Avon Care Homes LimitedIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Private limited company

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First report 2 Nov 2016•Latest report 2 Nov 2016

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

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
12

Described in responses

Concerns and recipient responses

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

  1. Addressed to: ████████ Managing Director Avon Care Homes Limited.

    Wiltshire and Swindon

    AI-generated summary

    William Edward Marson · 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

    William Edward Marson, who had breathing difficulties assisted by a ventilator, became anxious after believing the ventilator was not working and died on 18 June 2015. Evidence at the inquest raised concerns that staff had not been adequately trained to use the ventilator, were unaware of the user manual, and lacked information about its correct operation and fault identification.

    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 Avon Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the ventilator Users Manual extracts to provide guidance on normal operation, fault recognition and fault rectification

    Wider context from the report

    “During the course of the Inquest, evidence was heard from several witnesses as to the fact that no formal training on the correct use of the ventilator had been given to all members of staff. As a result there was no understanding of how the ventilator presented when it was working correctly, or as to the identification of any issues which would indicate that it was not working correctly and how they might be resolved. Although a copy of the Users Manual, for the ventilator had been printed off (in part) and placed in William's room, its existence and location were unknown to the sister or carers on duty. In any event I found that the extracts that had been printed off, would not have assisted in diagnosing that in fact the machine was functioning correctly, which may have reduced Williams anxiety, had that been made known to him. (1) That the staff on duty at Sutton Veny House had not been adequately trained if at all in the use of the ventilator. (2) That the staff were unaware of the existence of a Users Manual or its location. (3) That the extracts printed off in the Users Manual did not include details of how the machine presented when working correctly or how to recognise faults and how to rectify them. ”
    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 Avon Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff awareness of the ventilator Users Manual and its location

    Wider context from the report

    “During the course of the Inquest, evidence was heard from several witnesses as to the fact that no formal training on the correct use of the ventilator had been given to all members of staff. As a result there was no understanding of how the ventilator presented when it was working correctly, or as to the identification of any issues which would indicate that it was not working correctly and how they might be resolved. Although a copy of the Users Manual, for the ventilator had been printed off (in part) and placed in William's room, its existence and location were unknown to the sister or carers on duty. In any event I found that the extracts that had been printed off, would not have assisted in diagnosing that in fact the machine was functioning correctly, which may have reduced Williams anxiety, had that been made known to him. (1) That the staff on duty at Sutton Veny House had not been adequately trained if at all in the use of the ventilator. (2) That the staff were unaware of the existence of a Users Manual or its location. (3) That the extracts printed off in the Users Manual did not include details of how the machine presented when working correctly or how to recognise faults and how to rectify them. ”
    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 Avon Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of adequate staff training in ventilator use

    Wider context from the report

    “During the course of the Inquest, evidence was heard from several witnesses as to the fact that no formal training on the correct use of the ventilator had been given to all members of staff. As a result there was no understanding of how the ventilator presented when it was working correctly, or as to the identification of any issues which would indicate that it was not working correctly and how they might be resolved. Although a copy of the Users Manual, for the ventilator had been printed off (in part) and placed in William's room, its existence and location were unknown to the sister or carers on duty. In any event I found that the extracts that had been printed off, would not have assisted in diagnosing that in fact the machine was functioning correctly, which may have reduced Williams anxiety, had that been made known to him. (1) That the staff on duty at Sutton Veny House had not been adequately trained if at all in the use of the ventilator. (2) That the staff were unaware of the existence of a Users Manual or its location. (3) That the extracts printed off in the Users Manual did not include details of how the machine presented when working correctly or how to recognise faults and how to rectify them. ”
    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

    Train and assess authorised staff as competent before they manage a resident's specialist equipment or intervention.

    Verbatim wording from the response

    “• The resident would not be admitted until all appropriate team members had received training in the use of the equipment. This would include normal use of the equipment, hints and tips for addressing minor faults, contact details if there was a major problem with the equipment and contingency arrangements to keep the resident safe during a major equipment failure event.”

    Source location

    2016-0394-Response-by-Avon-Care-Home
    Page 2 · response
    Published 2 November 2016

    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

    Create an accessible specialist-equipment governance pack covering manuals, settings, checks, risk assessments, policies and best-practice evidence.

    Verbatim wording from the response

    “• A user friendly version of the equipment manual as well as the full manual would be devised and team members would be notified of the location of these documents. The location of this information would also be documented on the residents electronic and hard copy records.”

    Source location

    2016-0394-Response-by-Avon-Care-Home
    Page 3 · response
    Published 2 November 2016

    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

    Create a specialist-intervention care, risk and escalation plan with named and out-of-hours specialist support.

    Verbatim wording from the response

    “• A detailed care plan outlining the care and management of the resident and any equipment relating to the specialist intervention would be formulated which would also include the parameters for registered nurse and care team member’s involvement in the management of the resident. This care plan would also include sign posting information to the relevant resources available to the practitioner to support safe management of the resident.”

    Source location

    2016-0394-Response-by-Avon-Care-Home
    Page 2 · response
    Published 2 November 2016

    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

Data last updated 7 September 2026