10 Sep 2025 Stuart GILCHRIST · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1 Failure to make restaurants and food establishments aware of choking-rescue equipment View source
Responses linked to these concerns
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AI-generated summary
Stuart GILCHRIST · 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
Stuart GILCHRIST, aged 77, died after choking on food at a restaurant during an outing with care home staff and other service users. Despite prompt first aid, emergency treatment and CPR, he was declared deceased. The principal concern was that restaurants and food establishments may not be aware of, or have access to, LifeVac-type suction devices that may assist during choking incidents.
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× 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make restaurants and food establishments aware of choking-rescue equipment
Wider context from the report “1. During the evidence it was heard that there is a device that may assist in incidents of choking, it was referred to as a LifeVac (this may be a trade name). The care staff member, had recognised that Mr GILCHRIST was choking and while administering assistance to him had the foresight to ask if the restaurant had a “LifeVac” style device.
2. It was acknowledged during the inquest that restaurants have first aid items and some may have equipment such as a defibrillator however they may not be aware that this useful item exists, nor that it is relatively inexpensive.
3. At the time the evidence was heard, I was unaware of who would be responsible for advising restaurants and food establishments of the availability of such an item, or to raise with those outlets its usefulness should a customer begin to choke ; so therefore this RPFD is sent to three organisations who may have varying levels of responsibility - without restaurants and food establishments being made aware of such an item, they may not think to purchase one and retain it within their first aid armoury .
4. I also appreciate that LifeVac is probably a trade name and I only use it to describe the type of item that would be deemed useful.
” Open source report
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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 The HSE is the appropriate organisation to provide first-aid kit guidance; the authority will signpost businesses rather than issue specific guidance.
Verbatim wording from the response “The Health and Safety (First-Aid) Regulations 1981 require employers to provide adequate and appropriate equipment, facilities and personnel to ensure their employees receive immediate attention if they are injured or taken ill at work. The equipment provided should be determined by a medical needs assessment. The HSE publish guidance on the Regulations and the guidance includes information on what first aid equipment should be included in a first aid kit. For this reason, I recommend that the most appropriate organisation to serve the Regulation 28 onto was the HSE as they publish guidance freely available to all businesses in the UK. Our Local Authority would signpost businesses to this guidance and would not provide specific guidance ourselves.” Source location Response from East Riding Council
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 Businesses have no legal requirement to provide first aid to members of the public, although doing so is recommended as best practice.
Verbatim wording from the response “Furthermore, the Regulations cover first aid for employees only. There are no legal requirements for businesses to provide first aid to members of the public such as customers although it is recommended as best practice.” Source location Response from East Riding Council
Open published response
24 Nov 2024 Colin Wiles · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 5 Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect View source Excessive ambulance patient handover waiting times at Hull Royal Infirmary View source Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary View source Lack of criteria to reside for patients arriving in emergency ambulances View source Unclear advice to callers about calling emergency services back when concerns continue View source See 2 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
Colin Wiles · 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
Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.
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× 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect
Wider context from the report “(1) No Vulnerable Adult Risk Management meeting was held despite multifactorial concerns with Mr Wiles’ comorbidities and self neglect leading to poor living conditions and increased risk to his safety
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Excessive ambulance patient handover waiting times at Hull Royal Infirmary
Wider context from the report “(3) The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary
Wider context from the report “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances .
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of criteria to reside for patients arriving in emergency ambulances
Wider context from the report “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Unclear advice to callers about calling emergency services back when concerns continue
Wider context from the report “(2) It does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns.
” 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 and renew the VARM procedure into a more contemporary, seamless and accessible Multi Agency Risk Management meeting procedure.
Verbatim wording from the response “The current VARM procedure is available to all professionals and people in the east riding on the ERSAB website and guides them through the processes and paperwork involved (included as appendix 1). Training is provided to practitioners across the health and care system in the east riding on the use of VARM both through the ERSAB and the local authorities internal learning and skills team. To enable development in this area, the ERSAB and ASCH have collaborated with Hull City Council’s safeguarding adults board and Adult Services to review and renew the VARM procedure to contemporise the approach and develop a more seamless and accessible procedure in this geographical area.” Source location Response from East Riding of Yorkshire Council
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 Consider making Multi Agency Risk Management training mandatory for adult social care and health practitioners through the practice development board.
Verbatim wording from the response “The VARM training is therefore currently under review and will be relaunched following the completion of this work to ensure and enable effective roll out of the new procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be considered by the service at our practice development board which is chaired by our Head of Service for Safeguarding and Quality Assurance.” Source location Response from East Riding of Yorkshire Council
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 Relaunch risk-management training after the new Multi Agency Risk Management procedure is finalised.
Verbatim wording from the response “The VARM training is therefore currently under review and will be relaunched following the completion of this work to ensure and enable effective roll out of the new procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be considered by the service at our practice development board which is chaired by our Head of Service for Safeguarding and Quality Assurance.” Source location Response from East Riding of Yorkshire Council
Open published response
4 Nov 2024 Janet Brown Townend · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 8 Failure to consider reassessment of capacity View source Inaccurate recording of Early Warning Signs View source Insufficient time spent providing care and completing care duties View source Failure to escalate concerns about sickness View source Failure to follow up on intended GP support View source Failure to escalate concerns about reduced food intake View source Failure to escalate Early Warning Signs View source Failure to escalate concerns about unwise refusals of care, food and medical intervention View source See 5 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.
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AI-generated summary
Janet Brown Townend · 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
Janet Brown Townend, who had diabetes and other comorbidities, developed an infected foot wound that progressed to sepsis despite hospital treatment, and she died on 15 October 2023. Concerns arose about the care provided by carers, including brief visits, failure to escalate poor nutrition, sickness and early warning signs, inaccurate records, and failure to follow up or escalate refusals of care and medical intervention.
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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider reassessment of capacity
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity .
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of Early Warning Signs
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns . This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient time spent providing care and completing care duties
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend . Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks ; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate concerns about sickness
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness . There were a number of times Ms Townend presented with having been sick and this was not considered as a concern ;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up on intended GP support
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell . This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done ;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate concerns about reduced food intake
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating . As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate Early Warning Signs
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present . The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated ;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate concerns about unwise refusals of care, food and medical intervention
Wider context from the report “During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare.
These include:
a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ;
b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important;
c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern;
d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated;
e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done;
f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention . This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity.
” Open source report
4 Nov 2024 Janet Brown Townend · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 8 Failure to provide Safeguarding Adult Review outcomes and recommendations to review subjects View source Failure to appropriately probe responses during Safeguarding Adult Reviews View source Failure to document the full Safeguarding Adult Review process properly View source Failure to record how review responses were obtained View source Lack of adequate Safeguarding Adult Review quality View source Failure to record family input in Safeguarding Adult Reviews View source Failure to follow the full Safeguarding Adult Review process View source Hasty Safeguarding Adult Review processes View source See 5 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
Janet Brown Townend · 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
Janet Brown Townend developed an infected foot wound that progressed to sepsis after an injury, and she died in hospital on 15 October 2023 despite antibiotics, surgery and other treatment. Concerns were raised about the care she received and about the subsequent Safeguarding Adult Review, which was described as lacking professional curiosity, family input, appropriate scrutiny and proper documentation.
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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Safeguarding Adult Review outcomes and recommendations to review subjects
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately probe responses during Safeguarding Adult Reviews
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way .
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document the full Safeguarding Adult Review process properly
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly .
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record how review responses were obtained
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained . The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate Safeguarding Adult Review quality
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record family input in Safeguarding Adult Reviews
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the full Safeguarding Adult Review process
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Hasty Safeguarding Adult Review processes
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” 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 Disseminated lessons learned from the identified enquiry practice issues across the safeguarding team.
Verbatim wording from the response “The record of the enquiry also lacked analysis of the information that was received from both services approached for information and it was not fully triangulated with other information gathered from both Janet Brown Townend herself and members of her family within the record of the section 42 enquiry. It is difficult to say whether the outcome of the enquiry would have been different had these issues been addressed, however, it is acknowledged that the recorded evidence for decision making and subsequent actions in this case could have been improved. The practice issues identified in this enquiry have been addressed with the individual practitioner and lessons learned disseminated within the team.” Source location Response from East Riding of Yorkshire Council
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 Delivered training, learning and guidance to strengthen practitioners’ completion of safeguarding forms, professional curiosity and thorough enquiry practice.
Verbatim wording from the response “The roll out of the forms was accompanied by training and learning for those who are completing them, refreshing practitioners understanding about the expectations for their completion, what good looks like and encouraging professional curiosity. There is also accompanying guidance for practitioners within and external to the form to support them to undertake and record a thorough section 42 enquiry.” Source location Response from East Riding of Yorkshire Council
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 Implemented new forms guiding practitioners to undertake and record safeguarding concerns and Section 42 enquiries, including person and family voices and outcome-sharing records.
Verbatim wording from the response “In November 2023 (after this enquiry took place), as part of the implementation of a new service and practice model for safeguarding adults, the service launched a new set of forms to record safeguarding adult concerns and section 42 enquiries. These forms lead the practitioner through a much more succinct process for undertaking and recording their intervention with the voice of the person and their family/representative at the heart of the enquiry record.” Source location Response from East Riding of Yorkshire Council
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 Implemented practice workshops and a weekly safeguarding hub forum providing case discussion and leadership guidance.
Verbatim wording from the response “To support high quality safeguarding adults enquiry practice, the services practice development team has implemented a training programme of practice workshops accompanied by a weekly practice forum with the safeguarding adults hub where cases can be discussed and practitioners obtain clear guidance from the safeguarding adults leadership team. The service also leads a safeguarding champions programme bringing professionals from within and external to the local authority together to share good practice and develop consistent responses to safeguarding across the sector.” Source location Response from East Riding of Yorkshire Council
Open published response
27 Jun 2023 Richard Stephen LITTLEWOOD · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Repeated incidents on a particular stretch or bend of the A1033 View source Failure to set a timescale for assessment of additional road markings View source
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
Richard Stephen LITTLEWOOD · 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
Richard Stephen Littlewood was involved in a motorcycle collision on the A1033 on 8 July 2022 after his motorcycle crossed the white line and struck an oncoming vehicle. He sustained multiple traumatic injuries, spent three weeks in intensive care, and died on 29 July 2022. Concerns were raised about multiple incidents on the same bend and the lack of a timescale for assessing additional road markings and signage.
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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Repeated incidents on a particular stretch or bend of the A1033
Wider context from the report “(1) Evidence was heard that, on this particular stretch/bend of the A1033, there have been 3 incidents that have occurred within a short space of time .
• A fatality leading to the death of Mr Littlewood in July 2022.
• A fatality leading to the death of another male in November 2022.
• An incident involving a farm vehicle which shed its load in late June/early July 2022 (very little details are known of this, suffice that it occurred near the location of the bend in the road where Mr Littlewood died, albeit on the opposite side).
I do acknowledge that each of these incidents are completely different scenarios.
It may be worthwhile to note that it is local road users that have been involved in all the incidents.
” 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 East Riding of Yorkshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to set a timescale for assessment of additional road markings
Wider context from the report “(2) During evidence it was heard that signage and road markings have been discussed between the police and Highways that may make the road safer. Some signage had been put in place but an assessment needs to be completed for additional road markings and the timings for this were unclear . I am aware that after every fatality in this area the police and the Highways liaise with each other over signage/road markings as a matter of course. I have concerns only regarding the fact that no timescale had been set for the assessment to take place .
” 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 Replace chevron signs warning of bends for traffic approaching from both directions.
Verbatim wording from the response “1. The chevron signs warning of the bends facing traffic in both directions have been replaced. This work was carried out in July 2023.” Source location Response from East Riding of Yorkshire Council
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 Complete winter and summer visibility surveys to assess sightlines around the bends against the 40mph speed limit and existing centre lines.
Verbatim wording from the response “2. A winter visibility survey was undertaken at the bends on 17th January 2023.” Source location Response from East Riding of Yorkshire Council
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 Visibility is suitable for the 40mph limit and existing hazard warning centre lines are appropriate; no additional works are planned.
Verbatim wording from the response “4. These surveys confirmed that the visibility available around the bends is suitable for the 40mph speed limit that is in place and that the existing hazard warning centre lines are appropriate.” Source location Response from East Riding of Yorkshire Council
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations