Care Outlook Ltd

Private and voluntary organisations · Private limited company

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First report 5 Feb 2021•Latest report 7 Jun 2024

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: 2
Published responses: 100%
Concerns addressed: 3
Stated actions: 14

Concerns and recipient responses

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

7 Jun2024
West Sussex, Brighton and Hove
Concerns raised2
1. Failure to consider possible choking
2. Failure to attempt life-saving techniques
Actions described in response 6
1. Action
  Increase dysphagia and modified-diets e-learning refreshers to an annual frequency.
2. Action
  Purchase and use a choking vest for hands-on basic life support training.
3. Action
  Develop a lesson plan for practical choking recognition and response training using the choking vest.
1. Action
  Create and publish an online recorded choking-response training session with practical demonstrations for staff refreshers.
2. Action
  Roll out standalone practical choking-response sessions using the choking vest across services.
3. Action
  Provide amended choking-vest training through mandatory induction and refresher basic life support sessions.
AI-generated summary

Alan Richard LEE · 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

On 17 December 2023, Alan Richard LEE choked on a food bolus after being given dinner in his flat and died before the ambulance arrived. Staff who attended did not appear to recognise that he may have been choking, so no lifesaving techniques were attempted.

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 Care Outlook Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider possible choking
Wider context from the report
“The issue of concern is that despite the fact that Mr Lee had recently been given his dinner and there was evidence that some or part of it had been consumed, the staff who attended, following Mr Lee using his alarm, did not appear to consider that he may have been choking. Therefore, no life saving techniques were attempted. ”
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 Care Outlook Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to attempt life-saving techniques
Wider context from the report
“The issue of concern is that despite the fact that Mr Lee had recently been given his dinner and there was evidence that some or part of it had been consumed, the staff who attended, following Mr Lee using his alarm, did not appear to consider that he may have been choking. Therefore, no life saving techniques were attempted. ”
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
Increase dysphagia and modified-diets e-learning refreshers to an annual frequency.

Verbatim wording from the response
“Increased frequency of e-learning | All staff complete e-learning on Dysphagia and Modified Diets as part of their Induction. This training has been set to an increased refresher frequency of annually.”

Source location
Response from Care Outlook
Page 4 · response
Published 7 June 2024
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
Purchase and use a choking vest for hands-on basic life support training.

Verbatim wording from the response
“Action | Detail Purchase of a choking vest | The training team purchased a Choking Vest to incorporate into the practical BLS training we deliver.”

Source location
Response from Care Outlook
Page 3 · response
Published 7 June 2024
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
Develop a lesson plan for practical choking recognition and response training using the choking vest.

Verbatim wording from the response
“Development of training plan | The training team developed a lesson plan for the delivery of the additional practical element of the choking training which can be delivered as a standalone session and can be incorporated into the existing BLS training session currently delivered during induction and refresher training.”

Source location
Response from Care Outlook
Page 3 · response
Published 7 June 2024
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 and publish an online recorded choking-response training session with practical demonstrations for staff refreshers.

Verbatim wording from the response
“In addition, the training team are creating a recorded session with practical demonstrations using the choking vest which will be available to all staff across the business online and will be accessible at any time for refreshers via our e-learning platform. The recording has been completed and is now in the editing stages with the intention to have this live on the system before the end of August 2024.”

Source location
Response from Care Outlook
Page 4 · response
Published 7 June 2024
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
Roll out standalone practical choking-response sessions using the choking vest across services.

Verbatim wording from the response
“Action | Detail Roll out of training with choking vest | The new practical session was rolled out to services as a standalone session beginning on 01/07/2024.”

Source location
Response from Care Outlook
Page 4 · response
Published 7 June 2024
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
Provide amended choking-vest training through mandatory induction and refresher basic life support sessions.

Verbatim wording from the response
“Incorporation of choking vest training to induction and refresher | As noted above the lesson plan created by the training team can be delivered standalone or as part of the existing mandatory BLS training delivered during induction and refresher training.”

Source location
Response from Care Outlook
Page 4 · response
Published 7 June 2024
Open published response
5 Feb2021
Inner North London
Concerns raised3
1. Failure to resolve heating faults to maintain a safe temperature in the flat
2. Failure to provide sufficient prompting and encouragement to maintain hydration
3. Failure to recognise deterioration
Actions described in response 1
1. Action
  Produce and distribute a dehydration-risk factsheet with recognition, preventive and urgent-response guidance for care workers.
AI-generated summary

Joseph O’Neill · 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

Joseph O’Neill developed bronchopneumonia, suffered heat stroke, became dehydrated and died. Concerns included the failure to resolve faulty heating during a heatwave, inadequate rehydration and prompting to drink, and failure to recognise his deterioration.

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 Care Outlook Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to resolve heating faults to maintain a safe temperature in the flat
Wider context from the report
“When Mr O’Neill refused a place in a care home, the Care Outlook staff did not do anything to resolve the fault with Mr O’Neill’s heating, so it remained on in the middle of a heatwave. An engineer was called to fix his door hinge, but not his heating. Mr O’Neill desperately needed a reduction in the temperature of his flat, first and foremost by the heating being fixed, but Care Outlook staff did not deal with this. ”
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 Care Outlook Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide sufficient prompting and encouragement to maintain hydration
Wider context from the report
“He also needed immediate rehydration. When he was admitted to hospital, he was in deficit by about three litres. He was offered a drink by care staff at mealtimes, but he needed constant prompting and encouragement to drink enough. ”
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 Care Outlook Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise deterioration
Wider context from the report
“His deterioration was not 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
Produce and distribute a dehydration-risk factsheet with recognition, preventive and urgent-response guidance for care workers.

Verbatim wording from the response
“4. We have also prepared a factsheet providing enhanced guidance for care workers in relation to the risks of dehydration. The factsheet contains practical guidance on how to spot the signs of dehydration, the routine action that can be taken by care workers to prevent this and the urgent action that must be taken when a client is at risk. The fact sheet has been provided to all care workers.”

Source location
2021-0030-Response-from-Care-Outlook-Redacted
Page 2 · response
Published 9 February 2021
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 raised2

Failure to consider possible choking

Failure to attempt life-saving techniques

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.6

Concerns raised3

Failure to resolve heating faults to maintain a safe temperature in the flat

Failure to provide sufficient prompting and encouragement to maintain hydration

Failure to recognise deterioration

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.1

Actions described in response 6

Actions described in response 1