18 Sep 2023 Anthony John Friend · Prevention of Future Deaths report Worcestershire
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Concerns raised 8 Failure to remove unsuitable slings from the service user's property View source Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns View source Failure by incoming care providers to identify previous care providers and seek a handover View source Failure to provide handovers between care agencies about care needs and safety concerns View source Failure to communicate concerns about continued unsafe sling use in writing to care agencies View source Failure to ensure carers' participation in sling assessments View source Failure to discuss sling use with new carers View source Failure to demonstrate safer sling use to carers View source See 5 more concerns
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AI-generated summary
Anthony John Friend · 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
Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.
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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure to remove unsuitable slings from the service user's property
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend , ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property ;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property ;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address , and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling . In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies” , but that it “was not something which we had ever done” ;
5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care. In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so.
” 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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure by incoming care providers to identify previous care providers and seek a handover
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies”, but that it “was not something which we had ever done”;
5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care . In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so .
” 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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure to provide handovers between care agencies about care needs and safety concerns
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies” , but that it “was not something which we had ever done” .
” 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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerns about continued unsafe sling use in writing to care agencies
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers' participation in sling assessments
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ) ; and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure to discuss sling use with new carers
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling ;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Bluebird Care (Bromsgrove & Redditch); that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate safer sling use to carers
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided ;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Follow the enhanced handover process for all customers transitioning to or from Bluebird Care, not only CHC-funded customers.
Verbatim wording from the response “From our perspective, this process will not be limited to handovers concerning CHC funded patients and will be followed for all customers that are transitioning to or from our care.” Source location Response from Bluebird Care
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 Write to Herefordshire and Worcestershire CHC to seek clarification on handover protocols and establish best-practice standards for potential improvements.
Verbatim wording from the response “Whilst, as above, we do consider that in this case the handover process captured all the relevant information we had to share with the new provider, in an effort to improve this process going forward we have written to Herefordshire and Worcestershire CHC to seek guidance and clarification on the existing handover protocol for care providers when either taking on, or serving notice on, a package of care from CHC, as well as establishing best practice standards to implement any possible improvements. We are dedicated to continuing to be a high-quality care provider, and although the circumstances are unfortunate, we want to take this opportunity to work in partnership with other health care professionals to provide the best care and support to all those that we support.” Source location Response from Bluebird Care
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 Proactively seek opportunities to observe care calls when taking over packages, where circumstances require, to support assessment and handover.
Verbatim wording from the response “5. We would also value the opportunity, should it be required, to observe a care call being carried out by an outgoing provider if we were to take over a package of care. We have proactively sought out these opportunities ourselves and have found them beneficial when circumstances require this, for example visiting a customer in hospital to make observations prior to returning home, and visiting another customer at home who had an existing homecare provider visiting daily.” Source location Response from Bluebird Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.
Verbatim wording from the response “As part of this meeting, the management team reviewed the detailed care plan that had been prepared by CHC based on information provided by ourselves and provided to Divine Health Care as part of the process of finding a new care provider. Although the handover was from CHC to Divine Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns regarding the sling were very clearly documented within this detailed 14-page document. Our identity as the outgoing care provider was also included within this document. This document was shared with Divine Health Care in advance of them carrying out their assessment and agreeing to take over Mr Friend's package of care.” Source location Response from Bluebird Care
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations