All Care In One Limited

Private and voluntary organisations · Private limited company

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First report 3 Mar 2025•Latest report 3 Mar 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from All Care In One Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

3 Mar2025
Birmingham and Solihull
Concerns raised8
1. Failure of staff to take appropriate action on serious acute mental health issues
2. Failure to communicate serious concerns to the GP in writing
3. Absence of a formal internal post-death investigation report
1. Failure of staff to understand service users' best interests
2. Failure of staff to recognise serious acute mental health issues
3. Failure of post-death training to address identified concerns
4. Outstanding post-death internal training
5. Failure to maintain accurate contemporaneous records of behaviour and mood
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

JAVED IQBAL · 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

Javed died on 1 June 2024 after deliberately igniting his room with flammable liquid and sustaining major burn injuries and smoke inhalation, followed by multi-organ failure. The report identified concerns that staff did not recognise and appropriately act on serious acute mental health issues, including not escalating worsening mood and irrational behaviour to the GP in writing. It also identified the absence of a formal internal post-death investigation and outstanding internal training that had not addressed these concerns.

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 All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to take appropriate action on serious acute mental health issues
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate serious concerns to the GP in writing
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Absence of a formal internal post-death investigation report
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to understand service users' best interests
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to recognise serious acute mental health issues
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of post-death training to address identified concerns
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Outstanding post-death internal training
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain accurate contemporaneous records of behaviour and mood
Wider context from the report
“The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above concerns. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised8

Failure of staff to take appropriate action on serious acute mental health issues

Failure to communicate serious concerns to the GP in writing

Absence of a formal internal post-death investigation report

Failure of staff to understand service users' best interests

Failure of staff to recognise serious acute mental health issues

Failure of post-death training to address identified concerns

Outstanding post-death internal training

Failure to maintain accurate contemporaneous records of behaviour and mood