11 Jan 2024 Nicholas CORK · Prevention of Future Deaths report Inner North London
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Concerns raised 6 Lack of consistent criteria for welfare checks and their recording View source Failure to undertake required welfare checks at least every 24 hours View source Inadequacy of the welfare-check recording system View source Inconsistent staff performance in completing welfare-check records View source Failure to physically verify residents’ welfare when welfare concerns arise View source Failure to investigate and implement improvements to welfare-check systems View source See 3 more concerns
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Nicholas CORK · 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
Nicholas Cork lived in supported accommodation and was found unresponsive in his room in the early morning of 22 May 2023; paramedics verified his death at 06:28. The report raised concerns that required welfare checks were not completed for at least 36–48 hours before his death, including a missed opportunity when staff opened his door but did not enter or properly assess him. It also identified concerns about inconsistent recording practices, the adequacy of the spreadsheet system, and staff training and follow-up.
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 Sapphire Independent Housing Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent criteria for welfare checks and their recording
Wider context from the report “(1) There was evidence that staff at Conway House were significantly concerned for Mr Cork’s welfare, which is why he was deemed as ‘at risk’. As a result of being ‘at risk’ I was told that welfare checks were required to be undertaken, at least every 24 hours. Such checks required a staff member to physically see and interact with Mr Cork or, in the alternative, to telephone him and speak to him. Welfare checks were then required to be recorded on a spreadsheet. Despite this, I was told in evidence that welfare checks would only be recorded if the resident in question was actually ‘seen’ by the staff member undertaking the check; this raises the concern that there is disparity about what constitutes a welfare check and what will or will not be recorded .
” 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 Sapphire Independent Housing Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required welfare checks at least every 24 hours
Wider context from the report “(2) I heard evidence that prior to Mr Cork being found unresponsive in his room on 22 May 2023, the last recorded welfare check for Mr Cork was during the early shift of Saturday 20 May 2023. The concern here is that Mr Cork, despite being required to have welfare checks at least once every 24 hours, was not properly checked upon for between 36-48 hours prior to his death .
” 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 Sapphire Independent Housing Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the welfare-check recording system
Wider context from the report “(4) In evidence, I was taken through the spreadsheet that is used to record all checks and/or welfare checks required for any residents of Conway House. The record system appears to have been a basic Microsoft Excel spreadsheet devised by staff. I was told that the computer and/or spreadsheet often ‘crashed’, which led to data sometimes not being able to be recorded . I also observed that some fields of the spreadsheet were often left blank . Staff undertaking and recording checks regularly appeared not to input their name(s) or the time at which checks were undertaken . I was also told that while there was some training on how to undertake and record welfare checks, this was not needed because it was a simple task.
The concern here is that the recording system for welfare checks may not be adequate and that the approach taken to filling in the data required on the spreadsheet varied from one staff member to another, which may also indicate that there is a training need.
” 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 Sapphire Independent Housing Limited; that does not assign responsibility.
PFD Monitor interpretation Inconsistent staff performance in completing welfare-check records
Wider context from the report “(4) In evidence, I was taken through the spreadsheet that is used to record all checks and/or welfare checks required for any residents of Conway House. The record system appears to have been a basic Microsoft Excel spreadsheet devised by staff. I was told that the computer and/or spreadsheet often ‘crashed’, which led to data sometimes not being able to be recorded. I also observed that some fields of the spreadsheet were often left blank. Staff undertaking and recording checks regularly appeared not to input their name(s) or the time at which checks were undertaken. I was also told that while there was some training on how to undertake and record welfare checks, this was not needed because it was a simple task.
The concern here is that the recording system for welfare checks may not be adequate and that the approach taken to filling in the data required on the spreadsheet varied from one staff member to another , which may also indicate that there is a training need.
” 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 Sapphire Independent Housing Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to physically verify residents’ welfare when welfare concerns arise
Wider context from the report “(3) A night project worker at Conway House told me in evidence that they had opened Mr Cork’s door at about 20:35 on Sunday 21 May 2023, but did not enter the room to see or assess Mr Cork . The only reason for opening the door appears to have been the arrival of the ‘EMS team’ who were required to check that Mr Cork was at home for the purposes of conditions imposed by the criminal justice system.
Having heard what they believed to be snoring, the staff member closed the door and left. This fact was verified by Metropolitan Police Officers who checked CCTV footage as part of their initial investigation following Mr Cork’s death. The concern here is that staff made assumptions that the ‘snoring’ noise was coming from Mr Cork’s room and not an adjoining room, and that the noise was snoring, without investigating further . This was a missed opportunity to properly check on Mr Cork’s welfare, as required.
” 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 Sapphire Independent Housing Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate and implement improvements to welfare-check systems
Wider context from the report “(5) I was told in evidence that the same spreadsheet is still used to record any checks and/or welfare checks required for residents. I was told that the issues identified with a lack of checks for Mr Cork were caused by the fact that there were a significant number of agency staff on duty and that Conway House no longer uses agency staff. However, the staff member that opened Mr Cork’s door at 20:35 (without entering the room or seeing Mr Cork) on 21 May 2023 and subsequently found him unresponsive on the morning of 22 May 2023 was a substantive member of staff.
I was not reassured that any proper investigation into these issues had been undertaken or that any action(s) required to bring about improvements in the system of undertaking and recording welfare checks have been identified and/or implemented .
” 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