30 Dec 2016 Raymond David SHEPHERD · Prevention of Future Deaths report Manchester City
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Concerns raised 7 Failure to identify deterioration and make appropriate primary health care referrals View source Poor standard of record keeping in the Home Care Support Service User comment book View source Failure to undertake both daily care visits View source Failure to undertake or arrange review of a mental capacity assessment View source Failure to update and review the Home Care Support Customer file View source Failure to respond to indicators of self-neglect and inadequate nutrition View source Failure to notify the GP or ambulance service after reported or observed falls View source See 4 more concerns
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Raymond David SHEPHERD · 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
Raymond David SHEPHERD had chronic ill health, severely limited mobility and a high risk of falls and self-neglect. In January 2016, care records noted repeated falls, poor appetite and a deterioration in his condition, but referrals to a GP or ambulance service were not made; he later sustained a femur fracture after a further fall and died in hospital on 30 January 2016. The principal concerns were poor care record-keeping, missed care visits, failure to escalate reported or observed falls and deterioration, and the absence of a mental capacity assessment.
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× 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 Human Support Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to identify deterioration and make appropriate primary health care referrals
Wider context from the report “6. Over a period of some days there seems to have been a deterioration in his condition which could have been identified and steps taken to stop it by appropriate referrals to primary health care services . In the event it had led him to having a further significant fall in which he fractured a femur as well as sustaining other injuries. This in turn led to a hospital admission but he was not fit enough to undergo surgery and died.
” 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 Human Support Group Limited; that does not assign responsibility.
PFD Monitor interpretation Poor standard of record keeping in the Home Care Support Service User comment book
Wider context from the report “1. The standard and detail of the record keeping in the Home Care Support Service User comment book was of very poor standard .
” 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 Human Support Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake both daily care visits
Wider context from the report “3. On some occasions both daily visits were not undertaken .
” 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 Human Support Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake or arrange review of a mental capacity assessment
Wider context from the report “7. There was no mental capacity assessment undertaken or a review of this arranged .
” 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 Human Support Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to update and review the Home Care Support Customer file
Wider context from the report “2. The Home Care Support Customer file does not seem to have been updated and reviewed .
” 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 Human Support Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to indicators of self-neglect and inadequate nutrition
Wider context from the report “5. The deceased was a service user with chronic health problems which affected his mobility and was at high risk of suffering a fall as well as self-neglect . He reported not wishing to eat anything over a period of days which again should have triggered some concern .
” 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 Human Support Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the GP or ambulance service after reported or observed falls
Wider context from the report “4. From 18 January 2016 there were at least three occasions when the deceased had either reported a fall or been found having after fallen, but no action was taken to notify the GP or ambulance service .
” 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