5 Dec 2022 Richard Thomas SHANNON · Prevention of Future Deaths report Inner North London
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Concerns raised 9 Failure to consider documented pressure-ulcer risk when issuing care instructions View source Failure to adequately investigate safeguarding explanations and evidence View source Failure to implement system, training and partnership changes after safeguarding investigation View source Failure to involve district nursing team in discharge planning View source Failure to arrange pressure-relieving bed and mattress replacement before discharge View source Failure to provide required personal hygiene and catheter care during home visits View source Failure to issue and disseminate daily skin-integrity checking instructions to all carers View source Omission of daily skin-integrity checking instruction from discharge assessment form View source Failure to establish daily skin-integrity monitoring responsibility View source See 6 more concerns
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Richard Thomas SHANNON · 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 Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.
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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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to consider documented pressure-ulcer risk when issuing care instructions
Wider context from the report “5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions . She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers.
She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers.
She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately investigate safeguarding explanations and evidence
Wider context from the report “7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death.
In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done.
There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to implement system, training and partnership changes after safeguarding investigation
Wider context from the report “8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months . The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place .
Apparently, no lessons have been learnt.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to involve district nursing team in discharge planning
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting , it is much more likely that this measure would have been considered.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange pressure-relieving bed and mattress replacement before discharge
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide required personal hygiene and catheter care during home visits
Wider context from the report “6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag .
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it.
In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to issue and disseminate daily skin-integrity checking instructions to all carers
Wider context from the report “3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction .
Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice.
Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report “4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
” 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 Kapital Care (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to establish daily skin-integrity monitoring responsibility
Wider context from the report “2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer.
The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care.
If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
” 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