4 Dec 2024 Kayleigh Ann MELHUISH · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure to complete or review ACCT care plans and support actions at every review View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Avon and Wiltshire Mental Health Partnership NHS Trust Eastwood Park Prison and Young Offender Institution HM Prison and Probation Service Ministry of Justice Practice Plus Group Health And Rehabilitation Services Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of Justice
Provide ACCT case-review training and refresher training for case coordinators.
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Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of Justice
Develop and operate an ACCT quality-assurance process providing feedback, support and escalation for case-management concerns.
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Practice Plus Group Health And Rehabilitation Services Limited
Complete consideration of adding a SystmOne tick-box confirming review of care plans and support actions.
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Practice Plus Group Health And Rehabilitation Services Limited
Maintain regular audits of ACCT reviews to verify that care plans and support actions are reviewed and updated appropriately.
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Practice Plus Group Health And Rehabilitation Services Limited
Collaborate with the prison to ensure clinical staff complete updated ACCT training and have access to regular training sessions.
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Practice Plus Group Health And Rehabilitation Services Limited
Continue monitoring the ACCT review process.
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Avon and Wiltshire Mental Health Partnership NHS Trust
Revise and approve the local operating procedure for ACCT attendance.
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Avon and Wiltshire Mental Health Partnership NHS Trust
Monitor ACCT training, refresher completion, and record-keeping standards through a scheduled audit programme.
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Avon and Wiltshire Mental Health Partnership NHS Trust
Develop a Quality Improvement Plan supporting the ACCT procedure and associated monitoring.
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Kayleigh Ann MELHUISH · 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
Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by neglect.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete or review ACCT care plans and support actions at every review
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews ;
c. Little or no understanding of when constant supervision can be used and how is it used;
” Source location Kayleigh Ann MELHUISH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ACCT case-review training and refresher training for case coordinators.
Verbatim wording from the response “These issues are covered in the case review training that is provided to ACCT case coordinators, and a case review refresher course is also available for staff to attend. A new quality assurance process for ACCT has also been developed and provides an opportunity for managers to offer feedback to case co-ordinators to enhance their performance.” Source location Response from HMPPS/MoJ and HMP Eastwood Park
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and operate an ACCT quality-assurance process providing feedback, support and escalation for case-management concerns.
Verbatim wording from the response “These issues are covered in the case review training that is provided to ACCT case coordinators, and a case review refresher course is also available for staff to attend. A new quality assurance process for ACCT has also been developed and provides an opportunity for managers to offer feedback to case co-ordinators to enhance their performance.” Source location Response from HMPPS/MoJ and HMP Eastwood Park
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete consideration of adding a SystmOne tick-box confirming review of care plans and support actions.
Verbatim wording from the response “Matter of Concern 2: Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.” Source location Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain regular audits of ACCT reviews to verify that care plans and support actions are reviewed and updated appropriately.
Verbatim wording from the response “To address this matter effectively, we remain committed to maintaining robust oversight through regular audits of ACCT reviews. These audits will ensure that care plans and associated support actions are being reviewed and updated appropriately.” Source location Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with the prison to ensure clinical staff complete updated ACCT training and have access to regular training sessions.
Verbatim wording from the response “Additionally, we will continue to collaborate closely with the prison to ensure all relevant staff complete updated ACCT training. This will reinforce the importance of thorough and consistent care plan reviews as part of the ACCT process. As at today’s date, 78% of all clinical staff have completed ACCT training and we continue to work with the prison to ensure access to regular ACCT training sessions.” Source location Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring the ACCT review process.
Verbatim wording from the response “Practice Plus Group conduct regular audits of the ACCT process, in October and November 2024 Healthcare attended 100% of all ACCT reviews and this is documented on SystmOne. We will continue to monitor this process.” Source location Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and approve the local operating procedure for ACCT attendance.
Verbatim wording from the response “The Trust has reviewed our involvement and input into the ACCT process, and revised the Local Operating Procedure for ACCT attendance (attached). This was discussed and signed off at the service level Quality and Standards meeting on 22nd January 2025.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor ACCT training, refresher completion, and record-keeping standards through a scheduled audit programme.
Verbatim wording from the response “To ensure adherence with this procedure, the Quality and Standards meeting will monitor completion of ACCT training and refreshers through an audit schedule, which will also include monitoring improvements in standards across record keeping in ACCT and SystmOne.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Quality Improvement Plan supporting the ACCT procedure and associated monitoring.
Verbatim wording from the response “A Quality Improvement Plan has been developed to support this and is attached.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to SystmOne are limited because the software provider controls implementation of database changes.
Verbatim wording from the response “Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness.
However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted.” Source location Response from Practice Plus Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementation of a SystmOne care-plan review tick-box would require action by TPP, which owns and operates the software.
Verbatim wording from the response “Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness.
However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted.” Source location Response from Practice Plus Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A SystmOne tick-box would not ensure that meaningful care-plan reviews and updates were conducted.
Verbatim wording from the response “Response: We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions. Unfortunately, Practice Plus Group’s ability to makes changes to SystmOne is limited and this would require action by TPP who own and operate the software. We have forwarded a copy of the Prevention of Future Deaths Report to TPP for their awareness.
However, it is important to note that whilst a tick-box could serve as a prompt, it does not provide a mechanism for reporting or ensuring that meaningful reviews and updates are conducted.” Source location Response from Practice Plus Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regular audits of ACCT reviews are considered an effective alternative for ensuring care plans and support actions are reviewed and updated.
Verbatim wording from the response “To address this matter effectively, we remain committed to maintaining robust oversight through regular audits of ACCT reviews. These audits will ensure that care plans and associated support actions are being reviewed and updated appropriately.” Source location Response from Practice Plus Group
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28 Oct 2024 Ian Gilmore HEGARTY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to follow falls-risk care plans View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Barts Health NHS Trust
Conduct weekly documentation audits, assurance meetings, metrics reviews and ward action planning across all six divisional wards.
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Barts Health NHS Trust
Provide ward-based falls and enhanced-care risk-assessment training with senior-nurse oversight and refresher documentation sessions for staff.
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Ian Gilmore HEGARTY · 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
Ian Hegarty was admitted to hospital after a fall at home and later sustained an unwitnessed fall in hospital when the allocated staff member left the bay, causing a right femur fracture. His condition deteriorated and he died on 17 June 2024; the principal concern was that the care plan intended to reduce falls risk was not followed, with insufficient reassurance at the time of the inquest that the risk was being addressed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to follow falls-risk care plans
Wider context from the report “1) That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed .
I heard evidence that an internal investigation into the matter has been commenced but is not yet concluded. As such, there was insufficient reassurance, at the time of the inquest, that the risk is being addressed.
” Source location Ian Gilmore HEGARTY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly documentation audits, assurance meetings, metrics reviews and ward action planning across all six divisional wards.
Verbatim wording from the response “3. | Weekly documentation audits & action plans” Source location Response from Barts Health NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ward-based falls and enhanced-care risk-assessment training with senior-nurse oversight and refresher documentation sessions for staff.
Verbatim wording from the response “4. | Training, Falls and Enhanced Care risk assessments” Source location Response from Barts Health NHS Trust
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25 Oct 2024 Sylvia Prichard · Prevention of Future Deaths report Surrey
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Concerns raised 1
Care plans containing out-of-date and conflicting information View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Avery Healthcare Group
Complete a full audit of residents’ care plans for accuracy, currency and consistency.
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Avery Healthcare Group
Introduce and operate a care-plan tracker with daily management checks and monthly care-record audits.
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Avery Healthcare Group
Train key staff in care planning, record-keeping and falls management, with refresher training scheduled for record accuracy, falls management and risk recognition.
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Avery Healthcare Group
Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
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Avery Healthcare Group
Operate the Resident of the Day programme to review care plans with keyworkers and respond to current risks.
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Sylvia Prichard · 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
Sylvia Prichard, a resident of Moorlands Lodge Care Home, had an unwitnessed fall on 28 March 2024 after a delayed response to her call bell and later died in hospital from a traumatic acute subdural haemorrhage. The concerns included the absence of a falls minimisation plan, outdated and conflicting care-plan information, persistent delays in responding to call bells, and inadequate oversight and auditing of these issues.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Care plans containing out-of-date and conflicting information
Wider context from the report “- Mrs Prichard’s mobility care plan contained out of date and conflicting information. The Coroner is concerned that other residents’ care plans may contain out of date and conflicting information.
” Source location Sylvia Prichard · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a full audit of residents’ care plans for accuracy, currency and consistency.
Verbatim wording from the response “• A full audit of all residents’ care plans has been completed by the Regional Quality Team to ensure they are accurate, up-to-date, and consistent.” Source location Response from Avery Healthcare Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and operate a care-plan tracker with daily management checks and monthly care-record audits.
