Recipient

Revon Healthcare Ltd

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First report 2 Jan 2025•Latest report 2 Jan 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Revon Healthcare Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    James Stephen KEEN · 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

    James Stephen KEEN was found deceased in his room at supported accommodation on 8 December 2023. He had a history of severe mental ill-health and substance abuse, and the inquest conclusion recorded a drug-related death involving the cardiotoxic effects of methamphetamine and sildenafil. Concerns included confusion and inadequate documentation about physical health observations by untrained support workers, a broken thermometer, and a lack of evidence of appropriate training or competency checks.

    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 Revon Healthcare Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document physical health observations

    Wider context from the report

    “(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”
    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 Revon Healthcare Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide and verify support workers’ training and competence for physical health checks

    Wider context from the report

    “(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”
    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 Revon Healthcare Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of physical health observations to produce and support reliable interpretation of results

    Wider context from the report

    “(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”
    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 Revon Healthcare Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of qualified staff to recognise support workers’ lack of knowledge

    Wider context from the report

    “(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”
    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 Revon Healthcare Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a functioning thermometer

    Wider context from the report

    “(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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