The Avenues Trust GroupIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Registered charity

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First report 20 Oct 2021•Latest report 20 Oct 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

Statements from The Avenues Trust Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: ████████ Chief Executive The Avenues Trust Group.

    Surrey

    AI-generated summary

    Henry Edward Hullin Doll · 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

    Henry Edward Hullin Doll, who had a learning disability, Down’s Syndrome and dementia and was at high risk of aspiration and choking, entered the kitchen of his residential care home alone on 21 February 2021, obtained a shortbread biscuit, choked and aspirated on it, and died the following day from aspiration pneumonia. The court found that the risks of him obtaining unsuitable food and eating it unsupervised had not been identified or appropriately prevented. Concerns also related to the way risk assessments were completed and the effectiveness of staff CPR training.

    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 The Avenues Trust Group; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staff capability to provide effective CPR

    Wider context from the report

    “2. The court found that the CPR provided by staff to Mr Doll on 21 February 2021 prior to the arrival of the paramedics was ineffective, albeit this did not contribute to his death. The Avenues Groups is invited to consider whether staff have received sufficient practical training so as to ensure that they are confident and capable of carrying out effective CPR. ”
    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 The Avenues Trust Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess risks before considering mitigating measures

    Wider context from the report

    “1. Both the Kenilworth Home Manager and the Regional Director, responsible for some 50 homes, maintained at the inquest that Mr Doll’s risk assessment had been accurately completed and that the appropriate way to conduct a risk assessment was to first consider what mitigating measures were in place and then to go on to assess the likelihood of the risk occurring and the likely impact on the individual. Accordingly, the Coroner is concerned that the risk screening in respect of other residents at Kenilworth, but also other Avenues Group locations, may have been completed in a similar manner. ”
    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

Data last updated 7 September 2026