Verbatim wording from the response “• A Care Plan Tracker has been introduced. This is a live document which records all care plans required for each resident and the date they were last reviewed. This is checked daily by the Home Manager. The tracker is completed and reviewed in” Source location Response from Avery Healthcare Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train key staff in care planning, record-keeping and falls management, with refresher training scheduled for record accuracy, falls management and risk recognition.
Verbatim wording from the response “• All key staff have undergone additional training on care planning and record-keeping, with 100% compliance achieved for falls-related training. Refresher training is scheduled to address record accuracy, falls management, and risk recognition.” Source location Response from Avery Healthcare Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
Verbatim wording from the response “• Weekly Clinical Risk meetings are held within the Home, chaired by the General Manager and/or Deputy manager to analyse falls, accident and incidents, infections, admission, weight loss and medication reviews. Actions are agreed with timescales and ownership.” Source location Response from Avery Healthcare Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Resident of the Day programme to review care plans with keyworkers and respond to current risks.
Verbatim wording from the response “• A “Resident of the Day” programme is fully operational within the Home, involving a comprehensive review of a resident’s care plan with their keyworker to ensure it” Source location Response from Avery Healthcare Group
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12 Aug 2024 Mr David Thompson · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to open the four standard care plans during inpatient stay View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Priory Group
Remind staff to maintain four core care plans and review completion through daily dashboard checks and audits.
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AI-generated summary
Mr David Thompson · 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
Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to open the four standard care plans during inpatient stay
Wider context from the report “6. There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay.
” Source location Mr David Thompson · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to maintain four core care plans and review completion through daily dashboard checks and audits.
Verbatim wording from the response “Issue a reminder to all staff regarding the expectation that all patients have the four core care plans in place throughout the hospital admission.” Source location Response from Priory Group
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10 Jul 2024 Richard Michael Fitzgerald · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to escalate inability to consistently follow the SALT care plan and obtain a contingency care plan View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Serencroft
Establish escalation guidance identifying relevant professionals, care-review involvement and risk-management planning when safe care is difficult to provide.
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Serencroft
Monitor adherence to care plans and refer behavioural barriers to external professionals for care-plan adaptation.
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Serencroft
Review residents with swallowing difficulties and establish robust assessments capturing barriers to prescribed care.
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Serencroft
Meet with all staff to share inquest findings and reinforce escalation and documentation of care concerns.
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Serencroft
Use clinical review meetings to identify delivery difficulties and trigger re-referrals to relevant professionals.
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Serencroft
Hold fortnightly clinical reviews to identify high-risk residents, escalate concerns and notify relevant professional teams and funding authorities.
View source
Serencroft
Ensure clinical leads, managers or qualified senior staff attend SALT assessments and reviews and promptly flag changes.
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Richard Michael Fitzgerald · 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
Richard Michael Fitzgerald, a nursing home resident with Alzheimer’s dementia, died in hospital on 26 June 2023 after choking on food and suffering a catastrophic hypoxic brain injury. Concerns included the failure to develop and implement a sufficiently robust care plan addressing unsafe food access and supervision, failure to follow the emergency choking protocol, and an insufficiently thorough care home investigation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate inability to consistently follow the SALT care plan and obtain a contingency care plan
Wider context from the report “1. The Care Home staff were aware that the SALT care plan could not be consistently followed in terms of close supervision , but did not discuss this with the SALT team to ensure that a contingency care plan could be put into place .
” Source location Richard Michael Fitzgerald · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish escalation guidance identifying relevant professionals, care-review involvement and risk-management planning when safe care is difficult to provide.
Verbatim wording from the response “2. An Escalation to signpost the management team and leadership team at Gable Court, in particular if they are experiencing challenges with any resident in providing safe care. This includes which professionals should be contacted and involved in the residents care review. This also includes a risk management plan to support the home in minimising the risk of deterioration in the resident’s physical and mental wellbeing.” Source location Response from Serencroft
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor adherence to care plans and refer behavioural barriers to external professionals for care-plan adaptation.
Verbatim wording from the response “4. Ensure that all care plans are being followed and monitoring this, ensuring that difficulties in following care plans due to Residents behaviours are fed back to external professionals so that these can be adapted to ensure the Residents are safe and their needs are being met.” Source location Response from Serencroft
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review residents with swallowing difficulties and establish robust assessments capturing barriers to prescribed care.
Verbatim wording from the response “• The Senior management team, alongside a specialist Independent Consultancy team have reviewed every resident care needs, with swallowing difficulties. They have ensured” Source location Response from Serencroft
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with all staff to share inquest findings and reinforce escalation and documentation of care concerns.
Verbatim wording from the response “• Meetings are taking place with the whole staff team, to share the findings from the Inquest. These have been transparent and used as a learning opportunity for staff to understand, the importance of escalating concerns back to the practitioners that prescribed the resident’s care. These meetings will continue over the next couple of weeks, until all staff have been shared lessons learnt. We anticipate that we should have met with all the staff by the end of July ’24.” Source location Response from Serencroft
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use clinical review meetings to identify delivery difficulties and trigger re-referrals to relevant professionals.
Verbatim wording from the response “• Clinical review meetings that take place are specifically capturing any difficulties staff are experiencing in delivering safe, effective care and these will be triggered for a re-referral to the relevant professionals. This is an on-going piece of work.” Source location Response from Serencroft
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold fortnightly clinical reviews to identify high-risk residents, escalate concerns and notify relevant professional teams and funding authorities.
Verbatim wording from the response “• Clinical review meetings will take place every 2 weeks that will identify all high-risk residents and pick up on any barriers in delivering safe/ effective care. If any concerns are noted these will be escalated to the relevant professional team as well as the funding authority.” Source location Response from Serencroft
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure clinical leads, managers or qualified senior staff attend SALT assessments and reviews and promptly flag changes.
Verbatim wording from the response “• The Clinical lead / or home manager will ensure they are in attendance of any SALT assessments / reviews. If they are not available then it will always be a qualified nurse of senior carer that attends the review, to ensure any changes are flagged immediately to the SALT team.” Source location Response from Serencroft
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27 Jun 2024 Norman Leadbeater · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Insufficient care-plan detail for safe administration of thickened fluids View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Norman Leadbeater · 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
Norman Leadbeater, who had advanced Parkinson’s disease, vascular dementia and presumed liver cancer, developed aspiration pneumonia after being advised to have thickened fluids and died on 14 January 2024. Concerns were identified that his prescribed thickener was not listed on the Medication Administration Record and that his care plan lacked sufficient detail for staff to administer thickened fluids safely and correctly. A recommended audit of medication records had still not been completed four and a half months later, and no completion timescale was provided at the inquest.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient care-plan detail for safe administration of thickened fluids
Wider context from the report “Mr Leadbeater had been in receipt of domiciliary care from Evolve Services since October 2023. The care included the administration of medication. When a concern was raised that the carers had not been thickening fluids appropriately, the Community Commissioning Team at Bury Council undertook an investigation and found that the prescribed thickener was not listed on the Medication Administration Record (MAR) and that the care plan in place for Mr Leadbeater did not contain sufficient detail for care staff to safely and correctly administer thickened fluids .
In February 2024 and following its investigation into the concerns regarding Mr Leadbeater’s care, Bury Council Community Commissioning Team recommended that Evolve Services undertake a number of remedial actions. This included an immediate management audit of MAR for those service-users in receipt of medication support and liaison with GPs and Pharmacists to ensure that the medication listed for each service-user is up to date and accurate.
The concern had that four and half months since the recommendation was made, Evolve Services have not yet completed the management audit of MAR for those service users in receipt of medication support. The representative from Evolve Services who attended the inquest was unable to provide the Court with a timescale for completion of this work or the number of service users this affects.
” Source location Norman Leadbeater · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide enhanced medication, SALT, Care Certificate and related training, including annual refresher training.
Verbatim wording from the response “The Care Plans have been redefined inclusive of more details around the client's needs, choices and preferences, refer to attachment 2, also the training resources have been greatly updated, with an external training” Source location Response from Evolve
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redefine care plans to include greater detail about clients’ needs, choices and preferences.
Verbatim wording from the response “The Care Plans have been redefined inclusive of more details around the client's needs, choices and preferences, refer to attachment 2, also the training resources have been greatly updated, with an external training” Source location Response from Evolve
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16 Apr 2024 Edith Jane ALDEN · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Norfolk Care Homes
Revise care plans and risk assessments to provide person-focused, consistent falls-risk management guidance.
View source
Norfolk Care Homes
Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
View source
Norfolk Care Homes
Implement monthly care-plan and risk-assessment audits covering at least 10% of the home.
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AI-generated summary
Edith Jane ALDEN · 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
Edith Jane Alden, a resident assessed at very high risk of falls, left a communal area unnoticed and unsupervised on 13 September 2021, fell in the garden and suffered severe head injuries. She died on 25 September 2021. Concerns included unclear and inconsistent care plans and risk assessments, insufficient supervision and staffing, and the use of unlocked communal-area access for residents at very high risk of falls.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments
Wider context from the report “1. Care Plans and Risk Assessments were not consistent and clear as to what steps were required to mitigate the risks of Mrs Alden falling.
” Source location Edith Jane ALDEN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise care plans and risk assessments to provide person-focused, consistent falls-risk management guidance.
Verbatim wording from the response “Care plans and risk assessments were fully reviewed and revised. Working with an external consultancy for guidance and advice we changed the structure and wording of our care plans to better reflect a person focused approach with a higher emphasise of risk management embedded within these documents.” Source location 2024-0196 Response from The Limes Care Home
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
Verbatim wording from the response “Policies and procedure reviews
Policies and procedures are continuously reviewed as part of our development as a company. Special emphasis has been given to any of our policies linked to falls, including environmental factors, individual risks, actions to be taken to improve staff guidance around understanding and interventions required to mitigate risks where possible.” Source location 2024-0196 Response from The Limes Care Home
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement monthly care-plan and risk-assessment audits covering at least 10% of the home.
Verbatim wording from the response “Auditing care plans and risk assessments continue to be reviewed on a monthly basis as a minimum or when there is a significant change. Care plan audits have been completed with regional management support, and is now set as 10% of the home each month, being completed by the management team. This includes all aspects of the care plan including risk assessments, Mental Capacity assessments, front page, planned care, photo etc.” Source location 2024-0196 Response from The Limes Care Home
Open published response
8 Mar 2024 Rose Mary Hollingworth · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to properly complete Care & Support plans without significant errors View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Rose Mary Hollingworth · 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
Rose Mary Hollingworth, a frail woman with significant co-morbidities, was found unresponsive at home on 3 January 2022 after a carer left without carrying out welfare checks or providing care. She was admitted to hospital and died the following day from a spontaneous intracerebral haemorrhage. The concerns included failures to provide suitably trained and competent carers, supervise and manage carers, maintain an accurate care and support plan, and monitor the care agency.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to properly complete Care & Support plans without significant errors
Wider context from the report “(3) The Care & Support plan was not properly completed and contained significant errors .
” Source location Rose Mary Hollingworth · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve care assessments through supervisor retraining, specialist risk assessments and requests to the local authority for updated support plans when additional needs are identified.
Verbatim wording from the response “We have not been made aware that there were significant errors with the care assessment completed by HomeDot Care and are not sure if the above is in reference to HomeDot Care’s care assessment. However, we have continued to improve upon the care assessment planning process and we have done this by:” Source location Response from HomeDot Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing monitoring and audit arrangements are sufficient to oversee commissioned providers’ quality and safety.
Verbatim wording from the response “Adult Social Care have a dedicated team of 8 people who are employed to manage their contracts, this includes checking the quality of our providers who we commission with, ensuring they are delivering on their agreed key performance indicators. The team work alongside other teams to develop a holistic understanding of a provider. This includes social workers, occupational therapists, health colleagues and contract managers from other local authorities.” Source location Response from Islington
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The organisation had not been made aware that its care assessment contained significant errors.
Verbatim wording from the response “I. The care and support plan was not properly completed and contained significant errors” Source location Response from HomeDot Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No evidence was found that the concerns identified in the prevention of future death report remain.
Verbatim wording from the response “Given the action already taken by the Commission, we are reassured that HomeDotCare Limited have responded appropriately in response to the death of Rose Hollingworth. We have not seen evidence to suggest the concerns mentioned in section 5 of the regulation 28 report remain.” Source location Response from Care Quality Commission
Open published response
8 Feb 2024 Jake Brian BAKER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Inadequacy of pathway plans for care leavers View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Surrey County Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Care Quality Commission
Roll out the formal local-authority assessment programme, including assessing Surrey County Council and using reported concerns to inform that assessment.
View source
Surrey County Council
Deliver updated pathway plan training through a rolling programme for personal advisers.
View source
Surrey County Council
Provide pathway plan surgeries across relevant teams to support timely completion and practice guidance.
View source
Surrey County Council
Audit pathway plans and disseminate resulting learning across the service to improve practice.
