentation requirements for one-to-one care.

    Verbatim wording from the response

    “Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    Open published response

  3. Manchester West

    AI-generated summary

    Margaret Rogerson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Margaret Rogerson, known as Peggy, died at Victoria House, Mill View Care Home, Bolton, from asphyxia due to aspiration of pureed food while being fed. The report raised concerns about a care assistant’s inability to recall training on feeding techniques and risks, the absence of refresher training, and the lack of training available to family members and others close to patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of patient feeding training for family members and other close carers

    Wider context from the report

    “3. There was no evidence of there being any training available to family members and others close to patients in the above matters. There was clear and striking evidence that family members and others would appreciate such training being available to them because in patients with advanced dementia feeding was often the only communication available between patients and their loved ones. There was also evidence that being able to do this in a professional and safe manner would be a great comfort to patient’s relatives and loved ones, who would as a result feel that they themselves were doing something meaningful for the patient. ”

    Source location

    Margaret Rogerson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. West Yorkshire Eastern

    AI-generated summary

    Connor Adrian Turner · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Connor Adrian Turner, who had cystic fibrosis, congenital heart disease and required oxygen, stopped breathing while shopping with his parents after the oxygen cylinder valve was found to be off. His death was unascertained, with the inquest stating that lack of oxygen was a contributory factor. The concerns identified included the absence of a system to train and supervise parents or carers in transferring and checking portable oxygen equipment before leaving hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to initially supervise parents and carers performing oxygen-supply transfers until competent

    Wider context from the report

    “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder. (2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so. (3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes. ”

    Source location

    Connor Adrian Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    RHYS TUDOR WILLIAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of training of carers providing immediate care

    Wider context from the report

    “1. There appeared to be a lack of training (in a number of areas) of the carers having immediate care of Dr Williams. I was told that they should all undertake e-learning but it was far from clear as to how (or whether) this was monitored and checked. ”

    Source location

    RHYS TUDOR WILLIAMS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor and report team training completion, giving managers access to compliance information for their teams.

    Verbatim wording from the response

    “The company’s training programme consists of a combination of eLearning modules by an accredited provider, bespoke in-house classroom learning delivered by qualified trainers, and practical assessments to check competency together with completion of workbooks to confirm that staff understand their role and responsibilities in caring for residents.”

    Source location

    2014-0558-Response-by-Sunrise-Senior-Living
    Page 1 · response
    Published 15 December 2014

    Open published response

  6. Black Country

    AI-generated summary

    JAMES DWAYNE CLARKE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Dwayne Clarke was involved in a motorcycle collision, became paraplegic and had a tracheotomy tube. After he was discharged home, carers failed to check him during parts of the night and did not notice that his tracheotomy tube had become blocked, resulting in his death. The principal concerns were that the standard of care was seriously lacking and that the carers had received theoretical but no practical training, potentially placing others receiving services at risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of practical training for carers

    Wider context from the report

    “My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant, the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public. ”

    Source location

    JAMES DWAYNE CLARKE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Adopt the Health and Social Care Act 2008 fundamental standards, including requirements concerning personalised, safe and competent care.

    Verbatim wording from the response

    “In April 2015 CQC will adopt the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, known as the “fundamental standards”. The changes in the regulations have emerged from the Robert Francis recommendations that there should be very obvious standards below which care must not fall. Regulation 9 will ensure that people receive care and treatment that is personalised for them and meets their needs; Regulation 12 is intended to prevent people from receiving unsafe care and treatment, and prevent avoidable harm or risk of harm. These regulations in particular will require providers to ensure that care is planned and delivered in a way that makes it crystal clear to care staff what is required of them, and that staff are experienced, trained and competent in the areas where they are providing that care.”

    Source location

    2014-0398-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 10 September 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure the coroner’s report is noted and informs the provider’s next ratings inspection, including examination of processes and training.

    Verbatim wording from the response

    “We will ensure that your report is noted and informs the next ratings inspection that takes place of Complete Care Services; although the information is now a little dated the issues are well worth a further examination of their processes and training provision.”

    Source location

    2014-0398-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 10 September 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026