Recipient

United Response

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First report 14 Jan 2016•Latest report 14 Jan 2016

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company limited by guarantee. 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 United Response linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester West

    AI-generated summary

    Lee Joseph Rigby · 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

    Lee Joseph Rigby, who had Parkinsonism, swallowing difficulties and other disabilities, died in hospital on 7 October 2015 after choking while eating a sausage roll at his residence. The concerns included him being left unobserved while the sole support worker answered the door, staff not fully understanding the requirement to visually observe him while eating and drinking, and training and procedures not adequately addressing these risks.

    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 United Response; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff training to establish clear understanding of resident-observation risks

    Wider context from the report

    “During the Inquest evidence was heard that 1. During the Inquest evidence was heard that i. The support workers do not have keys to the premises at ████████ so that in circumstances where there was only one support worker in the premises that support worker would have to answer the door to allow another support worker entry to the premises. In those circumstances a resident requiring visual monitoring or observation would be left alone and unobserved. Evidence was heard during the course of the Inquest that one of the two support workers could leave the premises during the course of the day so that access to the premises would be required by a support worker either at the commencement of her shift or whenever the support worker left the premises at times when there would only be one support worker in the premises. It was accepted that if every support worker had a key to the premises the sole support worker in the premises would not have to be disturbed to answer the door and a resident, like Mr Rigby, who would not be left unattended at meal times, when Mr Rigby had to be observed at all times, and at any other times whenever he was eating and drinking. ii. Evidence was heard from the support staff that they did not fully understand that monitoring and observing Mr Rigby at all times when he was eating and drinking meant that they should visually observe him at those times. Evidence was also given by members of the support staff that if the telephone rang and there was a need to discuss a resident or something of a private and confidential nature a support worker, who may be the only support worker in the premises at the time, would go into another room to talk in a private and confidential manner, leaving a resident alone and unobserved during the course of the telephone conversation. The support staff did not understand the significance of the words used in the Health Action Plan and Management Guidelines that Mr Rigby should be observed at all times whilst he was eating and drinking and they did not fully understand the significance of observing him in relation to the risks identified in the Plan and Guidelines. iii. The internal training and procedures provided by United Response to the support staff and the procedures in place to address the risks identified by the Health Action Plan and Management Guidelines did not address the risks identified by the Plan and the Guidelines, particularly in relation to a clear understanding by the support staff with regard to observing a resident. ”
    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 United Response; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of procedures to address risks identified in care plans and management guidelines

    Wider context from the report

    “During the Inquest evidence was heard that 1. During the Inquest evidence was heard that i. The support workers do not have keys to the premises at ████████ so that in circumstances where there was only one support worker in the premises that support worker would have to answer the door to allow another support worker entry to the premises. In those circumstances a resident requiring visual monitoring or observation would be left alone and unobserved. Evidence was heard during the course of the Inquest that one of the two support workers could leave the premises during the course of the day so that access to the premises would be required by a support worker either at the commencement of her shift or whenever the support worker left the premises at times when there would only be one support worker in the premises. It was accepted that if every support worker had a key to the premises the sole support worker in the premises would not have to be disturbed to answer the door and a resident, like Mr Rigby, who would not be left unattended at meal times, when Mr Rigby had to be observed at all times, and at any other times whenever he was eating and drinking. ii. Evidence was heard from the support staff that they did not fully understand that monitoring and observing Mr Rigby at all times when he was eating and drinking meant that they should visually observe him at those times. Evidence was also given by members of the support staff that if the telephone rang and there was a need to discuss a resident or something of a private and confidential nature a support worker, who may be the only support worker in the premises at the time, would go into another room to talk in a private and confidential manner, leaving a resident alone and unobserved during the course of the telephone conversation. The support staff did not understand the significance of the words used in the Health Action Plan and Management Guidelines that Mr Rigby should be observed at all times whilst he was eating and drinking and they did not fully understand the significance of observing him in relation to the risks identified in the Plan and Guidelines. iii. The internal training and procedures provided by United Response to the support staff and the procedures in place to address the risks identified by the Health Action Plan and Management Guidelines did not address the risks identified by the Plan and the Guidelines, particularly in relation to a clear understanding by the support staff with regard to observing a resident. ”
    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 United Response; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of support staff to maintain required visual observation of residents

    Wider context from the report

    “During the Inquest evidence was heard that 1. During the Inquest evidence was heard that i. The support workers do not have keys to the premises at ████████ so that in circumstances where there was only one support worker in the premises that support worker would have to answer the door to allow another support worker entry to the premises. In those circumstances a resident requiring visual monitoring or observation would be left alone and unobserved. Evidence was heard during the course of the Inquest that one of the two support workers could leave the premises during the course of the day so that access to the premises would be required by a support worker either at the commencement of her shift or whenever the support worker left the premises at times when there would only be one support worker in the premises. It was accepted that if every support worker had a key to the premises the sole support worker in the premises would not have to be disturbed to answer the door and a resident, like Mr Rigby, who would not be left unattended at meal times, when Mr Rigby had to be observed at all times, and at any other times whenever he was eating and drinking. ii. Evidence was heard from the support staff that they did not fully understand that monitoring and observing Mr Rigby at all times when he was eating and drinking meant that they should visually observe him at those times. Evidence was also given by members of the support staff that if the telephone rang and there was a need to discuss a resident or something of a private and confidential nature a support worker, who may be the only support worker in the premises at the time, would go into another room to talk in a private and confidential manner, leaving a resident alone and unobserved during the course of the telephone conversation. The support staff did not understand the significance of the words used in the Health Action Plan and Management Guidelines that Mr Rigby should be observed at all times whilst he was eating and drinking and they did not fully understand the significance of observing him in relation to the risks identified in the Plan and Guidelines. iii. The internal training and procedures provided by United Response to the support staff and the procedures in place to address the risks identified by the Health Action Plan and Management Guidelines did not address the risks identified by the Plan and the Guidelines, particularly in relation to a clear understanding by the support staff with regard to observing a resident. ”
    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 United Response; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of keys for support workers requiring access to premises

    Wider context from the report

    “During the Inquest evidence was heard that 1. During the Inquest evidence was heard that i. The support workers do not have keys to the premises at ████████ so that in circumstances where there was only one support worker in the premises that support worker would have to answer the door to allow another support worker entry to the premises. In those circumstances a resident requiring visual monitoring or observation would be left alone and unobserved. Evidence was heard during the course of the Inquest that one of the two support workers could leave the premises during the course of the day so that access to the premises would be required by a support worker either at the commencement of her shift or whenever the support worker left the premises at times when there would only be one support worker in the premises. It was accepted that if every support worker had a key to the premises the sole support worker in the premises would not have to be disturbed to answer the door and a resident, like Mr Rigby, who would not be left unattended at meal times, when Mr Rigby had to be observed at all times, and at any other times whenever he was eating and drinking. ii. Evidence was heard from the support staff that they did not fully understand that monitoring and observing Mr Rigby at all times when he was eating and drinking meant that they should visually observe him at those times. Evidence was also given by members of the support staff that if the telephone rang and there was a need to discuss a resident or something of a private and confidential nature a support worker, who may be the only support worker in the premises at the time, would go into another room to talk in a private and confidential manner, leaving a resident alone and unobserved during the course of the telephone conversation. The support staff did not understand the significance of the words used in the Health Action Plan and Management Guidelines that Mr Rigby should be observed at all times whilst he was eating and drinking and they did not fully understand the significance of observing him in relation to the risks identified in the Plan and Guidelines. iii. The internal training and procedures provided by United Response to the support staff and the procedures in place to address the risks identified by the Health Action Plan and Management Guidelines did not address the risks identified by the Plan and the Guidelines, particularly in relation to a clear understanding by the support staff with regard to observing a resident. ”
    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