Concerns raised 21 Lack of procedures for safeguarding care data View source Lack of procedures for care handovers View source Failure to implement procedures for displaying SALT and allergy advice in service users’ kitchens View source Failure to incorporate significant relevant factors into regulatory risk assessment View source Failure to provide updated care information to visiting professionals View source Delays in CQC access to police and provider records after a significant event View source Inadequate safeguarding of service-user information on staff personal mobile phones View source Over-reliance on WhatsApp for care-plan updates causing delays in updating home support plans View source Unclear SALT guidance on consistency descriptions and modified or avoided foods View source Failure to promptly share policy and legislative changes through the organisation’s website View source Lack of contingency planning for sickness of the Director View source Lack of consistency in CQC decisions on using evidence for inspections or regulatory action View source Lack of procedures governing completion, storage, updating and review of risk assessments and care plans View source Lack of procedures for auditing care documentation and practice View source Failure to assign lead-carer responsibility for accurate and current home documentation View source Failure to maintain correct care plans and risk assessments at service users’ home addresses View source Failure to communicate care-plan updates to all caring staff View source Lack of understanding of the Mental Capacity Act in care delivery View source Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan View source Lack of a transparent and candid organisational culture View source Inaccurate and misleading regulatory inspection reporting View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Anthony Wilkinson · 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
Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.
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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for safeguarding care data
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded ; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for care handovers
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken . This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to implement procedures for displaying SALT and allergy advice in service users’ kitchens
Wider context from the report “(7) There was no evidence that fundamental matters such as standard operating procedures for displaying SALT advice or allergy advice in a service users’ kitchen where all can see it have been implemented by the Stars Social Support Limited.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate significant relevant factors into regulatory risk assessment
Wider context from the report “(15)CQC did not take into consideration significant relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile being established and an exaggerated level of confidence being placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide updated care information to visiting professionals
Wider context from the report “(6) Secondly, visiting professionals are not able to access the WhatsApp group and therefore will not be in receipt of this updated information which may be important for some service users.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in CQC access to police and provider records after a significant event
Wider context from the report “(13)CQC did not take adequate steps to access records held by the Police or the provider in a timely fashion following Tony's death. This potentially created risk to other service users as the Regulator had not inspected the service promptly following a significant event.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate safeguarding of service-user information on staff personal mobile phones
Wider context from the report “(4) Stars Social Support Limited have implemented the use of WhatsApp to ensure staff are aware of updates to service users plans and they require staff to confirm they have read and understood the update prior to caring for an individual. Whilst this is a positive use of technology to support staff in caring for service users it is in itself a safeguarding issue to hold personal information about the service user on personal mobile phones ; this is especially the case where there are not adequate policies in place around the use of personal phones by staff members .
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on WhatsApp for care-plan updates causing delays in updating home support plans
Wider context from the report “(5) The use of the WhatsApp group adds in two risks of its own, the first is that there is an over reliance on this being the means by which service users care plans are updated and by default this ends up being the service users care plan. This makes it more likely rather than less likely in my view that support plans in the service users’ home will not be updated in a timely fashion .
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Unclear SALT guidance on consistency descriptions and modified or avoided foods
Wider context from the report “(18)The advice from SALT was not an issue in this case, it was the application of this advice which was the primary concern. I would like to commend the approach that the Trust have taken in learning from the issues which I raised at the conclusion of the proceedings and the openness with which the Trust have received the concerns I had. The guidance sheets which have been produced are still not clear enough and will lead to confusion including around the consistency description and a list of foods which can be modified or should be avoided . This needs to be reviewed to avoid confusion.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly share policy and legislative changes through the organisation’s website
Wider context from the report “(2) Stars Social Support Limited do not utilise their own website to ensure that policy and legislative changes can be adequately and promptly shared with service users, their families, and staff.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of contingency planning for sickness of the Director
Wider context from the report “(9) There is now a significant reliance on the Director updating all records and delivering care and undertaking audits whilst she improves the culture of the organisation. There was no adequate description of contingency plans in the event of sickness of this individual .
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of consistency in CQC decisions on using evidence for inspections or regulatory action
Wider context from the report “(17)Where CQC are required to decide whether evidence ought to be used for the basis of an inspection OR for regulatory action, they ought to ensure there is a consistent approach to this including the consideration of policies and standard operating procedures . This should be approached on the basis of safeguarding the majority of remaining service users from harm being the priority even where that means prosecutions for breaches of Regulation may be compromised.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures governing completion, storage, updating and review of risk assessments and care plans
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented ; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for auditing care documentation and practice
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken ; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to assign lead-carer responsibility for accurate and current home documentation
Wider context from the report “(10)The Director, in evidence, did not describe consideration of a lead carer for service users who would hold some responsibility for ensuring documentation in the service users’ home was accurate and up to date .
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain correct care plans and risk assessments at service users’ home addresses
Wider context from the report “(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address .
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate care-plan updates to all caring staff
Wider context from the report “(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the Mental Capacity Act in care delivery
Wider context from the report “(8) There remained a lack of understanding about the mental capacity act and how that may affect the care delivery to service users where it meant that a carer or senior manager had to be the decision maker for specific aspects of their care such as nutrition or medication
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan
Wider context from the report “(14)CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had they done so an earlier re inspection may have been triggered or further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as a result of an inaccurate risk picture being provided by the CQC.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a transparent and candid organisational culture
Wider context from the report “(1) Stars Social Support Limited have a culture which does not encourage transparency or embrace the duty of candour . This was evidenced throughout the inquest proceedings and in the lack of engagement with CQC during the inspection regime.
” 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 Stars Social Support Limited; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and misleading regulatory inspection reporting
Wider context from the report “(16)The report from the August 2020 inspection was inaccurate and misleading and may have caused service users to be added to this service where that ought not to be the case. The report published in October 2020 refers to their being no evidence of harm however there is a woeful lack of detail about the context of this within the report .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.
Verbatim wording from the response “A decision has been taken by the Registered Manager and Director of Stars Social Support Limited for the organisation to cease to continue. The Registered Manager and Director at Stars Social Support Limited has contacted the Local Authority and the Care Quality Commission to notify them that Stars Social Support Limited will cease to continue.” Source location 2021-0102-Response-from-Stars-Social-Support-Ltd-Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations