Concerns raised 2 Failure to ensure that staff read, understand and can apply key policies and training View source Failure to provide staff with effective tools and implements for immediate life-saving action View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Upgrade HR software to improve digital records of training and policy reading and automate the policy-change confirmation process.
View source
Action
Provide ligature-cutting kits with safety knives and quick guides in every care and support office, with content included in audits.
View source
Action
Add policies and procedures to team-meeting agendas for discussion, minute-taking and auditing of staff understanding and application.
View source
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AI-generated summary
Kesia Blaine Waller · 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
Kesia Blaine Waller, aged 17, was found suspended from a ligature at her residential housing unit on 20 January 2020 and died in hospital on 25 January 2020 after life-sustaining treatment was withdrawn following a catastrophic hypoxic brain injury. The concerns included inadequate staff training and equipment to respond to a young person suspended from a ligature, and ineffective communication and implementation of policies and training.
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 A2Dominion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that staff read, understand and can apply key policies and training
Wider context from the report “At Kesia’s Inquest I heard that her place of residence, City Road in Winchester, was a residential housing unit for vulnerable young people aged 16-21. The facility meets a housing need only for the young persons placed there. It was found on the evidence that A2 Dominion employees did not have sufficient training or tools (i.e. implements) in place to prepare staff for the situation that they faced on the 20th January 2020 when they found Kesia hanging in her room, nor could they carry out any physical actions to assist her (i.e. cut her down). There appeared to be no prior appreciation of the risk(s) of self-harm, overdose or attempted suicide of residents, and so on discovering Kesia suspended in her room, the staff were inadequately prepared on multiple levels.
(a) I heard that whilst there has been additional training for the staff on areas of risk such as self-harm, overdose and/or suicide, there have been no physical changes in terms of the provision of tools and implements that staff could use should they be confronted by a young person in distress and/or in need of life-saving attention. It appears to me that without multi-factorial changes there remains a real and significant risk that staff at the residential units will remain unable to take any immediate and potentially life-saving action. The only tools and equipment that remain supplied is a standard home-style first aid kit which is entirely ineffective if a young person has suspended themselves from a ligature.
(b) Although additional training and courses have been added to both the induction training and on-going professional development of staff within the residential units similar to City Road, I remain concerned by the way in which key policies and training are communicated and implemented as this does not appear to have changed . It was clear from the evidence that updates to policies are emailed to employees with a request that the employee responds to the email to confirm receipt . This proved to be wholly ineffective as what appeared to be expected by the company was that the employee would read, digest and understand the policy, and confirm when he/she had done so. The employee on duty on the 20th January 2020 was clearly unfamiliar with the appropriate policies and had only confirmed that he had received the email (which appeared to be all that was required) and not that he had actually read, digested and understood the appropriate policy/policies; how to apply them in practice and what was reasonably expected of him . Although enhanced risk training is now place, it appears to me that without any enhanced diligence to ensure that policies are actually read and understood by those working face-to-face with the vulnerable young adults then the overall effectiveness of risk training and identification is severely flawed .
” 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 A2Dominion Housing Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff with effective tools and implements for immediate life-saving action
Wider context from the report “At Kesia’s Inquest I heard that her place of residence, City Road in Winchester, was a residential housing unit for vulnerable young people aged 16-21. The facility meets a housing need only for the young persons placed there. It was found on the evidence that A2 Dominion employees did not have sufficient training or tools (i.e. implements) in place to prepare staff for the situation that they faced on the 20th January 2020 when they found Kesia hanging in her room, nor could they carry out any physical actions to assist her (i.e. cut her down). There appeared to be no prior appreciation of the risk(s) of self-harm, overdose or attempted suicide of residents, and so on discovering Kesia suspended in her room, the staff were inadequately prepared on multiple levels.
(a) I heard that whilst there has been additional training for the staff on areas of risk such as self-harm, overdose and/or suicide, there have been no physical changes in terms of the provision of tools and implements that staff could use should they be confronted by a young person in distress and/or in need of life-saving attention . It appears to me that without multi-factorial changes there remains a real and significant risk that staff at the residential units will remain unable to take any immediate and potentially life-saving action. The only tools and equipment that remain supplied is a standard home-style first aid kit which is entirely ineffective if a young person has suspended themselves from a ligature .
(b) Although additional training and courses have been added to both the induction training and on-going professional development of staff within the residential units similar to City Road, I remain concerned by the way in which key policies and training are communicated and implemented as this does not appear to have changed. It was clear from the evidence that updates to policies are emailed to employees with a request that the employee responds to the email to confirm receipt. This proved to be wholly ineffective as what appeared to be expected by the company was that the employee would read, digest and understand the policy, and confirm when he/she had done so. The employee on duty on the 20th January 2020 was clearly unfamiliar with the appropriate policies and had only confirmed that he had received the email (which appeared to be all that was required) and not that he had actually read, digested and understood the appropriate policy/policies; how to apply them in practice and what was reasonably expected of him. Although enhanced risk training is now place, it appears to me that without any enhanced diligence to ensure that policies are actually read and understood by those working face-to-face with the vulnerable young adults then the overall effectiveness of risk training and identification is severely flawed.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upgrade HR software to improve digital records of training and policy reading and automate the policy-change confirmation process.
Verbatim wording from the response “As an organisation, we are also upgrading our HR software systems, which includes improved digital records of training undertaken and policies and procedures read. This will enhance the ‘purple ribbon’ process set out above by automating it. This is due to be implemented by 2022/23.” Source location 2021-0187-Response-from-A2Dominion_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ligature-cutting kits with safety knives and quick guides in every care and support office, with content included in audits.
Verbatim wording from the response “Additionally, we are providing ligature cutting kits in every office that provides any form of care and support provision and this will be fully rolled out by the end of July 2021. The kit includes a big fish safety knife which is recommended for ligature cutting. These kits will also have quick guides within them and are included in our audits for checking content.” Source location 2021-0187-Response-from-A2Dominion_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add policies and procedures to team-meeting agendas for discussion, minute-taking and auditing of staff understanding and application.
Verbatim wording from the response “also been added to the agenda of all team meetings. Any changes and amendments are discussed at team meetings to check understanding and how these will be applied in practice, this is also minuted and audited.” Source location 2021-0187-Response-from-A2Dominion_Published
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations