Hamilton Community Homes Limited

Private and voluntary organisations · Private limited company

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First report 22 Feb 2022•Latest report 22 Feb 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
8

Described in responses

Concerns and recipient responses

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

  1. Leicester City and South Leicestershire

    AI-generated summary

    Jane Louise SHILTON · 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

    Jane Louise Shilton, who had severe and enduring mental health difficulties and lived in a residential care home, was found unresponsive in her bedroom and was pronounced dead at the scene. The report raises concerns about the failure to check on her after missed medication, dinner and cigarettes, the absence of overnight proactive checks, and the staff’s response to the medical emergency, including not checking breathing or pulse and not attempting CPR. It also raises concerns about the quality and frequency of first-aid training.

    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 Hamilton Community Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide first aid during incidents

    Wider context from the report

    “I was told during the inquest that Hamilton House First Aid Training was outdate at the point Jane died and I have since been provided with the First Aid Training Certificates which evidence that First Aid Training was provided to staff once every 3 years, and this was in 2018 and staff had received updated training in 2021, within the 3 year time frame. I remain concerned and that concern is heightened when having heard the evidence of the support workers on shift that evening to learn that updated first aid training was only undertaken 5 days prior to this incident. I understand that the first aid training in 2021 was delivered online given the Cv19 restrictions. I further understand that whilst yearly first aid refresher training can be undertaken Hamilton House have not required staff to undergo such training. As I have found in this inquest sadly for Jane the failure to attempt to deliver any first aid would not have made any difference in her case as she had been sadly passed away for some time. However, the way in which the incident was handled which is evident from the 999 call which gave rise to a safeguarding alert does deeply trouble me especially in the context of learning that refresher training had been received by the individuals engaged with the incident only 5 days prior. This causes me to question quality of that training in the context of an online setting given the pandemic. I am further concerned that first aid training is only undertaken at the minimum requirement of every 3 years, given that Hamilton House is charged with the responsibility of looking after some of society’s most vulnerable individuals who I am told have co-existing difficulties of both mental health but also substance misuse. ”
    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 Hamilton Community Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequacy of online first aid training

    Wider context from the report

    “I was told during the inquest that Hamilton House First Aid Training was outdate at the point Jane died and I have since been provided with the First Aid Training Certificates which evidence that First Aid Training was provided to staff once every 3 years, and this was in 2018 and staff had received updated training in 2021, within the 3 year time frame. I remain concerned and that concern is heightened when having heard the evidence of the support workers on shift that evening to learn that updated first aid training was only undertaken 5 days prior to this incident. I understand that the first aid training in 2021 was delivered online given the Cv19 restrictions. I further understand that whilst yearly first aid refresher training can be undertaken Hamilton House have not required staff to undergo such training. As I have found in this inquest sadly for Jane the failure to attempt to deliver any first aid would not have made any difference in her case as she had been sadly passed away for some time. However, the way in which the incident was handled which is evident from the 999 call which gave rise to a safeguarding alert does deeply trouble me especially in the context of learning that refresher training had been received by the individuals engaged with the incident only 5 days prior. This causes me to question quality of that training in the context of an online setting given the pandemic. I am further concerned that first aid training is only undertaken at the minimum requirement of every 3 years, given that Hamilton House is charged with the responsibility of looking after some of society’s most vulnerable individuals who I am told have co-existing difficulties of both mental health but also substance misuse. ”
    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 Hamilton Community Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide first aid refresher training more frequently than every three years

    Wider context from the report

    “I was told during the inquest that Hamilton House First Aid Training was outdate at the point Jane died and I have since been provided with the First Aid Training Certificates which evidence that First Aid Training was provided to staff once every 3 years, and this was in 2018 and staff had received updated training in 2021, within the 3 year time frame. I remain concerned and that concern is heightened when having heard the evidence of the support workers on shift that evening to learn that updated first aid training was only undertaken 5 days prior to this incident. I understand that the first aid training in 2021 was delivered online given the Cv19 restrictions. I further understand that whilst yearly first aid refresher training can be undertaken Hamilton House have not required staff to undergo such training. As I have found in this inquest sadly for Jane the failure to attempt to deliver any first aid would not have made any difference in her case as she had been sadly passed away for some time. However, the way in which the incident was handled which is evident from the 999 call which gave rise to a safeguarding alert does deeply trouble me especially in the context of learning that refresher training had been received by the individuals engaged with the incident only 5 days prior. This causes me to question quality of that training in the context of an online setting given the pandemic. I am further concerned that first aid training is only undertaken at the minimum requirement of every 3 years, given that Hamilton House is charged with the responsibility of looking after some of society’s most vulnerable individuals who I am told have co-existing difficulties of both mental health but also substance misuse. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Arrange face-to-face First Aid training with the training provider.

    Verbatim wording from the response

    “• First Aid training is now mandated annually instead of the previous 3 year requirement and in light of Covid-19 restrictions coming to an end this training will be carried out face-to-face. We are communicating with our training provider to accommodate this training as we can not complete the training in one session. We hope to complete this by the end of April 2022.”

    Source location

    2022-0053-Response-from-Hamilton-Community-Homes-Ltd_Published
    Page 2 · response
    Published 24 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Mandate annual First Aid training instead of training every three years.

    Verbatim wording from the response

    “• First Aid training is now mandated annually instead of the previous 3 year requirement and in light of Covid-19 restrictions coming to an end this training will be carried out face-to-face. We are communicating with our training provider to accommodate this training as we can not complete the training in one session. We hope to complete this by the end of April 2022.”

    Source location

    2022-0053-Response-from-Hamilton-Community-Homes-Ltd_Published
    Page 2 · response
    Published 24 February 2022

    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

Data last updated 7 September 2026