2 Jun 2026 Francis Leech · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Lack of staff understanding of the importance of updating care and behavioural support plans 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. 1
Adept Care Homes Limited
Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.
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Francis Leech · 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
Francis Leech, who had advanced dementia and other significant medical conditions, died on 26 August 2024 after a decline following severe facial injuries inflicted by another care home resident. The principal concerns were that the resident’s aggressive behaviour and associated risks were not properly reflected in updated care and behavioural support plans, and that management and the subsequent internal investigation failed to identify or address these deficiencies.
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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 staff understanding of the importance of updating care and behavioural support plans
Wider context from the report “The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan ; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated.
” Source location Francis Leech · 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 Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.
Verbatim wording from the response “Following the conclusion of the Inquest into Mr Leech’s death, a further instruction was issued to the Home management and senior care team reaffirming the expectations in relation to the review and amendment of Behaviour Support Plans and the introduction of supporting risk assessments in reflection of lessons learnt. We would also note that a new Home Manager and Care Manager are now in place with oversight of the Home following the incident involving Mr Leech.” Source location Response from Adept Care Homes (Bowood Court)
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1 Aug 2025 Margaret Dorothy MEDLICOTT · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Lack of proper staff training in risk assessment and care planning 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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Margaret Dorothy MEDLICOTT · Prevention of Future Deaths report
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Report summary
Margaret Dorothy Medlicott, who lived with dementia, sustained a severe head injury after being deliberately pushed by another resident at Haresbrook Park Care Home on 23 April 2020. She died in hospital from complications of that injury on 3 May 2020. Concerns included the admission of residents despite agreed restrictions, failures to complete proper risk assessments and care plans, and whether staff were trained and supported to question unsafe decisions.
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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 proper staff training in risk assessment and care planning
Wider context from the report “2) Despite being aware of concerns about the behaviour of both Mrs. Medlicott and the other resident both before and shortly after their respective admissions to the care home, staff there failed to complete proper risk assessments and care plans addressing the risks posed by each of them to themselves and to others. Those failures were accepted, but the inquest heard no satisfactory explanation as to why they might have occurred. There is therefore concern that the staff concerned, and perhaps other staff at the care home, have not received proper training in how to carry out these important tasks .
” Source location Margaret Dorothy MEDLICOTT · 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 Train staff in PCS and mandatory care-documentation subjects, with refresher or repeat training where standards are not met.
Verbatim wording from the response “All staff are trained on PCS at their induction. This training is conducted by review of videos and use of the system in 'TUTOR' mode.” Source location Response from Capital Care 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 Complete organisation-wide audits of care documentation to establish baselines and identify lessons for training, tools, governance and further audit scheduling.
Verbatim wording from the response “To ensure organisation oversight, the organisation's compliance manager is completing a full audit of all Homes care documentation. This was completed for Haresbrook Park Care Home on 22 August 2025. The results have been shared with the Home Manager and all staff will be addressed at a mandatory Home-wide meeting on 24 September 2025. Beyond organisation oversight, the audit has allowed the compliance manager to obtain each Home's baseline and then work to generate an” Source location Response from Capital Care 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 Existing electronic systems, training, audits and governance are considered sufficient to support robust risk assessments and care documentation.
Verbatim wording from the response “The Home is now benefitting from a fully integrated electronic care system, namely PCS (Person-Centred Software). The maintaining of care documentation, including risk assessments, in one place allows for one point of reference for all members of staff.” Source location Response from Capital Care Group
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29 Jul 2025 Joan WHITWORTH · Prevention of Future Deaths report Northumberland
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Concerns raised 1
Lack of staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment View source
This report raised 7 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
Hill Care Group
Develop and deliver refresher training on assessments for nurses and senior care assistants, repeat it on a three-year cycle, and monitor completion electronically.
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Joan WHITWORTH · 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
Joan Whitworth, a resident of Oaks Care Home with advanced dementia and a DNACPR order, died there on 3 March 2023 after choking caused by massive aspiration. Concerns included the adequacy of the speech and language assessment, staff training and induction, delayed intervention when she showed signs of choking, and food being prepared contrary to her diet plan.
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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 staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment
Wider context from the report “3. Training
I am concerned that a Senior Care Assistant could not recall having received any formal training in the preparation of Care Plans, no training on MUST or calculating BMI yet was completing care plans and documents. I am further concerned than when the Senior Care Assistant completed the Nutritional Risk Assessment, on three dates the deceased was identified as high risk yet there was no referral to the GP, dietician or consideration of referral to SALT. I am concerned that in the absence of training there was not an understanding of the assessment .
” Source location Joan WHITWORTH · 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 Develop and deliver refresher training on assessments for nurses and senior care assistants, repeat it on a three-year cycle, and monitor completion electronically.
Verbatim wording from the response “2a. We can confirm that the Senior Care Assistant had received training as she had previously undertaken a 12 week Care Home Assistant Practitioner (CHAP) course. However, we acknowledge that measures were not in place to verify knowledge, nor was a schedule of refresher training in place to ensure she felt confident to carry out assessments and develop care plans. As a result of this, we have reviewed the content of the training that we deliver and have a plan for our internal quality improvement team to deliver training on assessments to nurses and senior care assistants as a refresher and build this into our training programme to be repeated on a 3 year cycle. We will monitor this schedule using our electronic training platform.” Source location Response from Hill Care 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 The measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.
Verbatim wording from the response “We trust that these measures are sufficient to satisfy your concerns.” Source location Response from Hill Care Group
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20 Dec 2024 Edith Theresa PYE · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure of care staff to read and understand key care-plan requirements 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
Care UK
Provide supervisory training to the entire care team on reading and understanding care plans and relevant Care UK e-learning requirements.
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Care UK
Introduce key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
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Care UK
Complete individual moving-and-handling supervision in which senior staff observe junior colleagues’ compliance with care plans and policies.
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Edith Theresa PYE · 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 Theresa PYE sustained a fracture after rolling from her bed at Chandler Court Care Home on 29 March 2024 while receiving personal care from one carer instead of the required two. She underwent an above-knee amputation, developed a chest infection and pulmonary emboli, and died at the care home on 28 April 2024. Concerns included ambiguous care-plan and handover information, inadequate staff awareness and compliance, lack of auditing, and weaknesses in the internal 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 of care staff to read and understand key care-plan requirements
Wider context from the report “2) The carer who provided personal care to Mrs. Pye on the occasion when she fell from her bed on 29.3.24 knew that he should have done so with a colleague, but would regularly do so on his own. He had never himself read Mrs. Pye’s care plan , and it became clear that two other members of staff who provided evidence at the inquest were also unaware of some key aspects of the care plan . Furthermore, other staff were aware that he would often provide care to Mrs. Pye on his own, but no-one had reported this to senior staff or taken any action to try to stop it happening;
” Source location Edith Theresa PYE · 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 supervisory training to the entire care team on reading and understanding care plans and relevant Care UK e-learning requirements.
Verbatim wording from the response “Since the Inquest hearing, the entire care team at Chandler Court has received supervisory training highlighting the importance of reading and understanding care plans and reiterating the relevant components of the Care UK e-learning programme.” Source location 2024-0706 - Response from Care UK Ltd
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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 key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
Verbatim wording from the response “Additionally, Chandler Court now involves key workers who, along with the shift leads, are responsible for having a sound knowledge of the residents’ care needs and disseminating key information to their teams.” Source location 2024-0706 - Response from Care UK Ltd
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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 individual moving-and-handling supervision in which senior staff observe junior colleagues’ compliance with care plans and policies.
Verbatim wording from the response “Additionally, individual supervision has been completed for moving and handling whereby senior members of the care team observe junior colleagues to ensure correct compliance with Care Plans and policies. Refresher training on moving and positioning has also been carried out. This training is currently at 90% compliant and is expected to be 100% compliant by close of business tomorrow; 14 February 2025. This refresher training will further assist colleagues with understanding the importance of following individual care plans and reporting bad practices, or any other concerns that may pose a risk to a resident or colleague as per Care UK policy.” Source location 2024-0706 - Response from Care UK Ltd
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30 Aug 2024 Wendy Ann AFFORD · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Inadequate training in the use of 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Wendy Ann AFFORD · 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
Wendy Ann Afford was bedbound and living alone with a package of care before developing worsening pressure damage and an infected pressure ulcer. After hospital treatment and discharge to a care home, her health declined and she died on 15 November 2023. Concerns included inadequate skin-integrity risk assessment and monitoring, incomplete repositioning records, unclear compliance with care plans, insufficient management oversight, and possible inadequate staff training.
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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 Inadequate training in the use of care plans
Wider context from the report “5. Given these numerous difficulties there is a concern that care staff are not properly trained in the use of care plans , record keeping and importance of monitoring skin integrity.
