Concerns raised 7 Failure to report and stop repeated breaches of required care arrangements View source Failure of handover documents to communicate required personal-care staffing arrangements View source Ambiguity in care plans about required staffing and gender for personal care View source Failure of internal investigations to identify deficiencies in handover documents View source Failure of care staff to read and understand key care-plan requirements View source Lack of auditing of handover documents View source Failure to provide personal care with the required number of carers View source See 4 more concerns
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
Edith Theresa PYE · 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
Edith Theresa PYE sustained a fracture after rolling from her bed at Chandler Court Care Home on 29 March 2024 while receiving personal care from one carer instead of the required two. She underwent an above-knee amputation, developed a chest infection and pulmonary emboli, and died at the care home on 28 April 2024. Concerns included ambiguous care-plan and handover information, inadequate staff awareness and compliance, lack of auditing, and weaknesses in the internal investigation.
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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to report and stop repeated breaches of required care arrangements
Wider context from the report “2) The carer who provided personal care to Mrs. Pye on the occasion when she fell from her bed on 29.3.24 knew that he should have done so with a colleague, but would regularly do so on his own. He had never himself read Mrs. Pye’s care plan, and it became clear that two other members of staff who provided evidence at the inquest were also unaware of some key aspects of the care plan. Furthermore, other staff were aware that he would often provide care to Mrs. Pye on his own, but no-one had reported this to senior staff or taken any action to try to stop it happening ;
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of handover documents to communicate required personal-care staffing arrangements
Wider context from the report “3) At the inquest, I was shown a handover document which had been drafted by the home’s Deputy Manager, and was told that a nurse in charge would have gone through this document with all carers at the beginning of the relevant shift. The document was meant to highlight each resident’s care needs, based on their respective care plans. It did not make clear that Mrs. Pye required two carers for the provision of personal care, or that at least one of those carers should be female ;
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in care plans about required staffing and gender for personal care
Wider context from the report “1) At the inquest, the care home manager gave evidence that the care home recognized that Mrs. Pye was a high risk of falling or rolling from her bed, and also had a history of making unsubstantiated accusations against staff. The care home therefore required:
(a) that Mrs. Pye’s personal care should always be provided by no less than two carers; and
(b) that personal care should be provided, where possible, by two female carers, and if not possible, one female carer should always be present. These requirements should have been reflected in Mrs. Pye’s care plan, but the care plan was ambiguous – for example, it stated:
“Edith may require the support of 2 carers with personal hygiene needs” and
“Edith prefers to receive care from female carers – if this is not possible with the allocated staff for the shift, assistance should be sought from another suite”;
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to identify deficiencies in handover documents
Wider context from the report “5) The Deputy Manager who had drafted this handover document, was also responsible for the care home’s own internal investigation into Mrs. Pye’s fall. That internal investigation failed to highlight the deficiencies in the handover document , and the handover document itself was not disclosed to the Coroner’s Office until the final inquest hearing.
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of care staff to read and understand key care-plan requirements
Wider context from the report “2) The carer who provided personal care to Mrs. Pye on the occasion when she fell from her bed on 29.3.24 knew that he should have done so with a colleague, but would regularly do so on his own. He had never himself read Mrs. Pye’s care plan , and it became clear that two other members of staff who provided evidence at the inquest were also unaware of some key aspects of the care plan . Furthermore, other staff were aware that he would often provide care to Mrs. Pye on his own, but no-one had reported this to senior staff or taken any action to try to stop it happening;
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of handover documents
Wider context from the report “4) There was no system in place at the time for auditing these handover documents ;
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide personal care with the required number of carers
Wider context from the report “2) The carer who provided personal care to Mrs. Pye on the occasion when she fell from her bed on 29.3.24 knew that he should have done so with a colleague, but would regularly do so on his own. He had never himself read Mrs. Pye’s care plan, and it became clear that two other members of staff who provided evidence at the inquest were also unaware of some key aspects of the care plan. Furthermore, other staff were aware that he would often provide care to Mrs. Pye on his own, but no-one had reported this to senior staff or taken any action to try to stop it happening;
” Open source report
Concerns raised 7 Failure to coach non-clinical staff to improve chest compressions View source Failure to check breathing during resuscitation View source Failure of a nurse to administer chest compressions View source Failure to maintain oxygenation throughout nurse-led resuscitation View source Failure to confirm absent breathing using an adequate assessment View source Failure to provide consistently effective chest compressions View source Incorrect application of defibrillator pads View source See 4 more concerns
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
Robert Thomas GINN · 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
Robert Thomas Ginn hanged himself in his cell at HM Prison Pentonville and was discovered at around 1.05am on 29 November 2018. Concerns were raised about the quality of the nurse-led resuscitation attempt, including failure to check breathing, inadequate oxygenation, variable chest compressions, lack of coaching, and incorrectly applied defibrillator pads.
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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to coach non-clinical staff to improve chest compressions
Wider context from the report “7. No attempt was made by either of the nurses to coach the prison officer to improve the quality of chest compressions .
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to check breathing during resuscitation
Wider context from the report “2. Throughout the resuscitation attempt captured on BWC, no staff member checked Mr Ginn’s breathing .
It is possible that the breathing was checked before the commencement of the bodycam footage, and indeed one of the prison officers said he checked it at the outset, but the footage ran for nearly eleven minutes before the London Ambulance Service arrived and took over, and it was not checked in that time .
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of a nurse to administer chest compressions
Wider context from the report “8. One of the nurses (Hotel 7) did not administer chest compressions at all . She did not give evidence at inquest and so the reason for this is unclear.
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain oxygenation throughout nurse-led resuscitation
Wider context from the report “4. After the first two minutes of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn .
5. Given that Mr Ginn’s heart had stopped beating, he must have stopped breathing as well. A full, effective, nurse led resuscitation attempt should have included an attempt to oxygenate throughout .
Hotel 12 said that she did not do this because Mr Ginn’s jaw was too stiff to insert an airway, but the LAS did so without any difficulty. And if he had been cold and stiff when they arrived, the LAS paramedics would not have commenced resuscitation.
In any event, an oxygen mask can be applied even if there is stiffness (as it was here, but then it was removed two minutes into the resuscitation and nearly nine minutes before LAS took over).
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm absent breathing using an adequate assessment
Wider context from the report “3. At inquest, one of the nurses said that she looked at Mr Ginn’s chest at the outset, but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing .
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistently effective chest compressions
Wider context from the report “6. Chest compressions given by different members of staff were variable and some, including those of one of the nurses, were sub optimal .
At one point, chest compressions were given by a staff member sandwiched between Mr Ginn and the wall, where there was not enough space to be effective .
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Incorrect application of defibrillator pads
Wider context from the report “9. The defibrillator pads were incorrectly applied by the nursing team , rendering the defibrillator reading unreliable .
” Open source report
Concerns raised 6 Failure of GPs to know that they are allowed to verify death View source Failure to request an ambulance promptly after a level one call View source Unclear responsibility for attending prisoners with life-threatening conditions View source Unclear process for attending prisoners with life-threatening conditions View source Confusion over requesting an ambulance after a level one call View source Failure of prison GPs to understand procedures for verifying death View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William DAVIES · 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 Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification of death.
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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to know that they are allowed to verify death
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death , and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances.
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to request an ambulance promptly after a level one call
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013 ) that prison comms should call an ambulance as soon as they have been notified of a level one .
However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called . ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either.
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for attending prisoners with life-threatening conditions
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one.
However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either.
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Unclear process for attending prisoners with life-threatening conditions
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances.
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Confusion over requesting an ambulance after a level one call
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances.
” 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 UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of prison GPs to understand procedures for verifying death
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one.
However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death , and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either .
” 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 Review emergency care arrangements, including staff training and standardisation of emergency bags.
Verbatim wording from the response “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.” Source location Response from Care UK
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 Brief and reinforce all HMP Pentonville GPs’ responsibilities and legal authority to declare life extinct after emergency examination.
Verbatim wording from the response “The Care UK National Medical Director for Health in Justice has spoken with the lead GP to clarify her role regarding decision to cease CPR and declare life extinct. The Head of Healthcare has additionally briefed all General Practitioners working at HMP Pentonville about their responsibility and legal right to declare life extinct following their examination in an emergency situation. All doctors are given orientation and induction prior to working at HMP Pentonville; this has been reinforced with the existing team and any locum providers. This is also included in all GP inductions.” Source location Response from Care UK
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 Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.
Verbatim wording from the response “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.” Source location Response from Care UK
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations