PFD report

Jean Alice WALDRON · Prevention of Future Deaths report

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Issued 8 Jan 2026•Worcestershire

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.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 raised2

  1. Lack of adequate training on following advice from specialist doctors and nurses
  2. Lack of adequate training on the limits of care carers are able to provide
    Part of recurring concern: Inadequate training and competence assurance for carers providing care
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.3

  1. Action

    Review supervision and audit processes to strengthen oversight of adherence to scope-of-practice boundaries.

    Stated by Ignite Health and HomecareStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
  2. Action

    Reinforce guidance that wound care and pressure sore management are outside carers’ scope and must be undertaken only by qualified persons.

    Stated by Ignite Health and HomecareStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
  3. Action

    Issue formal reminders requiring staff to escalate clinical concerns to district nursing or medical professionals and not act beyond authorised duties.

    Stated by Ignite Health and HomecareStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The incidents reflected individual judgment contrary to policy, training and instructions, not a deficiency in carers’ understanding or the agency’s systems and governance.

    Stated by Ignite Health and HomecareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 adequate training on following advice from specialist doctors and nurses

Wider context from the report

“In her evidence at the inquest a carer from your agency, who was a Team Leader, gave evidence that: (a) she had read and understood an email from the District Nurse Clinical Lead, dated 15.1.25, which made clear that carers should not provide any care in relation to Mrs. Waldron's pressure sore as they did not have the correct licence to provide wound care; and (b) despite that clear instruction, she had on 3 separate occasions thereafter removed soiled wound dressings from the pressure sore and attempted to clean the wound with saline and gauze because she felt that it was in the deceased's "best interests" so to do. The lead Tissue Viability Nurse who gave evidence at the inquest said that the use of gauze was inappropriate and would have led to further adverse complications with the pressure sore. It is particularly concerning that a carer who was a Team Leader acted in the way described, and suggests that carers employed by your agency may not have received adequate training about: (a) the limits of the care which they are able to provide; and (b) the need to accept and follow advice given by specialist doctors and nurses at all times. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 adequate training on the limits of care carers are able to provide

Wider context from the report

“In her evidence at the inquest a carer from your agency, who was a Team Leader, gave evidence that: (a) she had read and understood an email from the District Nurse Clinical Lead, dated 15.1.25, which made clear that carers should not provide any care in relation to Mrs. Waldron's pressure sore as they did not have the correct licence to provide wound care; and (b) despite that clear instruction, she had on 3 separate occasions thereafter removed soiled wound dressings from the pressure sore and attempted to clean the wound with saline and gauze because she felt that it was in the deceased's "best interests" so to do. The lead Tissue Viability Nurse who gave evidence at the inquest said that the use of gauze was inappropriate and would have led to further adverse complications with the pressure sore. It is particularly concerning that a carer who was a Team Leader acted in the way described, and suggests that carers employed by your agency may not have received adequate training about: (a) the limits of the care which they are able to provide; and (b) the need to accept and follow advice given by specialist doctors and nurses at all times. ”

Is this part of a recurring concern?

Yes — Inadequate training and competence assurance for carers providing care.

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

Review supervision and audit processes to strengthen oversight of adherence to scope-of-practice boundaries.

Verbatim wording from the response

“3. Governance Oversight Existing supervision and audit processes have been reviewed to ensure continued oversight of adherence to scope-of-practice boundaries.”

Source location

Response from Ignite Health and Homecare Services
Page 2 · response
Published 20 January 2026

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

Reinforce guidance that wound care and pressure sore management are outside carers’ scope and must be undertaken only by qualified persons.

Verbatim wording from the response

“1. Scope-of-Practice Reinforcement All staff have received reinforced guidance clarifying that wound care and pressure sore management are outside the scope of carer practice and must only be undertaken by appropriately qualified persons.”

Source location

Response from Ignite Health and Homecare Services
Page 2 · response
Published 20 January 2026

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

Issue formal reminders requiring staff to escalate clinical concerns to district nursing or medical professionals and not act beyond authorised duties.

Verbatim wording from the response

“2. Escalation and Accountability Reminder Formal reminders have been issued confirming that where clinical concerns arise, staff must escalate to district nursing or medical professionals and must not act independently outside authorised duties.”

Source location

Response from Ignite Health and Homecare Services
Page 2 · response
Published 20 January 2026

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 incidents reflected individual judgment contrary to policy, training and instructions, not a deficiency in carers’ understanding or the agency’s systems and governance.

Verbatim wording from the response

“The Team Leader who gave evidence confirmed that she had read and understood this instruction. This demonstrates that the agency’s communication, governance, and escalation systems were effective and that staff were aware of the limits of care they were permitted to provide.”

Source location

Response from Ignite Health and Homecare Services
Page 1 · response
Published 20 January 2026

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