Recipient

Avon Care Homes Limited

First report 2 Nov 2016•Latest report 2 Nov 2016

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 12

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

12stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

2 Nov2016
Wiltshire and Swindon
Concerns raised3
1. Failure of the ventilator Users Manual extracts to provide guidance on normal operation, fault recognition and fault rectification
2. Failure to ensure staff awareness of the ventilator Users Manual and its location
3. Lack of adequate staff training in ventilator use
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Train and assess authorised staff as competent before they manage a resident's specialist equipment or intervention.
  Stated planned
2. Action
  Create an accessible specialist-equipment governance pack covering manuals, settings, checks, risk assessments, policies and best-practice evidence.
  Stated planned
3. Action
  Create a specialist-intervention care, risk and escalation plan with named and out-of-hours specialist support.
  Stated planned
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

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 raised3

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

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

Lack of adequate staff training in ventilator use

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

Actions described in response 3