PFD report

Alison Dawn Evers · Prevention of Future Deaths report

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Issued 2 Mar 2015•West Yorkshire Eastern

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
5

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. Lack of a policy ensuring first-aid-trained staff on duty for each shift
    Part of recurring concern: Failure to provide adequate first aid where emergency assistance may be neededPart of recurring concern: Unreliable on-site emergency medical and first-aid response arrangements
  2. Lack of a written no-treats policy
  3. Insufficient first-aid training level among health support workers
    Part of recurring concern: Inadequate staff competence to provide first aid
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.2

  1. Action

    Provide and renew First Aid at Work and Fundamental First Aid training through a continuing professional-development programme.

    Stated by Leeds City CouncilStated completedThe respondent said that this action was complete when they made their response on 2 March 2015.
  2. Action

    Assess individual customer needs with specialist professional input and create bespoke risk assessments, support plans and dietary placemat plans.

    Stated by Leeds City CouncilStated completedThe respondent said that this action was complete when they made their response on 2 March 2015.

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

  1. Position

    Individual risk assessments, support plans and placemat plans adequately address choking risks, making a mandatory written no-treats policy inappropriate.

    Stated by Leeds City CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Lack of a policy ensuring first-aid-trained staff on duty for each shift

Wider context from the report

“(2) The lack of a policy ensuring a first aid trained member of staff is on duty for each shift. ”

Is this part of a recurring concern?

Yes — Failure to provide adequate first aid where emergency assistance may be needed; Unreliable on-site emergency medical and first-aid response arrangements.

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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

Lack of a written no-treats policy

Wider context from the report

“(1) The lack of a written ‘no treats policy’. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Insufficient first-aid training level among health support workers

Wider context from the report

“(3) Level of first Aid training of health support workers, particularly if working with service users who suffer from cognitive and/or physical impairment and are dependant on carers to meet their personal and dietary needs. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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

Provide and renew First Aid at Work and Fundamental First Aid training through a continuing professional-development programme.

Verbatim wording from the response

“The Council provides staff with First Aid Training as part of its on-going programme of continuing professional development. The courses which are provided are First Aid in Work and Fundamental First Aid.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 5 · response
Published 2 March 2015

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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

Assess individual customer needs with specialist professional input and create bespoke risk assessments, support plans and dietary placemat plans.

Verbatim wording from the response

“The ethos of the Council’s Social Care Services is to provide in all cases the best and most appropriate person centred care that it can for each individual that it serves. The customers of the Learning Disability Community Support Service have vastly divergent and highly individualised needs and wishes. We aim to meet them all. To achieve this we have created a range of highly personalised risk assessment tools and Individual Support Plans which are bespoke to each of our customers.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 4 · response
Published 2 March 2015

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

Individual risk assessments, support plans and placemat plans adequately address choking risks, making a mandatory written no-treats policy inappropriate.

Verbatim wording from the response

“The ethos of the Council’s Social Care Services is to provide in all cases the best and most appropriate person centred care that it can for each individual that it serves. The customers of the Learning Disability Community Support Service have vastly divergent and highly individualised needs and wishes. We aim to meet them all. To achieve this we have created a range of highly personalised risk assessment tools and Individual Support Plans which are bespoke to each of our customers.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 4 · response
Published 2 March 2015

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 existing first-aid training regime adequately addresses concerns about staff first-aid competence, so additional training is unnecessary.

Verbatim wording from the response

“The Council provides staff with First Aid Training as part of its on-going programme of continuing professional development. The courses which are provided are First Aid in Work and Fundamental First Aid.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 5 · response
Published 2 March 2015

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

There is no need to engage health support workers because customers generally do not have complex or additional medical needs.

Verbatim wording from the response

“As previously mentioned, the customers that are served by the Learning Disability Community Support Service do not generally present with complex and additional medical needs. There is therefore no need for the service to engage the services of “health support workers” as mentioned in the Coroner’s report.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 5 · response
Published 2 March 2015

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.3

  1. 1

    Organise staff into consistent teams supporting small customer groups familiar with individual needs and care requirements.

    Stated by Leeds City CouncilStated completedThe respondent said that this action was complete when they made their response on 2 March 2015.
  2. 2

    Provide induction, care-plan training, gradual introduction and supervised shadowing before permitting new staff to work directly with customers.

    Stated by Leeds City CouncilStated completedThe respondent said that this action was complete when they made their response on 2 March 2015.
  3. 3

    Keep customer risk assessments under regular review.

    Stated by Leeds City CouncilStated completedThe respondent said that this action was complete when they made their response on 2 March 2015.

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

Organise staff into consistent teams supporting small customer groups familiar with individual needs and care requirements.

Verbatim wording from the response

“We organise staff teams so that our staff work with small groups of customers on a consistent basis and are very familiar with their individual needs, and are knowledgeable in how to appropriately meet and respond to them.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 4 · response
Published 2 March 2015

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

Provide induction, care-plan training, gradual introduction and supervised shadowing before permitting new staff to work directly with customers.

Verbatim wording from the response

“All risk assessments are kept under regular review. In the case of Alison, all staff working with her were very familiar with it. The practice of the Learning Disability Community Support Service is that all new staff (whether they be agency or permanent staff) receive a full induction and training before working directly with customers. Having first read the care plans, all new staff are gradually introduced to the customers with whom they will be working whilst working alongside and shadowing established workers. In this way they gain customer specific knowledge of each customer’s individual care plans, risk assessments and needs and gain insight and experience of best practice. Only after this process has taken place are new staff permitted to work directly with customers.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 4 · response
Published 2 March 2015

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

Keep customer risk assessments under regular review.

Verbatim wording from the response

“All risk assessments are kept under regular review. In the case of Alison, all staff working with her were very familiar with it. The practice of the Learning Disability Community Support Service is that all new staff (whether they be agency or permanent staff) receive a full induction and training before working directly with customers. Having first read the care plans, all new staff are gradually introduced to the customers with whom they will be working whilst working alongside and shadowing established workers. In this way they gain customer specific knowledge of each customer’s individual care plans, risk assessments and needs and gain insight and experience of best practice. Only after this process has taken place are new staff permitted to work directly with customers.”

Source location

2015-0074-Response-by-Leeds-City-Council
Page 4 · response
Published 2 March 2015

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