30 Aug 2024 Wendy Ann AFFORD · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 8 Inadequate training in the use of care plans View source Incomplete recording of repositioning movements View source Unreliable use of electronic care-record repositioning prompts and mandatory tasks View source Failure to complete body maps at the required frequency for monitoring pressure areas View source Failure to audit records and compliance with care plans View source Inadequate training in record keeping View source Inadequate training in monitoring skin integrity View source Failure to identify and assess high risk of pressure damage in skin-integrity risk assessments View source See 5 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Create an incident matrix covering skin-integrity documentation in risk assessments, care notes and care plans.
View source
×
AI-generated summary
Wendy Ann AFFORD · 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
Wendy Ann Afford was bedbound and living alone with a package of care before developing worsening pressure damage and an infected pressure ulcer. After hospital treatment and discharge to a care home, her health declined and she died on 15 November 2023. Concerns included inadequate skin-integrity risk assessment and monitoring, incomplete repositioning records, unclear compliance with care plans, insufficient management oversight, and possible inadequate staff 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Inadequate training in the use of care plans
Wider context from the report “5. Given these numerous difficulties there is a concern that care staff are not properly trained in the use of care plans , record keeping and importance of monitoring skin integrity.
” 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Incomplete recording of repositioning movements
Wider context from the report “3. It was not clear whether the carers were properly following the care plan and the records showing whether or not Mrs Afford was repositioned were incomplete . The records that did exist only recorded her position or stated ‘repositioned’ they did not record whether she was moved, for example, from left to right . The facility within the electronic care record system to highlight the need for carers to reposition Mrs Afford, and record the move, were not used reliably and I heard evidence from a manager which suggested they were not aware of the ability to set repositioning as a mandatory task for each visit.
” 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Unreliable use of electronic care-record repositioning prompts and mandatory tasks
Wider context from the report “3. It was not clear whether the carers were properly following the care plan and the records showing whether or not Mrs Afford was repositioned were incomplete. The records that did exist only recorded her position or stated ‘repositioned’ they did not record whether she was moved, for example, from left to right. The facility within the electronic care record system to highlight the need for carers to reposition Mrs Afford, and record the move, were not used reliably and I heard evidence from a manager which suggested they were not aware of the ability to set repositioning as a mandatory task for each visit .
” 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to complete body maps at the required frequency for monitoring pressure areas
Wider context from the report “2. It is not clear whether body maps were completed as often as required by the carers and therefore there is a concern that they were not monitoring Mrs Affords pressure areas properly .
” 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to audit records and compliance with care plans
Wider context from the report “4. The management of the care company did not appear to carry out audits of records and compliance with care plans nor have any other effective means of oversight .
” 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Inadequate training in record keeping
Wider context from the report “5. Given these numerous difficulties there is a concern that care staff are not properly trained in the use of care plans, record keeping and importance of monitoring skin integrity.
” 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Inadequate training in monitoring skin integrity
Wider context from the report “5. Given these numerous difficulties there is a concern that care staff are not properly trained in the use of care plans, record keeping and importance of monitoring skin integrity .
” 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 Happy at Home Community Care Services Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and assess high risk of pressure damage in skin-integrity risk assessments
Wider context from the report “1. The risk assessment for Mrs Afford in respect of her skin integrity did not record her high risk of developing pressure damage and it was entirely unclear how the risk was assessed in the first place .
” 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 Create an incident matrix covering skin-integrity documentation in risk assessments, care notes and care plans.
Verbatim wording from the response “Further to the incident that happened regarding the death of the late Wendy Afford, the following action plans have been taken and implemented:” Source location Response from Happy at Home Community Care Services Ltd
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations