Recipient

Camino Healthcare Limited

First report 6 Sep 2019•Latest report 6 Sep 2019

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: 2
Stated actions: 7

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

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

6 Sep2019
Black Country
Concerns raised7
1. Failure to adhere to the five-minute patient observation level
2. Inconsistent and minimal training for care staff in managing complex patient needs
3. Minimal training for care staff in performing patient resuscitation
1. Lack of a joint multidisciplinary care plan
2. Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers
3. Insufficient contact with the care coordinator
4. Failure to provide a ligature-free environment despite escalating ligature and self-harm risk
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
  Provide staff with further Intensive Life Support and, where required, Basic First Aid training including CPR.
  Stated completed
2. Action
  Evaluate staff training requirements and provision.
  Stated completed
3. Action
  Review the premises and make environmental changes to achieve an anti-ligature environment as far as reasonably practicable.
  Stated completed
AI-generated summary

Ms Shannon Quinn · 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

Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.

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 Camino Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to adhere to the five-minute patient observation level
Wider context from the report
“5. The patient observation level of 5 minutes was introduced to minimise risk of self-harm but not adhered to. ”
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 Camino Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent and minimal training for care staff in managing complex patient needs
Wider context from the report
“2. There was inconsistent and minimal training provided to Oak House staff in respect of managing SQ’s complex needs by the Mental Health Trust. ”
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 Camino Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation
Minimal training for care staff in performing patient resuscitation
Wider context from the report
“6. Evidence emerged during the inquest that there had been minimal training for Oak House staff in performing resuscitation on patients. The training received included general first aid training by e-learning. ”
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 Camino Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of a joint multidisciplinary care plan
Wider context from the report
“3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence. ”
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 Camino Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers
Wider context from the report
“1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector. In particular, there was no sharing of medical notes/care plans between the Birmingham and Solihull and Mental Health Trust and Oak House. ”
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 Camino Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation
Insufficient contact with the care coordinator
Wider context from the report
“3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence. ”
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 Camino Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide a ligature-free environment despite escalating ligature and self-harm risk
Wider context from the report
“4. There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment. ”
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
Provide staff with further Intensive Life Support and, where required, Basic First Aid training including CPR.

Verbatim wording from the response
“We have also evaluated all of our training and our staff have received further training in Intensive Life Support and also Basic First Aid (where required) which includes CPR. The Intensive Life Support which is mandatory for our staff exceeds the regulatory requirements of the service.”

Source location
2019-0499-Response-from-Camino-Healthcare-Redacted
Page 1 · response
Published 25 March 2020
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
Evaluate staff training requirements and provision.

Verbatim wording from the response
“We have also evaluated all of our training and our staff have received further training in Intensive Life Support and also Basic First Aid (where required) which includes CPR. The Intensive Life Support which is mandatory for our staff exceeds the regulatory requirements of the service.”

Source location
2019-0499-Response-from-Camino-Healthcare-Redacted
Page 1 · response
Published 25 March 2020
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
Review the premises and make environmental changes to achieve an anti-ligature environment as far as reasonably practicable.

Verbatim wording from the response
“A full and thorough review of the premises was undertaken immediately after the incident and changes were made to make the environment anti-ligature as far as is reasonably practicable.”

Source location
2019-0499-Response-from-Camino-Healthcare-Redacted
Page 1 · response
Published 25 March 2020
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 raised7

Failure to adhere to the five-minute patient observation level

Inconsistent and minimal training for care staff in managing complex patient needs

Minimal training for care staff in performing patient resuscitation

Lack of a joint multidisciplinary care plan

Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers

Insufficient contact with the care coordinator

Failure to provide a ligature-free environment despite escalating ligature and self-harm risk

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