Recurring concern

Unreliable recording of significant incidents and disclosures

First to latest report 28 Dec 2014 — 8 Feb 2026

Reports that mention this concern
11
Times this concern has been raised
13
Stated actions linked to this concern
13

What this concern includes

Includes failures in care, custody or comparable safety processes to recognise and record significant incidents, disclosures and their material circumstances in the designated records used for ongoing care, safeguarding, review or risk management.

What is not included
  • Excludes general clinical or care-record deficiencies where no significant incident or safety-relevant disclosure is involved.
  • Excludes failures to investigate, escalate or learn from an incident after it has been reliably recorded.
  • Excludes generic staff training, auditing or governance deficiencies unless they directly impair recording of significant incidents or disclosures.
  • Excludes ordinary administrative events and routine care entries without a material safety incident or disclosure context.

Reports and published responses 11 reports

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

  1. Essex

    AI-generated summary

    Elise Kay Louise Sebastian · 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

    Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate recording of ligature incidents and risks

    Wider context from the report

    “3. There was poor communication between ward staff and vital information about self-harm and ligaturing was not handed over on shift change. It was undisputed that Elise tied 12 Ligatures between 7ᵗʰ and 14ᵗʰ April and ████████ on 15 April. The Datix incident recording gave minimal details and only the ligatures from the 13ᵗʰ and 14ᵗʰ were recorded on the whiteboard in the nurse’s office. ”

    Source location

    Elise Kay Louise Sebastian · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement Trust-wide incident-reporting improvements covering form revisions, risk-assessment prompts, change communications, reporter feedback and completion of key fields.

    Verbatim wording from the response

    “The Trust undertook a project as part of a Trust-wide CQC action plan to improve incident reporting (both to ensure all incidents are recorded and to ensure all key information was captured in the incident). Actions taken have included:”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 8 · response
    Published 13 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Improve CAMHS incident learning through ABC-format Datix records, staff training, action recording and ligature-risk categorisation.

    Verbatim wording from the response

    “▪ Training with preceptor nurses as part of induction”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 8 · response
    Published 13 February 2026

    Open published response

  2. Worcestershire

    AI-generated summary

    Vera Fortey · 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

    Vera Fortey suffered an unwitnessed fall at her care home, after which her mobility and condition deteriorated. Her fractured hip was not medically identified for approximately two and a half days, and she later underwent surgery, declined despite treatment, and died in hospital. The principal concerns were inadequate recording of the fall, missed opportunities to obtain medical assessment, insufficient auditing of residents’ records, and inadequate staff familiarity with the care home’s records system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record significant incidents contemporaneously in residents’ records

    Wider context from the report

    “1) Mrs. Fortey suffered an unwitnessed fall in her room at The Willows Care Home, Worcester shortly after midnight on 25.9.24. The carers who came and assisted her felt that she had not injured herself, and did not seek any medical attention for her. In fact, no medical attention was sought until shortly before midday on 27.9.24, when she was recorded as not being able to support her own body weight. The disclosure provided by the care home for the inquest did not contain: - any contemporaneous account of this fall written by either of the two carers who dealt with her at the time; - any entry made in Mrs. Fortey’s Daily Notes of this fall. Furthermore, although there was a document which the then manager of the care home had written, which was said to summarize the accounts of the fall given to her by the carers concerned, this document made no reference to the date of the fall; I was forced to conclude that no contemporaneous account of the fall on 25.9.24 ever made its way to Mrs. Fortey’s file. ”

    Source location

    Vera Fortey · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Insufficient measures to ensure staff understand significant-incident recording requirements

    Wider context from the report

    “4) Although she had only been in post since 13 August 2024, the then care home manager told the inquest that a reason why she may not herself have picked up on the above failings was because at the time of these events, she was still not familiar with the care home’s records system, was unable to scroll through residents’ notes, and was instead just “muddling through”. It therefore appears that insufficiently robust measures are in place at The Willows Care Home to ensure: (a) that staff understand the need to record significant incidents in residents’ records; (b) that a regular auditing procedure is in place to help ensure that residents’ records are being updated properly; and (c) that all staff at the care home ( including managers ) have received training so as to be as familiar with the computerized records system in use there as their role may require. ”

    Source location

    Vera Fortey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.

    Verbatim wording from the response

    “To address the specific items raised in the Regulation 28 Report we drew up an action plan that covered:”

    Source location

    Response from The Willows Care Home
    Page 1 · response
    Published 3 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provided carers and the Home Manager with training on the Care Docs Portal’s core functionality.

    Verbatim wording from the response

    “In addition, further training was provided to the carers and Home Manager on the core functionality of the Care Docs Portal. An outline of the training provided by Care Docs is contained at Appendix 3. I trust that this provides you and Mrs Fortey's family reassurance that the home has taken onboard the concerns raised and made requisite changes.”

    Source location

    Response from The Willows Care Home
    Page 1 · response
    Published 3 July 2025

    Open published response

  3. Essex

    AI-generated summary

    Georgia Dehaney-Perkins · 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

    Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Incomplete recording of alcohol consumption incidents after leave

    Wider context from the report

    “(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”

    Source location

    Georgia Dehaney-Perkins · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete leave risk assessments, offer post-leave engagement, record incidents through Datix, update risk assessments, and share relevant information with involved professionals.

    Verbatim wording from the response

    “A risk assessment is completed prior to a patient going on leave. Upon the patient returning from leave one to one engagement is offered to the patient, if any incident has occurred whilst the patient has been on leave this is reported via Datix and the risk assessment is updated accordingly. The incident is also documented within the patients’ notes and information is shared with all health professionals involved in the care of the patient during handover, Multidisciplinary Team meetings and ward reviews.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 14 February 2024

    Open published response

  4. Cornwall and Isles of Scilly

    AI-generated summary

    Ian Jacka · 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 Jacka suffered serious injuries after a fall from height on 3 June 2022 and later developed hypoxic brain injury following airway complications during spinal surgery. He died in intensive care on 15 June 2022. The principal concerns were omissions in record keeping and handover about a serious medical episode before surgery, and the absence of a formal written handover process for significant events involving complex patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record the full extent of significant critical incidents in hospital notes

    Wider context from the report

    “(1) There was an error of omission in record keeping and in handover from critical care to surgery, and that this error likely contributed to Ian’s death. (2) There was no entry in Ian’s hospital notes to indicate the full extent of the critical incident of 5 June 2022. ”

    Source location

    Ian Jacka · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The clinical record comprehensively documented the critical incident, and there was no omission in record keeping or handover.

    Verbatim wording from the response

    “The documentation in relation to the critical incident is both comprehensive and appropriate. Mr Jacka deteriorated, requiring intubation and ventilation as a result of type 2 respiratory failure caused by his significant chest and spinal injuries. His blood oxygen saturations and blood pressure fell significantly but were rapidly restored to normal upon the arrival of the ICU registrar with simple interventions after a relatively short period of time. The lowest oxygen saturations and blood pressure values were recorded in the notes by the ICU nurse at the time. Mr Jacka was anaesthetised and intubated – this was technically challenging and represented a difficult airway, but Mr Jacka remained stable throughout this process with no further drop in oxygen levels.”

    Source location

    Response from University Hospitals Plymouth NHS Trust
    Page 2 · response
    Published 18 December 2023

    Open published response

  5. Worcestershire

    AI-generated summary

    Matthew David Harris · 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

    Matthew David Harris was found suspended in his cell at HMP Long Lartin on 27 May 2022 and died from his injuries at Alexandra Hospital, Redditch, on 29 May 2022. The inquest concluded that he died by suicide. The principal concern was that recent suicidal ideation disclosed during a police interview was not recorded on the documents accompanying him between police custody, court and prison, potentially leading to the risk of suicide or self-harm being underestimated or ignored.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms

    Wider context from the report

    “(1) Following his arrest, and before he was interviewed about the alleged offence of murder, Mr. Harris was assessed by a consultant forensic psychiatrist, ████████ concluded that Mr. Harris was fit to be detained and fit to be interviewed, he did not possible symptoms of Post Traumatic Stress Disorder, likely due to some trauma in Mr. Harris’ background, possible symptoms of a personality disorder, and “potentially a psychotic process, with potential underlying delusional beliefs”; (2) During his police interview on 14.5.22, when describing his movements before the alleged murder had taken place, Mr. Harris told officers he had ████████ intending to jump off in order to take his own life, but had decided against it because “I thought no, I’ve got to reveal all this first”; (3) Despite the fact that these comments revealed very recent suicidal ideation on Mr. Harris’ part, no mention of them appears to have been made in any of the following documents: (a) The Person Escort Record ( PER ) and Suicide and Self-Harm ( SASH ) Warning forms which accompanied Mr. Harris from police custody at Haverfordwest Police Station to Haverfordwest Magistrates’ Court on 16.5.22; (b) The PER and SASH Warning forms which accompanied Mr. Harris from Haverfordwest Magistrates’ Court to HMP Swansea later that same day. (4) Although I was quite satisfied that the omission of these comments from the above documents made no difference to the sad outcome in this case, I am concerned that the failure by Dyfed-Powys Police officers to realise that such comments ought to be included on a PER and SASH Warning form, if repeated in future, may lead to a person in custody’s risk of suicide and/or self-harm, being either underestimated, or ignored completely. ”

    Source location

    Matthew David Harris · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Inform investigation and custody staff, anonymously, about the omission of relevant suicidal-ideation information.

    Verbatim wording from the response

    “To confirm, on 1st August 2023 via my Head of Custody Services, all staff involved in investigations and those responsible for the care of detainees whilst in police custody have been informed, in an anonymized manner, of the nature of the omission in this case.”

    Source location

    Response from Dyfed-Powys Police
    Page 2 · response
    Published 6 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Instruct custody officers to ask interviewing officers about information relevant to ongoing detainee risk assessment.

    Verbatim wording from the response

    “Custody Officers have been instructed to specifically ask interviewing officers whether they have any information that is relevant to the ongoing duty of risk assessment; information needed to best manage the welfare of the detainee.”

    Source location

    Response from Dyfed-Powys Police
    Page 2 · response
    Published 6 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind investigators to inform custody officers about disclosures relevant to ongoing risk management.

    Verbatim wording from the response

    “Further, investigators have been reminded of their duty to inform the custody officer of any information disclosed to them that should be considered as part of ongoing risk management.”

    Source location

    Response from Dyfed-Powys Police
    Page 2 · response
    Published 6 September 2023

    Open published response

  6. Dorset

    AI-generated summary

    Ryan Albert Frederick Merna · 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

    Ryan Albert Frederick Merna died from injuries sustained in a knife attack at his home on 14 August 2016. The concerns included that information about the perpetrator possessing a knife and sleeping rough was not probed, recorded, or raised at a care programme meeting, resulting in a missed opportunity to reassess risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to contemporaneously document disclosures of possession of an offensive weapon

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Warwickshire

    AI-generated summary

    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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record resident aggression incidents in care plans

    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
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    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
    Page 1 · response
    Published 9 July 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.

    Verbatim wording from the response

    “The Operations Team has implemented an enhanced agenda for the fortnightly staff meetings that are held at Clifton Court to include inter alia infection control – Covid, health and safety and accurate and systematic recording of behavioral issues.”

    Source location

    2021-0230-Response-from-Crosscrown-Ltd_Published
    Page 3 · response
    Published 9 July 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.

    Verbatim wording from the response

    “Under the new scheme such behaviour is recorded on the CareDocs system which prompts the completion of an Antecedent Behaviour Consequences form on the CareDocs system. The Care Home Manager at Clifton Court checks on a daily basis for amongst other things any ABC charts which may have been completed by members of staff. Should any safeguarding issues be recorded then the Manager will contact Adult Social Services and complete that process. The Operations Team are copied into all emails in relation to any safeguarding issues. In the last eighteen months Clifton Court has made eight referrals to the Adult Social Services Team at Warwickshire County Council all of which were closed down without an action by the Council. The issue of safeguarding is also now part of the Monthly Managers Report and is analysed by the Operations Team and evaluated for any patterns or learning issues.”

    Source location

    2021-0230-Response-from-Crosscrown-Ltd_Published
    Page 3 · response
    Published 9 July 2021

    Open published response

  8. Manchester West

    AI-generated summary

    KENNETH SMITH · 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

    Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.

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    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 determine whether falls should be recorded in the Accident Record

    Wider context from the report

    “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020. Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered. The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury. Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all. Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020. The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns: 1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful. 2. The failure to consider and specify a review date; 3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review. 4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority; ”

    Source location

    KENNETH SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Manchester West

    AI-generated summary

    Thomas Nicholls · 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

    Thomas Nicholls died in hospital on 14 April 2015 after recurrent vomiting, aspiration pneumonia and deterioration following PEG feeding, in the context of prior strokes and other illness. The substantive concerns included inadequate staff training in the mobility, handling and care of residents receiving PEG feeds, an unreported vomiting incident, inadequate recording of incidents, and malfunctioning bed equipment.

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    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 record and escalate incidents involving PEG feeding

    Wider context from the report

    “1. During the Inquest evidence was heard that i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted. Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success. Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding. ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds. The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes. iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed. iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed. v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident. vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues. ”

    Source location

    Thomas Nicholls · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester South

    AI-generated summary

    Paul Mc Guigan · 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

    Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of recording of pre-conviction disclosures

    Wider context from the report

    “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made. It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made. ”

    Source location

    Paul Mc Guigan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Security Industry Authority does not comment on concerns relating to other parties, including GMP’s understanding of the former notification scheme.

    Verbatim wording from the response

    “For ease of reference, I have set out below the extracts from your letter which relate to the SIA, which are then followed by our response. The issues raised in concerns 2 to 5 of your letter relate to other parties and as such we have not commented on those matters in the responses below.”

    Source location

    2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
    Page 6 · response
    Published 12 May 2015

    Open published response

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

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Data last updated 7 September 2026