4 Nov 2024 Janet Brown Townend · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 8 Failure to consider reassessment of capacity View source Inaccurate recording of Early Warning Signs View source Insufficient time spent providing care and completing care duties View source Failure to escalate concerns about sickness View source Failure to follow up on intended GP support View source Failure to escalate concerns about reduced food intake View source Failure to escalate Early Warning Signs View source Failure to escalate concerns about unwise refusals of care, food and medical intervention View source See 5 more concerns
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Janet Brown Townend · 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
Janet Brown Townend, who had diabetes and other comorbidities, developed an infected foot wound that progressed to sepsis despite hospital treatment, and she died on 15 October 2023. Concerns arose about the care provided by carers, including brief visits, failure to escalate poor nutrition, sickness and early warning signs, inaccurate records, and failure to follow up or escalate refusals of care and medical intervention.
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. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to consider reassessment of capacity
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of Early Warning Signs
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns . This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient time spent providing care and completing care duties
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend . Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks ; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate concerns about sickness
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness . There were a number of times Ms Townend presented with having been sick and this was not considered as a concern ;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up on intended GP support
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell . This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done ;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate concerns about reduced food intake
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating . As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate Early Warning Signs
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present . The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated ;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to A & B Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate concerns about unwise refusals of care, food and medical intervention
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention . This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations