22 Jul 2024 Omar Abdi Ahmed · Prevention of Future Deaths report East London
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Concerns raised 1
Failure of domiciliary care to provide essential cleaning, personal care and meal support View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care East London NHS Foundation Trust London Borough of Newham Sunlight Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
London Borough of Newham
Meet with Sunlight Care to address and mitigate risks to residents receiving its care and support.
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London Borough of Newham
Implement and continue the quality improvement plan for Sunlight Care.
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London Borough of Newham
Provide enhanced monitoring of all residents receiving care and support from Sunlight Care.
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London Borough of Newham
Conduct welfare checks for Sunlight Care residents who live alone.
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London Borough of Newham
Develop an escalation procedure for partners to flag high unmitigated risk or differing risk assessments, including reviews of no-reply and refusal-of-care protocols.
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Sunlight Care
Update safeguarding, notification, response and monitoring policies, including 24-hour reporting, 48-hour response expectations and proactive follow-up.
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Sunlight Care
Implement an eight-week programme of revised-policy communication and staff training covering self-neglect, safety, nutrition, risk, capacity, safeguarding and multidisciplinary collaboration.
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Sunlight Care
Implement new inter-agency communication and escalation strategies for timely safeguarding escalation across teams.
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Sunlight Care
Introduce regular multidisciplinary reviews for cases involving self-neglect, incorporating physical, mental and social wellbeing in decision-making.
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Department of Health and Social Care
Publish the first part of the Care Workforce Pathway for adult social care.
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Department of Health and Social Care
Develop the Care Workforce Pathway to work alongside existing standards and competency frameworks.
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Omar Abdi Ahmed · 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
Omar Abdi Ahmed, who had significant comorbidity and bilateral lower-limb amputations, was found unresponsive and severely hypothermic at home on 15 November 2023 after receiving domiciliary and district nursing care. He died in hospital on 20 November 2023; the inquest concluded that hypothermia, with pneumonia and ischaemic heart disease contributing, was the medical cause of death. Concerns included poor communication between care organisations, shortcomings in district nursing oversight, and domiciliary care arrangements that did not adequately address his personal care, nutrition, cleaning, and heating needs.
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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 domiciliary care to provide essential cleaning, personal care and meal support
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café .
” Source location Omar Abdi 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 Meet with Sunlight Care to address and mitigate risks to residents receiving its care and support.
Verbatim wording from the response “2. Action: A meeting with the Sunlight Care to ensure that any risks to residents they provide care and support to is mitigated. This will be achieved by the following actions
By who: Strategic Safeguarding and Quality Assurance and
By when: Meeting held on 17/07/24 although the QIP is ongoing” Source location Response from London Borough of Newham
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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 continue the quality improvement plan for Sunlight Care.
Verbatim wording from the response “2. Action: A meeting with the Sunlight Care to ensure that any risks to residents they provide care and support to is mitigated. This will be achieved by the following actions
By who: Strategic Safeguarding and Quality Assurance and
By when: Meeting held on 17/07/24 although the QIP is ongoing” Source location Response from London Borough of Newham
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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 monitoring of all residents receiving care and support from Sunlight Care.
Verbatim wording from the response “• Enhanced monitoring of all residents Sunlight Care provide care and support to is in place” Source location Response from London Borough of Newham
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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 welfare checks for Sunlight Care residents who live alone.
Verbatim wording from the response “• Welfare checks of all residents Sunlight Care provide care and support to who live alone has taken place
By who: Commissioning Team” Source location Response from London Borough of Newham
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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 an escalation procedure for partners to flag high unmitigated risk or differing risk assessments, including reviews of no-reply and refusal-of-care protocols.
Verbatim wording from the response “4. Adult Social Care will lead on the development of an escalation procedure which will enable partners to flag cases where there is concern about a high level of unmitigated risk or differences of opinion about level of risk. This procedure will involve reviews of the following protocols:” Source location Response from London Borough of Newham
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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 Update safeguarding, notification, response and monitoring policies, including 24-hour reporting, 48-hour response expectations and proactive follow-up.
Verbatim wording from the response “In addition to updating and, where necessary amending our policies, we commenced an eight-week implementation programme on 5 August 2024. A summary of this programme setting out the topics of training, appears in Appendix A.” Source location Response from Sunlight 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 Implement an eight-week programme of revised-policy communication and staff training covering self-neglect, safety, nutrition, risk, capacity, safeguarding and multidisciplinary collaboration.
Verbatim wording from the response “We are committed to providing the highest standards of safety and care and wish to ensure that any lessons to be learnt from the circumstances of Mr Ahmed’s tragic death are identified and implemented as necessary within our agency. Alongside our engagement with the coroner’s investigation, we have conducted our own internal review process, updated our policies, commenced the implementation of a full programme of updated communication, consultation and training, and proactively liaised with the East London Foundation NHS Trust (‘the Trust’) and the London Borough of Newham (‘the Local Authority’).” Source location Response from Sunlight 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 Implement new inter-agency communication and escalation strategies for timely safeguarding escalation across teams.
Verbatim wording from the response “In addition, we attended a multi-agency discussion with the Local Authority and NHS Trust to discuss lessons learnt on 23 July 2024 and arranged a follow up on 4 September 2024. At the second meeting, the following actions were agreed to be undertaken within a twelve week time frame:” Source location Response from Sunlight 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 Introduce regular multidisciplinary reviews for cases involving self-neglect, incorporating physical, mental and social wellbeing in decision-making.
Verbatim wording from the response “3. We are introducing regular multidisciplinary reviews for cases involving self-neglect, allowing for a more holistic approach to care that includes input from a range of professionals. This will help ensure that all aspects of the client's well-being—physical, mental, and social—are considered in decision-making processes;” Source location Response from Sunlight 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 Publish the first part of the Care Workforce Pathway for adult social care.
Verbatim wording from the response “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.” Source location Response from DHSC
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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 the Care Workforce Pathway to work alongside existing standards and competency frameworks.
Verbatim wording from the response “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.” Source location Response from DHSC
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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 Formal interventions for capacitous clients depend on statutory agencies rather than the care provider.
Verbatim wording from the response “An element of Mr Ahmed’s Care and Support Plan was to facilitate community engagement and social interaction, which was important to Mr Ahmed. In circumstances where there is evidence of self-neglect and a client may not be making appropriate decisions concerning eating, cleaning, hearing and personal care, it is clear that this must be addressed by those involved in the client’s care. As the coroner is aware, Mr Ahmed had capacity and was therefore able to make his own decisions. This creates significant challenges for care providers, which are reliant upon working alongside the statutory agencies to make any formal interventions necessary.” Source location Response from Sunlight Care Group
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How this respondent position was interpreted
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PFD Monitor interpretation Existing DoLS safeguards do not apply to people living at home, and the proposed LPS framework will not be implemented.
Verbatim wording from the response “The Local Authority has informed us that the LPS framework will no longer be implemented. As a result, they will continue to rely on the existing DoLS framework, which does not apply to individuals living at home. We understand that the new LPS framework would have provided those involved in Mr Ahmed’s care with the opportunity for assessment of his ability to make appropriate decisions in his own best interests. This is a challenge we trust will be remedied within new legislation.” Source location Response from Sunlight 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 Trust cannot comment on behalf of the local authority or domiciliary care company regarding their communication and care arrangements.
Verbatim wording from the response “4. The Trust is unable to comment on behalf of London Borough of Newham (‘LBN’) or the domiciliary care company. However, it can confirm that LBN and the Trust have systems in place which facilitate joint working to improve care for service users under both services.” Source location Response from ELFT
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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 commissioner and General Practitioner are expected to manage concerns about domiciliary care and the service user’s poor decision-making.
Verbatim wording from the response “The local authority, not the Trust commissioned the domiciliary care providers. Consequently, it is expected that the commissioner and the General Practitioner would manage concerns. However, as outlined in paragraph 8, Trust staff should be proactive when they witness concerns and arrange professionals’ meetings between agencies. This will be reviewed with staff over the next two months.” Source location Response from ELFT
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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 Employers have ultimate responsibility for ensuring health and care staff possess the necessary skills and competence.
Verbatim wording from the response “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.” Source location Response from DHSC
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31 Aug 2023 Donna Levy · Prevention of Future Deaths report East London
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Concerns raised 1
Domiciliary care visits failing to provide personal care View source
This report raised 4 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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Donna Levy · 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
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious 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 Domiciliary care visits failing to provide personal care
Wider context from the report “1. Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken . Ms Levy was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided . Carers had escalated to the local authority Ms Levy’s reluctance to accept personal care and raised safeguarding reports regarding Ms Levy’s living conditions.
” Source location Donna Levy · Prevention of Future Deaths report
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5 Dec 2022 Richard Thomas SHANNON · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to provide required personal hygiene and catheter care during home visits View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Central London Community Healthcare NHS Trust Kapital Care (UK) Limited University College London Hospitals NHS Foundation Trust
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
Central London Community Healthcare NHS Trust
Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.
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Central London Community Healthcare NHS Trust
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
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Central London Community Healthcare NHS Trust
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
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Kapital Care (UK) Limited
Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
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Kapital Care (UK) Limited
Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
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Kapital Care (UK) Limited
Complete manual-handling, mobility-equipment and environmental assessments during initial visits.
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Kapital Care (UK) Limited
Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
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Richard Thomas SHANNON · 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 Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.
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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 provide required personal hygiene and catheter care during home visits
Wider context from the report “6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag .
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it.
In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
” Source location Richard Thomas SHANNON · 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 Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
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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 Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
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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 improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Verbatim wording from the response “• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.” Source location Response from Central London Community Healthcare
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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 manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
Verbatim wording from the response “• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.” Source location Response from Kapital Care
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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 Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
Verbatim wording from the response “• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.” Source location Response from Kapital Care
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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 manual-handling, mobility-equipment and environmental assessments during initial visits.
Verbatim wording from the response “• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.” Source location Response from Kapital Care (UK) Limited
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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 Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
Verbatim wording from the response “• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.” Source location Response from Kapital Care (UK) Limited
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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 Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Verbatim wording from the response “We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.” Source location Response from University College London Hospitals
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16 Nov 2017 Doreen Wilkins · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to provide the assessed duration of care 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. 1
James Thorburn
Include travel time between care assignments as a separate element in staff rotas.
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Doreen Wilkins · 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
Doreen Wilkins died in hospital at age 78 after a choking incident at home following a routine care visit that did not last for its full duration. The inquest raised concerns that care-visit rotas did not allow travel time, potentially causing carers to arrive late, shorten visits, and provide less care than assessed or commissioned.
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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 provide the assessed duration of care
Wider context from the report “In the course of the inquest I heard evidence to the effect that Comfort Call carers’ visits are scheduled in blocks via rotas which do not always allow for travel time between scheduled visits. The matters of concern arising from this are as follows:
1. An absence of any travel time allowance in such circumstances may cause a carer to arrive late for a time critical care visit (such as one where a client is to be supported with regular medication);
2. A carer may cut short his / her visit to one client to enable them to arrive at their next scheduled appointment on time;
3. In circumstances where a carer is cutting short a visit, the client in question does not receive the duration of care they have been assessed as requiring (or indeed which Comfort Call Ltd has been paid to provide) .
It is observed that Comfort Call Limited’s registration with the Care Quality Commission is contingent inter alia upon a requirement that the registered person must submit on the first day of every month to CQC a report showing:
“The actions that have been taken to ensure staff rotas are meeting the needs of service users including time critical calls and travel time between visits”.
” Source location Doreen Wilkins · 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 Include travel time between care assignments as a separate element in staff rotas.
Verbatim wording from the response “That said, this fact does not preclude the possibility that inadequate travel time in care worker rotas could risk an individual not having as much contact time with the care worker as they need. This fact had already been recognised by Tameside Borough Council and I am very pleased to report that following discussions with them, it has now been agreed that they will pay an additional sum for time spent travelling between care assignments under their contract, thereby allowing us to include travel time as a separate and discrete element in staff rotas, which we have now done. This effectively increases the amount of time care workers will be able to spend in direct contact with their service users, improving the quality of the service.” Source location 2017-0399-Response-by-Comfort-Call
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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 care call being shortened by a few minutes does not inherently mean that adequate care was not delivered.
Verbatim wording from the response “As well as the concerns around the delivery of critical care, your report also raised the issue of inadequate travel time and the related issue of care workers leaving assignments early to get to the next visit.” Source location 2017-0399-Response-by-Comfort-Call
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30 Dec 2016 Raymond David SHEPHERD · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to undertake both daily care visits View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Raymond David SHEPHERD · 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
Raymond David SHEPHERD had chronic ill health, severely limited mobility and a high risk of falls and self-neglect. In January 2016, care records noted repeated falls, poor appetite and a deterioration in his condition, but referrals to a GP or ambulance service were not made; he later sustained a femur fracture after a further fall and died in hospital on 30 January 2016. The principal concerns were poor care record-keeping, missed care visits, failure to escalate reported or observed falls and deterioration, and the absence of a mental capacity assessment.
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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 undertake both daily care visits
Wider context from the report “3. On some occasions both daily visits were not undertaken .
” Source location Raymond David SHEPHERD · Prevention of Future Deaths report
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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 alleged missed visits did not all occur: some were unscheduled, discontinued under the care plan, or cancelled by the individual.
Verbatim wording from the response “16th January (Saturday) – The most recent commissioning paperwork from Trafford Council dated 10.08.2015 does not schedule a tea visit on Saturday evenings.” Source location 2016-0467-Response-by-Human-Support-Group.pdf
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.