” Source location Wendy Ann AFFORD · Prevention of Future Deaths report
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11 Aug 2023 Doris Irene URCH · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Staff unfamiliarity with risk assessments and care plans View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Doris Irene URCH · 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
Doris Irene Urch, aged 90, fell at a care home on 6 February 2023 after support was not offered while she was ambulating. She sustained an acute left frontal intracranial haemorrhage and died on 28 February 2023. Concerns included inadequate fall-risk assessment and care planning, staff unfamiliarity with the care plan, failure to update it after an earlier fall, and inadequate preservation of historical care plans.
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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 Staff unfamiliarity with risk assessments and care plans
Wider context from the report “(3) Staff seemed unfamiliar with the risk assessment/care plan , which I consider more of a systemic problem. It is unclear if/when care plans were reviewed by staff.
” Source location Doris Irene URCH · Prevention of Future Deaths report
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14 Feb 2022 Norman Barnes · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure of care staff to know the care-plan dietary recommendations for residents with swallowing difficulties View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Norman Barnes · 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 Barnes died after choking on food while eating lunch at Ashley Gardens Care Centre. His meal was not prepared as minced or moist, contrary to the recommendation in his SALT assessment and care plan. Staff were aware of his Parkinson’s disease but were not aware of, or did not refer to, key information in his care plan and risk assessments.
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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 of care staff to know the care-plan dietary recommendations for residents with swallowing difficulties
Wider context from the report “Evidence was given by health care staff who were responsible for personal care which included service of and delivery of meals at Ashley Gardens Care Centre that:
(1) Whilst they were aware Mr Barnes had a background of Parkinson’s disease and this by its very nature often causes difficulties in chewing and swallowing, they were not aware of the contents of the care plan which reflected the recommendations of the SALT assessment for a ‘moist and minced’ diet for this resident .
(2) Care Home staff who attend to patients who should be referring to key information contained within care plans and risk assessments to understand and effectively deliver a patient’s daily needs and requirements had not and it was of concern to note that they were not fully aware of important information contained in these documents.
” Source location Norman Barnes · Prevention of Future Deaths report
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7 Jul 2021 Dorothy Seekings · Prevention of Future Deaths report Warwickshire
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Concerns raised 1
Failure of staff to be aware of care plan contents View source
This report raised 2 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. 2
Crosscrown Limited
Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.
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Crosscrown Limited
Provide new staff with supernumerary induction, CareDocs training and a role-dependent buddying period.
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Dorothy Seekings · 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
Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.
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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 of staff to be aware of care plan contents
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident.
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Source location Dorothy Seekings · 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 Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.
Verbatim wording from the response “The two key changes are the acceleration of the implementation of a digital care management software system called CareDocs. This was being gradually introduced into the Homes run by Crosscrown during the Summer of 2019 but the events of August 8th accelerated the implementation of the new system and it is now in place in all Crosscrown Homes including Clifton Court and has been for some time. The digital CareDocs system allows Care Plans to be created that meet the specific requirements of individual service users and it allows the creation of a care plan reflective of the needs and preferences of the individual user.” Source location 2021-0230-Response-from-Crosscrown-Ltd_Published
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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 new staff with supernumerary induction, CareDocs training and a role-dependent buddying period.
Verbatim wording from the response “Clifton Court has purchased a number of tablets to be given to each member of staff for their use and that is the usual device upon which information is recorded. It should be stressed that all nurses and carers have access to CareDocs. When a new member of staff joins the organisation they undergo a two week period of training for which time they are supernumerary and thereafter there is a “buddy” scheme which lasts from between two weeks and three months depending on the requirements of the individual member of staff. During that time the individual undergoes a detailed period of training into the CareDocs system.” Source location 2021-0230-Response-from-Crosscrown-Ltd_Published
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12 May 2017 Nasar AHMED · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure of school staff to familiarise themselves with pupils’ care plans View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Bow School Compass Wellbeing CIC
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
Compass Wellbeing CIC
Review school-nurse training requirements and deliver competency-framework retraining and IHCP training to staff.
View source
Compass Wellbeing CIC
Continue delivering specific IHCP training on a biannual basis.
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Compass Wellbeing CIC
Prepare a Partnership Agreement defining school and School Health Service responsibilities, including school liaison arrangements for IHCPs and review meetings.
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Compass Wellbeing CIC
Work with Tower Hamlets partners and head-teacher representatives to finalise and roll out the Partnership Agreement across schools.
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Compass Wellbeing CIC
Revise the asthma plan template and commence secure electronic sharing of individual asthma plans with schools and the School Health Service, supported by staff training.
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Bow School
Provide all staff access to pupils’ medical-needs information through electronic registers and require confirmation that key medical-needs and safeguarding policies are understood.
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Bow School
Attach Individual Health Care Plans and medical alerts to electronic pupil records and add allergy alerts to the cashless catering system.
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Bow School
Brief staff on pupils’ medical needs, provide recurring reminders and conduct Safeguarding Committee compliance spot checks.
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Bow School
Maintain and half-termly update prominently displayed registers of pupils with medical needs, including symptoms and key actions.
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Nasar AHMED · Prevention of Future Deaths report
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Report summary
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
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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 of school staff to familiarise themselves with pupils’ care plans
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion . The internal exclusion room (IER) supervisor had not done this for the pupils in the IER . Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Source location Nasar AHMED · 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 Review school-nurse training requirements and deliver competency-framework retraining and IHCP training to staff.
Verbatim wording from the response “CWB has also fully reviewed and identified the training received by school nurses and what they are required to receive in order to complete IHCPs in line with CWB's Competency Framework. The Competency Framework is a learning and development resource for nurses and this is completed upon their induction to the service. Re-training has been delivered in line with this Competency Framework. IHCP training has also been undertaken by all staff on 22 June 2017 in order to re-emphasise the role of a qualified nurse with reference to the guidance and the support of administering medication by non-” Source location Response from Compass Wellbeing
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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 delivering specific IHCP training on a biannual basis.
Verbatim wording from the response “Specific IHCP training will continue to take place on a bi-annual basis. The next scheduled training is for September 2017.” Source location Response from Compass Wellbeing
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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 Prepare a Partnership Agreement defining school and School Health Service responsibilities, including school liaison arrangements for IHCPs and review meetings.
Verbatim wording from the response “Following Nasar’s sad death CWB have prepared a Partnership Agreement between CWB and schools across the Borough of Tower Hamlets. This agreement sets out arrangements for support and training for education staff, as well as detailing the expectations across the organisational boundaries. Page 7 of the Agreement (copy enclosed) outlines the roles and responsibilities of the School Health Service and the school. It specifically requires that a member of staff will be identified who will liaise with the School Health Service. The identified school staff member is the person responsible for that child and who has” Source location Response from Compass Wellbeing
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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 Work with Tower Hamlets partners and head-teacher representatives to finalise and roll out the Partnership Agreement across schools.
Verbatim wording from the response “the appropriate levels of authority to agree possible actions generated from an IHCP and who is able to disseminate information regarding the child’s care across the school, including what to do in an emergency. The staff member will work to ensure support and consistency is provided by the school and School Health Service, particularly in relation to the creation of IHCPs and attendance at review meetings. CWB is currently working with the London Borough of Tower Hamlets Public Health and Education departments, as well as Tower Hamlets head teachers representatives, to finalise and roll out the agreements across all schools.” Source location Response from Compass Wellbeing
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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 the asthma plan template and commence secure electronic sharing of individual asthma plans with schools and the School Health Service, supported by staff training.
Verbatim wording from the response “Furthermore, as part of this partnership, CWB with the assistance of the respiratory clinical nurse specialist, has revised an asthma plan template for children and a process for sharing individual asthma plans with the school nursing service and schools has been commenced. A child’s individual asthma plan created by the GP/practice nurse or the specialist team will now be sent directly through to the School Health Service via secure generic email accounts. These email accounts are monitored on a daily basis. The plan will be attached to the child’s health record and an email sent to the relevant school nurse. Training has been given to our staff team.” Source location Response from Compass Wellbeing
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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 all staff access to pupils’ medical-needs information through electronic registers and require confirmation that key medical-needs and safeguarding policies are understood.
Verbatim wording from the response “The Coroner commented that school staff were encouraged to familiarise themselves with pupil’s care plans and required to do so for school excursions, but in other circumstances staff may not have been familiar with health needs of all pupils. In response to this the school now have a clear understanding between Compass Wellbeing, parents and pupils that information regarding a child’s medical needs will be shared with all staff on the basis that all staff need to have access to, and understanding of, this information. This information has been made more visible for staff as detailed below and policies and processes have been revised to reflect this common understanding, for example, all staff have access to the school’s electronic medical needs registers. The amended policies are due to be ratified by the Governing Body on the 12.07.17.” Source location Response from Bow School
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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 Attach Individual Health Care Plans and medical alerts to electronic pupil records and add allergy alerts to the cashless catering system.
Verbatim wording from the response “In addition, all IHPs are being scanned and attached to the relevant child’s electronic record (the SIMS profile) so that it can be viewed quickly by staff. An alert symbol has also been added to relevant pupils’ SIMS profiles so that it is immediately visible if a child has an IHP. Alerts have also been added to the school’s Cashless Catering System to flag students with allergies so that staff are aware of those children. Catering staff are encouraged to liaise with the relevant pastoral team or Compass Wellbeing to check if unsure and continue to challenge if they feel a pupil’s choice may place them at risk. There is also a procedure for catering staff to report concerns where children with allergies regularly seek to purchase food containing allergens.” Source location Response from Bow School
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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 Brief staff on pupils’ medical needs, provide recurring reminders and conduct Safeguarding Committee compliance spot checks.
Verbatim wording from the response “The school’s SENDCo will provide briefings to all staff for children with medical needs each September. Further briefings will be provided to all staff if a child with medical needs starts in year and all new staff receive the briefing as part of their induction if they do not start in September or if a child’s needs change following a review. All staff received a briefing on the pupils with medical needs on the 05.06.17 and will receive half-termly reminders. Those reminders will also require they review their ‘class context sheets’ to ensure medical information for students is up to date. The Safeguarding Committee will undertake spot checks to ensure compliance, the first of which will be completed by the 04.07.17.” Source location Response from Bow School
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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 and half-termly update prominently displayed registers of pupils with medical needs, including symptoms and key actions.
Verbatim wording from the response “Since the Inquest the Deputy Head teacher responsible for safeguarding has reviewed all information held in respect of children with medical needs to ensure that the IHP register, Asthma Register, Allergies Register and Other conditions register is accurate. The registers are now discreetly displayed by type of need, the pupil’s name and photograph, symptoms and key actions in each of the staff common areas, the kitchen, learning support areas and internal exclusion room. These are reviewed and updated on a half-termly basis.” Source location Response from Bow School
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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 Schools share responsibility for preparing and updating IHCPs and ensuring an appropriate school representative attends review meetings.
Verbatim wording from the response “CWB recognises and understands the importance of the collaborative working arrangements involved in preparing IHCPs and the ongoing support, communication and processes for children in schools with medical conditions. The Supporting Medical Needs Policy clearly sets out that a number of organisations have roles and responsibilities and that school staff, school nurses and parents must work in partnership to ensure that the needs of pupils with medical conditions are met effectively.” Source location Response from Compass Wellbeing
Open published response
14 Jan 2016 Lee Joseph Rigby · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure of staff training to establish clear understanding of resident-observation risks View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lee Joseph Rigby · 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
Lee Joseph Rigby, who had Parkinsonism, swallowing difficulties and other disabilities, died in hospital on 7 October 2015 after choking while eating a sausage roll at his residence. The concerns included him being left unobserved while the sole support worker answered the door, staff not fully understanding the requirement to visually observe him while eating and drinking, and training and procedures not adequately addressing these risks.
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 of staff training to establish clear understanding of resident-observation risks
Wider context from the report “During the Inquest evidence was heard that
1. During the Inquest evidence was heard that
i. The support workers do not have keys to the premises at ████████ so that in circumstances where there was only one support worker in the premises that support worker would have to answer the door to allow another support worker entry to the premises. In those circumstances a resident requiring visual monitoring or observation would be left alone and unobserved.
Evidence was heard during the course of the Inquest that one of the two support workers could leave the premises during the course of the day so that access to the premises would be required by a support worker either at the commencement of her shift or whenever the support worker left the premises at times when there would only be one support worker in the premises.
It was accepted that if every support worker had a key to the premises the sole support worker in the premises would not have to be disturbed to answer the door and a resident, like Mr Rigby, who would not be left unattended at meal times, when Mr Rigby had to be observed at all times, and at any other times whenever he was eating and drinking.
ii. Evidence was heard from the support staff that they did not fully understand that monitoring and observing Mr Rigby at all times when he was eating and drinking meant that they should visually observe him at those times.
Evidence was also given by members of the support staff that if the telephone rang and there was a need to discuss a resident or something of a private and confidential nature a support worker, who may be the only support worker in the premises at the time, would go into another room to talk in a private and confidential manner, leaving a resident alone and unobserved during the course of the telephone conversation.
The support staff did not understand the significance of the words used in the Health Action Plan and Management Guidelines that Mr Rigby should be observed at all times whilst he was eating and drinking and they did not fully understand the significance of observing him in relation to the risks identified in the Plan and Guidelines.
iii. The internal training and procedures provided by United Response to the support staff and the procedures in place to address the risks identified by the Health Action Plan and Management Guidelines did not address the risks identified by the Plan and the Guidelines, particularly in relation to a clear understanding by the support staff with regard to observing a resident .
” Source location Lee Joseph Rigby · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.