PFD report

Joseph O’Neill · Prevention of Future Deaths report

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Issued 5 Feb 2021•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to resolve heating faults to maintain a safe temperature in the flat
    Part of recurring concern: Failure to maintain safe indoor temperatures in occupied premises
  2. Failure to provide sufficient prompting and encouragement to maintain hydration
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
  3. Failure to recognise deterioration
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Produce and distribute a dehydration-risk factsheet with recognition, preventive and urgent-response guidance for care workers.

    Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to resolve heating faults to maintain a safe temperature in the flat

Wider context from the report

“When Mr O’Neill refused a place in a care home, the Care Outlook staff did not do anything to resolve the fault with Mr O’Neill’s heating, so it remained on in the middle of a heatwave. An engineer was called to fix his door hinge, but not his heating. Mr O’Neill desperately needed a reduction in the temperature of his flat, first and foremost by the heating being fixed, but Care Outlook staff did not deal with this. ”

Is this part of a recurring concern?

Yes — Failure to maintain safe indoor temperatures in occupied premises.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide sufficient prompting and encouragement to maintain hydration

Wider context from the report

“He also needed immediate rehydration. When he was admitted to hospital, he was in deficit by about three litres. He was offered a drink by care staff at mealtimes, but he needed constant prompting and encouragement to drink enough. ”

Is this part of a recurring concern?

Yes — Inadequate management of patients' nutrition and hydration needs.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to recognise deterioration

Wider context from the report

“His deterioration was not recognised. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Produce and distribute a dehydration-risk factsheet with recognition, preventive and urgent-response guidance for care workers.

Verbatim wording from the response

“4. We have also prepared a factsheet providing enhanced guidance for care workers in relation to the risks of dehydration. The factsheet contains practical guidance on how to spot the signs of dehydration, the routine action that can be taken by care workers to prevent this and the urgent action that must be taken when a client is at risk. The fact sheet has been provided to all care workers.”

Source location

2021-0030-Response-from-Care-Outlook-Redacted
Page 2 · response
Published 9 February 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Implement and operate the People Planner digital care planning, real-time reporting and concern-alert system for all staff.

    Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
  2. 2

    Prepare an induction introduction and competency test supporting the incident-recording and reporting training.

    Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 9 February 2021.
  3. 3

    Integrate the Cause for Concern form into People Planner electronic reports.

    Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 9 February 2021.
  4. 4

    Retrain all Hackney staff on incident recording, reporting, escalation responsibilities and comprehensive record-keeping.

    Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 9 February 2021.
  5. 5

    Introduce a Cause for Concern form guiding staff on incidents and concerns requiring escalation.

    Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
  6. 6

    Develop delivery of the incident-recording and reporting training within the formal e-learning package.

    Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 9 February 2021.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement and operate the People Planner digital care planning, real-time reporting and concern-alert system for all staff.

Verbatim wording from the response

“1. Since the incident Care Outlook has introduced a digital care planning and monitoring system; People Planner. The system allows care plans to be accessed by staff on a mobile handset and to record the care delivered in real time. The system has a reporting facility whereby staff are able to complete and submit a report on their handset which is then flagged up on the system and email received by the office in real time.”

Source location

2021-0030-Response-from-Care-Outlook-Redacted
Page 1 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Prepare an induction introduction and competency test supporting the incident-recording and reporting training.

Verbatim wording from the response

“We are working to ensure this training can also be delivered as part of our formal e-learning package. Our training lead is preparing an introduction to the training and a supporting competency test, which will form part of our formal induction process.”

Source location

2021-0030-Response-from-Care-Outlook-Redacted
Page 2 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Integrate the Cause for Concern form into People Planner electronic reports.

Verbatim wording from the response

“2. We have also introduced a “Cause for Concern” form for staff to complete, to guide care staff in relation to the types of incident or concern that need to be raised. We are currently working to ensure that the form can be included in the electronic reports on People Planner.”

Source location

2021-0030-Response-from-Care-Outlook-Redacted
Page 1 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Retrain all Hackney staff on incident recording, reporting, escalation responsibilities and comprehensive record-keeping.

Verbatim wording from the response

“3. All staff in Hackney are being re-trained in the Recording and Reporting of incidents. Initial guidance has been issued in the form of a PowerPoint presentation that has been circulated to all staff. The training outlines the importance of reporting all concerns and ensuring that clear and comprehensive records are made. The training also covers the responsibilities of supervisors and managers to ensure that any concerns raised are resolved and reported to appropriate third parties (including medical professionals, emergency services, commissioners and safeguarding authorities).”

Source location

2021-0030-Response-from-Care-Outlook-Redacted
Page 1 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce a Cause for Concern form guiding staff on incidents and concerns requiring escalation.

Verbatim wording from the response

“2. We have also introduced a “Cause for Concern” form for staff to complete, to guide care staff in relation to the types of incident or concern that need to be raised. We are currently working to ensure that the form can be included in the electronic reports on People Planner.”

Source location

2021-0030-Response-from-Care-Outlook-Redacted
Page 1 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop delivery of the incident-recording and reporting training within the formal e-learning package.

Verbatim wording from the response

“We are working to ensure this training can also be delivered as part of our formal e-learning package. Our training lead is preparing an introduction to the training and a supporting competency test, which will form part of our formal induction process.”

Source location

2021-0030-Response-from-Care-Outlook-Redacted
Page 2 · response
Published 9 February 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026