PFD report

William Edward Marson · Prevention of Future Deaths report

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Issued 2 Nov 2016•Wiltshire and Swindon

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 of the ventilator Users Manual extracts to provide guidance on normal operation, fault recognition and fault rectification
    Part of recurring concern: Unsafe ventilator operation and safety controls
  2. Failure to ensure staff awareness of the ventilator Users Manual and its location
    Part of recurring concern: Unsafe ventilator operation and safety controls
  3. Lack of adequate staff training in ventilator use
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

    Train and assess authorised staff as competent before they manage a resident's specialist equipment or intervention.

    Stated by Avon Care Homes LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 November 2016.
  2. Action

    Create an accessible specialist-equipment governance pack covering manuals, settings, checks, risk assessments, policies and best-practice evidence.

    Stated by Avon Care Homes LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 November 2016.
  3. Action

    Create a specialist-intervention care, risk and escalation plan with named and out-of-hours specialist support.

    Stated by Avon Care Homes LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 November 2016.

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 of the ventilator Users Manual extracts to provide guidance on normal operation, fault recognition and fault rectification

Wider context from the report

“During the course of the Inquest, evidence was heard from several witnesses as to the fact that no formal training on the correct use of the ventilator had been given to all members of staff. As a result there was no understanding of how the ventilator presented when it was working correctly, or as to the identification of any issues which would indicate that it was not working correctly and how they might be resolved. Although a copy of the Users Manual, for the ventilator had been printed off (in part) and placed in William's room, its existence and location were unknown to the sister or carers on duty. In any event I found that the extracts that had been printed off, would not have assisted in diagnosing that in fact the machine was functioning correctly, which may have reduced Williams anxiety, had that been made known to him. (1) That the staff on duty at Sutton Veny House had not been adequately trained if at all in the use of the ventilator. (2) That the staff were unaware of the existence of a Users Manual or its location. (3) That the extracts printed off in the Users Manual did not include details of how the machine presented when working correctly or how to recognise faults and how to rectify them. ”

Is this part of a recurring concern?

Yes — Unsafe ventilator operation and safety controls.

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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 ensure staff awareness of the ventilator Users Manual and its location

Wider context from the report

“During the course of the Inquest, evidence was heard from several witnesses as to the fact that no formal training on the correct use of the ventilator had been given to all members of staff. As a result there was no understanding of how the ventilator presented when it was working correctly, or as to the identification of any issues which would indicate that it was not working correctly and how they might be resolved. Although a copy of the Users Manual, for the ventilator had been printed off (in part) and placed in William's room, its existence and location were unknown to the sister or carers on duty. In any event I found that the extracts that had been printed off, would not have assisted in diagnosing that in fact the machine was functioning correctly, which may have reduced Williams anxiety, had that been made known to him. (1) That the staff on duty at Sutton Veny House had not been adequately trained if at all in the use of the ventilator. (2) That the staff were unaware of the existence of a Users Manual or its location. (3) That the extracts printed off in the Users Manual did not include details of how the machine presented when working correctly or how to recognise faults and how to rectify them. ”

Is this part of a recurring concern?

Yes — Unsafe ventilator operation and safety controls.

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

Lack of adequate staff training in ventilator use

Wider context from the report

“During the course of the Inquest, evidence was heard from several witnesses as to the fact that no formal training on the correct use of the ventilator had been given to all members of staff. As a result there was no understanding of how the ventilator presented when it was working correctly, or as to the identification of any issues which would indicate that it was not working correctly and how they might be resolved. Although a copy of the Users Manual, for the ventilator had been printed off (in part) and placed in William's room, its existence and location were unknown to the sister or carers on duty. In any event I found that the extracts that had been printed off, would not have assisted in diagnosing that in fact the machine was functioning correctly, which may have reduced Williams anxiety, had that been made known to him. (1) That the staff on duty at Sutton Veny House had not been adequately trained if at all in the use of the ventilator. (2) That the staff were unaware of the existence of a Users Manual or its location. (3) That the extracts printed off in the Users Manual did not include details of how the machine presented when working correctly or how to recognise faults and how to rectify them. ”

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

Train and assess authorised staff as competent before they manage a resident's specialist equipment or intervention.

Verbatim wording from the response

“• The resident would not be admitted until all appropriate team members had received training in the use of the equipment. This would include normal use of the equipment, hints and tips for addressing minor faults, contact details if there was a major problem with the equipment and contingency arrangements to keep the resident safe during a major equipment failure event.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 2 · response
Published 2 November 2016

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

Create an accessible specialist-equipment governance pack covering manuals, settings, checks, risk assessments, policies and best-practice evidence.

Verbatim wording from the response

“• A user friendly version of the equipment manual as well as the full manual would be devised and team members would be notified of the location of these documents. The location of this information would also be documented on the residents electronic and hard copy records.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 3 · response
Published 2 November 2016

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

Create a specialist-intervention care, risk and escalation plan with named and out-of-hours specialist support.

Verbatim wording from the response

“• A detailed care plan outlining the care and management of the resident and any equipment relating to the specialist intervention would be formulated which would also include the parameters for registered nurse and care team member’s involvement in the management of the resident. This care plan would also include sign posting information to the relevant resources available to the practitioner to support safe management of the resident.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 2 · response
Published 2 November 2016

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.9

  1. 1

    Operate under the oversight of a newly appointed Home Manager responsible for clinical competence and safe care delivery.

    Stated by Avon Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 2 November 2016.
  2. 2

    Maintain continuous quality improvement through regular care reviews and staff participation in implementing improvements.

    Stated by Avon Care Homes LimitedStated in progressThe respondent said that this action was in progress when they made their response on 2 November 2016.
  3. 3

    Conduct regular multidisciplinary reviews and revisions of specialist-intervention management and care.

    Stated by Avon Care Homes LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 November 2016.
  4. 4

    Provide specialist development through clinical leads, education materials, apprenticeships, qualification training, mandatory training, supervision and performance feedback.

    Stated by Avon Care Homes LimitedStated in progressThe respondent said that this action was in progress when they made their response on 2 November 2016.
  5. 5

    Monitor and audit care delivery against specified corporate audits.

    Stated by Avon Care Homes LimitedStated in progressThe respondent said that this action was in progress when they made their response on 2 November 2016.
  6. 6

    Review and revise workforce establishment and skill mix, refreshing team membership.

    Stated by Avon Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 2 November 2016.
  7. 7

    Improve resident assessment and care-plan documentation, with monthly audits and registered-nurse support.

    Stated by Avon Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 2 November 2016.
  8. 8

    Develop, share and implement a specialist-intervention checklist and flowchart across all group homes.

    Stated by Avon Care Homes LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 November 2016.
  9. 9

    Assess suitability and establish a GP- or specialist-agreed clinical plan before admitting a resident requiring a specialist intervention.

    Stated by Avon Care Homes LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 November 2016.

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

Operate under the oversight of a newly appointed Home Manager responsible for clinical competence and safe care delivery.

Verbatim wording from the response

“The home also has a new Home Manager who understands the importance of ensuring that the staff within the home attain the requisite level of clinical competence required to deliver safe and effective care to residents.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 1 · response
Published 2 November 2016

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

Maintain continuous quality improvement through regular care reviews and staff participation in implementing improvements.

Verbatim wording from the response

“The Home Manager in collaboration with other members of the Sutton Veny House team has developed an ethos of continuous quality improvement to ensure that all aspects of care are reviewed on a regular basis. Team members are encouraged to make recommendations on areas for improvement and actively participate in supporting implementation into practice.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 1 · response
Published 2 November 2016

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

Conduct regular multidisciplinary reviews and revisions of specialist-intervention management and care.

Verbatim wording from the response

“• The Home Manager in partnership with senior clinical colleagues within the team as well as relevant members of the medical team, equipment supplier representative, the resident and family would monitor and conduct regular reviews and revisions to the residents management to ensure that the resident continued to receive safe and effective management and care delivery.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 3 · response
Published 2 November 2016

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 specialist development through clinical leads, education materials, apprenticeships, qualification training, mandatory training, supervision and performance feedback.

Verbatim wording from the response

“Team members are encouraged to participate in further development of their knowledge and skills and update training / education. There are several initiatives within the home to support knowledge and skill development including individual registered nurse team members assuming lead responsibility for a specialist area of clinical interest, Display of Education Topic of the Month information, apprenticeships, Care Certificate and NVQ training for care team members as well as online and delivered mandatory / statutory training. All team members receive regular supervision and monitoring, support and feedback relating to their work performance.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 2 · response
Published 2 November 2016

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

Monitor and audit care delivery against specified corporate audits.

Verbatim wording from the response

“The Home Manager regularly monitors and audits the standard of care delivery against a suite of specified corporate audits to ensure that high quality care is maintained.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 1 · response
Published 2 November 2016

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

Review and revise workforce establishment and skill mix, refreshing team membership.

Verbatim wording from the response

“The workforce establishment and skill mix within the home has been reviewed, revised and membership of the team has been refreshed.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 1 · response
Published 2 November 2016

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

Improve resident assessment and care-plan documentation, with monthly audits and registered-nurse support.

Verbatim wording from the response

“The quality and comprehensiveness of the resident’s initial and ongoing assessment and care plan documentation has been improved. The Deputy Manager audits the contents of these documents on a monthly basis and also advises and supports her registered nurse colleagues in the development of their skills in this area.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 1 · response
Published 2 November 2016

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, share and implement a specialist-intervention checklist and flowchart across all group homes.

Verbatim wording from the response

“The learning from this incident will be shared with the Home Managers from all the homes associated with the group at a Home Managers meeting scheduled for the 14th December 2016. Immediately after this meeting it will be expected that the process detailed above is communicated and implemented across all Avon Care Homes. A process checklist and flow chart will also be formulated for use to support the future planning for any resident requiring specialist intervention or management who may be admitted into any of the group’s homes.”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 3 · response
Published 2 November 2016

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

Assess suitability and establish a GP- or specialist-agreed clinical plan before admitting a resident requiring a specialist intervention.

Verbatim wording from the response

“In the event of a resident either being admitted or unexpectedly requiring specialist intervention then the following process would be initiated:”

Source location

2016-0394-Response-by-Avon-Care-Home
Page 2 · response
Published 2 November 2016

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