John Stanley's Care Agency Limited

Private and voluntary organisations · Social-care provider

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First report 20 Feb 2015•Latest report 20 Feb 2015

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from John Stanley's Care Agency Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. London (East)

    AI-generated summary

    Michael Joseph Lyons · 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

    Michael Joseph Lyons had Parkinson’s disease with significant difficulties in balance, speech and swallowing. On 23 September 2014, while being cared for at home, he choked on cheese on toast after it was not cut into small pieces and he was left eating unsupervised, causing his death. Concerns included the absence of an adequate care plan addressing the known choking risk, including food preparation and supervision, and the failure to establish and implement the speech and language therapist’s recommendations.

    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 John Stanley's Care Agency Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure carers are aware of required food preparation for swallowing safety

    Wider context from the report

    “(1) The Care Agency were aware of the swallowing difficulties experienced by Mr Lyons and they had been informed of a SALT assessment having taken place in June 2014. (2) There was no evidence that the Care Agency had made any attempt to determine the outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the risk of choking. (3) Some carers were aware of the need for food to be cut into small pieces. The carer who attended on the 23 September confirmed that she was not aware that food needed to be cut up. (4) The care plan did not provide a management plan to protect Mr Lyons from the risk of choking. The care plan did not specify that food should be cut up and did not confirm that Mr Lyons should be supervised. (5) The care plan was dated 10 September 2014. The information from the SALT was available at that time and the author of the care plan should have taken steps to ensure that the care plan reflected the recommendations from the assessment. ”
    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 John Stanley's Care Agency Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Care plans failing to specify swallowing-risk management measures

    Wider context from the report

    “(1) The Care Agency were aware of the swallowing difficulties experienced by Mr Lyons and they had been informed of a SALT assessment having taken place in June 2014. (2) There was no evidence that the Care Agency had made any attempt to determine the outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the risk of choking. (3) Some carers were aware of the need for food to be cut into small pieces. The carer who attended on the 23 September confirmed that she was not aware that food needed to be cut up. (4) The care plan did not provide a management plan to protect Mr Lyons from the risk of choking. The care plan did not specify that food should be cut up and did not confirm that Mr Lyons should be supervised. (5) The care plan was dated 10 September 2014. The information from the SALT was available at that time and the author of the care plan should have taken steps to ensure that the care plan reflected the recommendations from the assessment. ”
    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 John Stanley's Care Agency Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to determine the outcome of swallowing assessments

    Wider context from the report

    “(1) The Care Agency were aware of the swallowing difficulties experienced by Mr Lyons and they had been informed of a SALT assessment having taken place in June 2014. (2) There was no evidence that the Care Agency had made any attempt to determine the outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the risk of choking. (3) Some carers were aware of the need for food to be cut into small pieces. The carer who attended on the 23 September confirmed that she was not aware that food needed to be cut up. (4) The care plan did not provide a management plan to protect Mr Lyons from the risk of choking. The care plan did not specify that food should be cut up and did not confirm that Mr Lyons should be supervised. (5) The care plan was dated 10 September 2014. The information from the SALT was available at that time and the author of the care plan should have taken steps to ensure that the care plan reflected the recommendations from the assessment. ”
    Open source report
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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