Recipient

Sister of Kala Skinner

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First report 3 Sep 2015•Latest report 3 Sep 2015

Recipient record

Reports, concerns and published responses

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 Sister of Kala Skinner linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Avon

    AI-generated summary

    Ms. Kala Michelle Skinner · 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

    On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.

    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 Sister of Kala Skinner; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise critical clinical red flags

    Wider context from the report

    “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”
    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 Sister of Kala Skinner; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to audit at least 3% of Clinical Advisor calls every month

    Wider context from the report

    “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”
    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 Sister of Kala Skinner; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a safety net to identify potential risks or training needs

    Wider context from the report

    “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”
    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 Sister of Kala Skinner; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make sufficient and timely welfare calls when no response is provided

    Wider context from the report

    “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”
    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 Sister of Kala Skinner; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide appropriate safety-focused clinical advice

    Wider context from the report

    “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”
    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