Recipient

Bupa

First report 21 Apr 2016•Latest report 10 May 2017

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 100%
Concerns addressed: 9
Stated actions: 19

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

19stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

10 May2017
Inner South London
Concerns raised3
1. Failure to document required smoking-risk mitigations and responses to their refusal
2. Variation in nurses’ skills in smoking risk assessment
3. Failure to recognise immobility and require supervision in smoking risk assessments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Require all safe smoking assessments to follow the updated Bupa Smoking Policy BFM 20.
  Stated completed
2. Action
  Revise the smoking risk assessment process to require apron offers, capability assessment, pendant alarms for garden smokers, and supervision where protective clothing is declined.
  Stated completed
Respondent positions 1
1. Position
  A capable resident’s right to make an unwise decision prevents smoking without supervision or an apron being prohibited wherever possible.
  Unable to act
AI-generated summary

Cedrick Sykers · 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

Cedrick Sykers, a hemiplegic nursing-home resident who could not stand, reposition himself or propel his wheelchair, died in hospital after his clothes caught fire while he was smoking unsupervised in a garden. The report identified concerns about insufficient recognition and mitigation of the risks faced by immobile residents who smoke and cannot summon help, including the lack of clearly documented requirements for supervision, smoking aprons and alarm pendants.

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 Bupa; that does not assign responsibility.
PFD Monitor interpretation
Failure to document required smoking-risk mitigations and responses to their refusal
Wider context from the report
“The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern. BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere. The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice. Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised. ”
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 Bupa; that does not assign responsibility.
PFD Monitor interpretation
Variation in nurses’ skills in smoking risk assessment
Wider context from the report
“The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern. BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere. The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice. Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised. ”
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 Bupa; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise immobility and require supervision in smoking risk assessments
Wider context from the report
“The management of the Care Home and its owners, BUPA, have undertaken a thorough investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident’s smoking identified in the inquest. But one area remains a concern. BUPA corporate guidance indicated, at the time of Mr Skyer’s death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Sykers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere. The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice. Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator’s evidence that the resident’s clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised. ”
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
Require all safe smoking assessments to follow the updated Bupa Smoking Policy BFM 20.

Verbatim wording from the response
“In light of the prevention of future deaths report, Bupa has undertaken a further review of the smoking risk assessment documentation and process used throughout our care homes. I attach, for your information, the revised Bupa Care Services Safe Smoking Assessment document. The updated process puts an increased emphasis on the use of smoking aprons and supervision. You will note that the document requires staff to offer all residents a smoking apron and encourage them to wear it when smoking. It further takes staff through a process of considering the capability of an individual resident to smoke, and removes a significant amount of discretion which was previously available to staff completing the risk assessment.”

Source location
Response from BUPA
Page 1 · response
Published 7 October 2022
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
Revise the smoking risk assessment process to require apron offers, capability assessment, pendant alarms for garden smokers, and supervision where protective clothing is declined.

Verbatim wording from the response
“Those actions included a review of the smoking risk assessment form used across all Bupa homes, which was considered by HM Coroner at the inquest. We note that there were some remaining concerns about whether residents were offered smoking aprons and pendant alarms, as this was not evident from the documentation.”

Source location
Response from BUPA
Page 1 · response
Published 7 October 2022
Open published response
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
A capable resident’s right to make an unwise decision prevents smoking without supervision or an apron being prohibited wherever possible.

Verbatim wording from the response
“HM Coroner recognised that a provider should not override a capable individual’s right to make unwise decisions, and therefore if a resident insists on smoking without supervision or a smoking”

Source location
Response from BUPA
Page 1 · response
Published 7 October 2022
Open published response
21 Apr2016
Manchester West
Concerns raised3
1. Lack of refresher training in patient feeding techniques and associated risks
2. Lack of patient feeding training for family members and other close carers
3. Lack of comprehensive staff training in patient feeding techniques and associated risks
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Margaret Rogerson · 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

Margaret Rogerson, known as Peggy, died at Victoria House, Mill View Care Home, Bolton, from asphyxia due to aspiration of pureed food while being fed. The report raised concerns about a care assistant’s inability to recall training on feeding techniques and risks, the absence of refresher training, and the lack of training available to family members and others close to patients.

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 Bupa; that does not assign responsibility.
PFD Monitor interpretation
Lack of refresher training in patient feeding techniques and associated risks
Wider context from the report
“2. There was no evidence of there being any refresher training in the above matters. ”
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 Bupa; that does not assign responsibility.
PFD Monitor interpretation
Lack of patient feeding training for family members and other close carers
Wider context from the report
“3. There was no evidence of there being any training available to family members and others close to patients in the above matters. There was clear and striking evidence that family members and others would appreciate such training being available to them because in patients with advanced dementia feeding was often the only communication available between patients and their loved ones. There was also evidence that being able to do this in a professional and safe manner would be a great comfort to patient’s relatives and loved ones, who would as a result feel that they themselves were doing something meaningful for the patient. ”
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 Bupa; that does not assign responsibility.
PFD Monitor interpretation
Lack of comprehensive staff training in patient feeding techniques and associated risks
Wider context from the report
“1. A Care Assistant giving evidence at the Inquest could not recall having been trained in the mechanisms of and techniques of how to feed a patient. Particularly there was no evidence of any training relating to the risks involved in feeding patients nor as to the risks created by particular conditions from which patients were suffering. ”
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 raised3

Failure to document required smoking-risk mitigations and responses to their refusal

Variation in nurses’ skills in smoking risk assessment

Failure to recognise immobility and require supervision in smoking risk assessments

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.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised3

Lack of refresher training in patient feeding techniques and associated risks

Lack of patient feeding training for family members and other close carers

Lack of comprehensive staff training in patient feeding techniques and associated risks

Actions described in response 2

Respondent positions 1