View source See 1 more action
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AI-generated summary
Jake Brian BAKER · 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
Jake Baker, who had learning disability and type 1 diabetes, developed diabetic ketoacidosis while staying with his family and died at home on 31 December 2019. The report identified concerns about inadequate pathway planning, risk assessment, information-sharing, diabetes support and advice to his family, as well as failures to assess his capacity and ensure appropriate care-leaver support.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequacy of pathway plans for care leavers
Wider context from the report “a.) The issues surrounding the inadequacy of Jake’s pathway plan have not been addressed comprehensively in the last 4 years . Training for personal advisers is not mandatory and is only now being rolled out. The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation.
” Source location Jake Brian BAKER · Prevention of Future Deaths report
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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 Roll out the formal local-authority assessment programme, including assessing Surrey County Council and using reported concerns to inform that assessment.
Verbatim wording from the response “Between May and November 2023, CQC completed 5 pilot local authority assessments, to test the associated assessment framework, methods and processes. In December 2023, CQC commenced a rollout of its formal local authority assessment programme.” Source location Response from Care Quality Commission
Open published response
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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 Deliver updated pathway plan training through a rolling programme for personal advisers.
Verbatim wording from the response “The current training content for personal advisers was updated in 2024 with a rolling programme of training throughout the year. In addition, the pathway plan surgeries are in place across the Looked After Teams which also extend to social workers in the Safeguarding Adolescents Teams to ensure timely completion of pathway plans whilst providing advice and guidance on the content of the pathway plan.” Source location Response from Surrey County Council
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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 Provide pathway plan surgeries across relevant teams to support timely completion and practice guidance.
Verbatim wording from the response “The current training content for personal advisers was updated in 2024 with a rolling programme of training throughout the year. In addition, the pathway plan surgeries are in place across the Looked After Teams which also extend to social workers in the Safeguarding Adolescents Teams to ensure timely completion of pathway plans whilst providing advice and guidance on the content of the pathway plan.” Source location Response from Surrey County Council
Open published response
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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 Audit pathway plans and disseminate resulting learning across the service to improve practice.
Verbatim wording from the response “SCC has a well-developed audit process and pathway plans are audited as part of that activity within the Looked After Children and Care Leavers service with any learning arising disseminated across the service to further improve practice.” Source location Response from Surrey County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation At the time of Mr Baker’s death, CQC lacked statutory powers to assess Surrey County Council or other local authorities.
Verbatim wording from the response “At the time of Mr. Baker’s death, CQC did not have any statutory powers in relation to the assessment of Surrey County Council or any other local authority.” Source location Response from Care Quality Commission
Open published response
15 Jan 2024 Nadia Wyatt · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3
Lack of bespoke care plans tailored to individual needs View source Failure to include key current clinical information in care plans View source Failure to include risk management and contingency planning in care plans View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Nadia Wyatt · 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
Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of bespoke care plans tailored to individual needs
Wider context from the report “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer.
(2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale.
(3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history.
(4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan.
(5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was.
(6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists.
(7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission.
(8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well.
” Source location Nadia Wyatt · Prevention of Future Deaths report
Open source report × 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 include key current clinical information in care plans
Wider context from the report “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer.
(2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale.
(3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history.
(4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan.
(5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was.
(6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists.
(7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission.
(8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well.
” Source location Nadia Wyatt · Prevention of Future Deaths report
Open source report × 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 include risk management and contingency planning in care plans
Wider context from the report “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer.
(2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale.
(3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history.
(4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan.
(5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was.
(6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists.
(7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission.
(8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well.
” Source location Nadia Wyatt · Prevention of Future Deaths report
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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 Implement the International Fundamentals of Care Framework in urgent and inpatient care, including its principles in Newman’s care-planning form.
Verbatim wording from the response “Response:
The Trust’s Urgent Care and Inpatient Care Unit is implementing a new initiative ‘International Fundamentals of Care Framework’, which is a nursing framework that supports transition and care planning based on trustworthy relationship, integration of care and context of care. The Home Treatment Team in Mid and South have added the framework principles to the Newman’s form that is given to patients to develop and assist with their view and planning of their care and treatment needs. The Newman’s form is based on the Newman’s model of care, which encourages individuals to be involved and interact with their health needs.” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Admission Checklist to support care planning, timely escalation and referrals, and reduce missed actions.
Verbatim wording from the response “The Admission Checklist in place will also support staff to plan care, escalate required support and referrals in a timely way, and reduces risk levels in respect of avoidance of actions being missed.” Source location Response from Essex Partnership NHS
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.