8 May 2026 Jake Daniel Taylor · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Lack of airway equipment View source Lack of airway training for staff View source Unavailability of a defibrillator on site View source Lack of individual emergency planning for service users with high-tier needs and life-threatening risk profiles View source Staff misunderstanding of defibrillator function View source Inadequate staff training to conduct CPR unless a contrary decision exists View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jake Daniel Taylor · 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
Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.
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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Lack of airway equipment
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies .
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Lack of airway training for staff
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator on site
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Lack of individual emergency planning for service users with high-tier needs and life-threatening risk profiles
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate .
” 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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Staff misunderstanding of defibrillator function
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator .
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training to conduct CPR unless a contrary decision exists
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 Develop and finalise individualised first aid support plans for people supported at Roy Kinnear House, including emergency interventions, equipment and staff training.
Verbatim wording from the response “All people currently supported at (5 people) Roy Kinnear House will now have a clearly documented first aid support plan. The steps to fulfil this are as follows:
- Draft plans to be developed through multidisciplinary team involvement and best interests decision-making. As the support provider we will liaise with medical professionals who are best placed to make decisions around the type of support and equipment people will need in emergency interventions.
- Detail the level of support and interventions required during medical emergencies
- Detail the type of equipment needed, which may include airway equipment
- Staff will have relevant training on the first aid support plan and on the necessary equipment.
- Final plans to be uploaded onto each person’s profile” Source location Response from Choice Support
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 Provide individualised first aid support plans across Choice Support, recording them on Nourish and updating them at least annually or when needs change.
Verbatim wording from the response “In line with our First Aid Policy (last updated May 2026) all people we support across Choice Support will be supported to have a First Aid Support Plan that details the support they may need for various medical emergencies.
This Plan will be visible on Nourish and updated as and when needs change, but yearly as a minimum.” Source location Response from Choice Support
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 Circulate organisation-wide guidance requiring CPR where no DNACPR exists, with updated CPR practice guidance.
Verbatim wording from the response “Circulate a briefing reminding all staff at Choice Support that CPR must be performed where no DNACPR exists, alongside updated CPR practice guidance in line with our First Aid Policy.
Timescales: 30th June 2026” Source location Response from Choice Support
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 Reinforce CPR and safe AED-use training for Roy Kinnear House staff.
Verbatim wording from the response “First Aid training already includes training and practical competency of CPR and safe use of AEDs in line with national guidance. This will be reinforced for the staff at Roy Kinnear House.” Source location Response from Choice Support
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 Require all Roy Kinnear House staff to repeat First Aid training and practical competency assessment, including CPR where no DNACPR exists.
Verbatim wording from the response “All staff at Roy Kinnear House will re-complete First Aid Training and Practical Competency, with the understanding that staff should always conduct CPR if there is no decision to the contrary.
Timescales: 31st July 2026” Source location Response from Choice Support
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 Purchase and install an AED at Roy Kinnear House.
Verbatim wording from the response “Choice Support will purchase an AED to be installed at Roy Kinnear House. We are liaising with Quality Assurance Commissioners and the ICB.
Timescales: Completed and delivered on 8th June 2026” Source location Response from Choice Support
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 AEDs are not routinely installed across services; installation is determined through service-specific risk assessment and governance processes.
Verbatim wording from the response “We recognise the concern regarding the absence of an on-site AED. Choice Support does not routinely install defibrillators unless determined through risk assessment and governance processes. We will be taking actions against this.” Source location Response from Choice Support
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 Health professionals determine appropriate emergency interventions and the training required to deliver them for each individual.
Verbatim wording from the response “the training, staff are introduced to possible equipment, including airway supports.
The use of such equipment will then be based on the needs of the person supported, their health needs and in best interests discussions with the family and health professionals. The health professionals will guide on the most appropriate interventions for each individual and training requirements to support their use.” Source location Response from Choice Support
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 Airway equipment is provided only where clinically indicated, prescribed and documented in an individual's care plan.
Verbatim wording from the response “We note the concern regarding airway management and equipment. In this service model, clinical equipment such as oxygen therapy and suctioning is provided where clinically indicated, prescribed and documented within an individual’s care plan. The nursing team is supported to undertake clinical observations, including monitoring of blood pressure, oxygen saturation and temperature, to identify deterioration and escalate appropriately. Where a person requires additional medical equipment as part of a planned emergency response, this will be agreed through multidisciplinary team discussion and appropriate equipment and training will be put in place to ensure staff have the skills and confidence to deliver care safely and effectively.” Source location Response from Choice Support
Open published response
18 Dec 2023 David Hemmings · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Insufficient and unmemorable training for managers and support workers View source Unsafe movement of injured people View source
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.
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AI-generated summary
David Hemmings · 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
David Hemmings fell in his flat, sustaining severe pelvic fractures and a displaced right femur fracture. He later developed a wound infection and died of peritonitis following surgical treatment. The principal concern was that staff training on moving and handling after a fall was insufficient or unmemorable, leading staff to move him unsafely and delay seeking clinical care.
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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Insufficient and unmemorable training for managers and support workers
Wider context from the report “That the training given to both the manager and the support worker was insufficient and unmemorable , such that it was disregarded when it was required , and that moving injured people in such a way could worsen injury and endanger life.
” 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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Unsafe movement of injured people
Wider context from the report “That the training given to both the manager and the support worker was insufficient and unmemorable, such that it was disregarded when it was required, and that moving injured people in such a way could worsen injury and endanger life .
” Open source report
Concerns raised 1 Failure to access and read all relevant information across nursing and clinical records View source
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
Russell James Felstead · 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
Russell James Felstead, who had severe learning disabilities, epilepsy and a history of falls, was found unresponsive on the floor of his room on 7 January 2013 and died on 28 January 2013 after a subdural haematoma was identified and operated on. Relevant information about his falls and helmet was available in the hospital records from 7 January but was not noted by doctors until 11 January, when an urgent CT scan was requested.
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 Choice Support; that does not assign responsibility.
PFD Monitor interpretation Failure to access and read all relevant information across nursing and clinical records
Wider context from the report “Doctors must ensure that all relevant information is accessed and read even if this is in the Nursing notes as opposed to the Clinical records. It is clear that the information which prompted an urgent CT scan on the 11th January had been available in Mr Felstead’s medical records since the 7th January and his helmet had in fact been at the hospital.
” Open source report
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Addressed to Choice Support, now represented here by Choice Support.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations