PFD report

Maria Katarina HRYNIW · Prevention of Future Deaths report

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Issued 20 Dec 2018•Manchester South

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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 establish clear responsibility for PEG feeding assessment and key decisions
    Part of recurring concern: Failure to maintain clear clinical responsibility for patient carePart of recurring concern: Unsafe coordination of shared care
  2. Failure to assess the suitability and volume of continued PEG feeding in the community
    Part of recurring concern: Unreliable post-operative PEG care and complication managementPart of recurring concern: Untimely or incomplete community care assessments
  3. Failure to hold a community MDT when prescribing end of life medications
    Part of recurring concern: Unreliable end-of-life care decision-making and consultation
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

    Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 20 December 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 establish clear responsibility for PEG feeding assessment and key decisions

Wider context from the report

“The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding. ”

Is this part of a recurring concern?

Yes — Failure to maintain clear clinical responsibility for patient care; Unsafe coordination of shared care.

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 assess the suitability and volume of continued PEG feeding in the community

Wider context from the report

“The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding. ”

Is this part of a recurring concern?

Yes — Unreliable post-operative PEG care and complication management; Untimely or incomplete community care assessments.

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 hold a community MDT when prescribing end of life medications

Wider context from the report

“The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding. ”

Is this part of a recurring concern?

Yes — Unreliable end-of-life care decision-making and consultation.

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

Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.

Verbatim wording from the response

“We look at how people’s end of life needs are met under Assessment Framework key question “Is the service Responsive?” The framework has ‘Key Lines of Enquiry’ (KLOEs) for inspectors to follow when answering the key questions. One of the KLOEs for ‘Responsive’ asks: How are people supported at the end of their life to have a comfortable, dignified and pain-free death? Inspectors explore how people, and their family, friends and other carers are involved in planning, managing and making decisions about their end of life care, and how people’s pain and other symptoms are assessed and managed effectively, including having access to specialised support.”

Source location

2018-0398-Response-by-CQC
Page 2 · response
Published 20 December 2018

Open published response

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

CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.

Verbatim wording from the response

“In accordance with CQC’s regulatory remit, as with other regulators, we highlight breaches of the regulations to a Provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the Provider and/or Registered Manager (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. We expect registered persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.”

Source location

2018-0398-Response-by-CQC
Page 2 · response
Published 20 December 2018

Open published response

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

CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.

Verbatim wording from the response

“In accordance with CQC’s regulatory remit, as with other regulators, we highlight breaches of the regulations to a Provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the Provider and/or Registered Manager (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. We expect registered persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.”

Source location

2018-0398-Response-by-CQC
Page 2 · response
Published 20 December 2018

Open published response

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

The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.

Verbatim wording from the response

“You will appreciate that I am not in a position to comment on the quality of end of life care provided by the nursing home and others to Ms Hryniw. I expect the Care Quality Commission to respond to you as regulator of health and adult social care in England on its consideration of the matters of concern raised with regard to the provision of services in this case.”

Source location

2018-0398-Response-by-Department-of-Health-and-Social-Care
Page 1 · response
Published 20 December 2018

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.5

  1. 1

    Discuss with the registered manager developing end-of-life care plans on admission and reviewing them regularly.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 20 December 2018.
  2. 2

    Publish the end-of-life care Choice Commitment, aligned with the Five Priorities for Care.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 December 2018.
  3. 3

    Form the Leadership Alliance for the Care of Dying People to coordinate improvements in end-of-life care.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 December 2018.
  4. 4

    Commission an independent review of the Liverpool Care Pathway.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 December 2018.
  5. 5

    Publish a one-year report detailing progress on improvements to care in the last days and hours of life.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 December 2018.

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

Discuss with the registered manager developing end-of-life care plans on admission and reviewing them regularly.

Verbatim wording from the response

“At the time of this inspection the nursing home was not supporting anyone at the end of their life. The nursing home had achieved beacon status with the Gold Standard Framework for end of life care, demonstrating that they are committed to providing good quality evidenced based care for people approaching the end of life. We spoke with the Registered Manager about the importance of”

Source location

2018-0398-Response-by-CQC
Page 2 · response
Published 20 December 2018

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

Publish the end-of-life care Choice Commitment, aligned with the Five Priorities for Care.

Verbatim wording from the response

“Furthermore, this Government’s end of life care Choice Commitment⁹, published in 2016, fully aligned with the Five Priorities of Care, and builds on previous end of life care strategies. The Commitment states that everyone should be able to expect:”

Source location

2018-0398-Response-by-Department-of-Health-and-Social-Care
Page 6 · response
Published 20 December 2018

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

Form the Leadership Alliance for the Care of Dying People to coordinate improvements in end-of-life care.

Verbatim wording from the response

“For example, following an independent review of the Liverpool Care Pathway (LCP), commissioned by the Government, 21 national organisations, including the Department and its key system partners and stakeholders, came together to form the Leadership Alliance for the Care of Dying People. The purpose of the Alliance was to take collective action to secure improvements in the consistency of care given in England to everyone in the last few days and hours of life, and their families. Its objectives were to:”

Source location

2018-0398-Response-by-Department-of-Health-and-Social-Care
Page 4 · response
Published 20 December 2018

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

Commission an independent review of the Liverpool Care Pathway.

Verbatim wording from the response

“For example, following an independent review of the Liverpool Care Pathway (LCP), commissioned by the Government, 21 national organisations, including the Department and its key system partners and stakeholders, came together to form the Leadership Alliance for the Care of Dying People. The purpose of the Alliance was to take collective action to secure improvements in the consistency of care given in England to everyone in the last few days and hours of life, and their families. Its objectives were to:”

Source location

2018-0398-Response-by-Department-of-Health-and-Social-Care
Page 4 · response
Published 20 December 2018

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

Publish a one-year report detailing progress on improvements to care in the last days and hours of life.

Verbatim wording from the response

“The Department published a one year on report⁸ in August 2015 detailing progress. The report set out that there had been a genuine, sustained commitment across the health and care system to the principles set out in the Priorities for Care and to deliver improvements to the care of dying people. This included preventing and avoiding repetitions of the poor care identified by the Independent Review of the LCP.”

Source location

2018-0398-Response-by-Department-of-Health-and-Social-Care
Page 5 · response
Published 20 December 2018

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