PFD report

James Stephen KEEN · Prevention of Future Deaths report

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Issued 2 Jan 2025•West 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.

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Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised5

  1. Failure to document physical health observations
  2. Failure to provide and verify support workers’ training and competence for physical health checks
    Part of recurring concern: Failure to ensure staff competence in conducting and interpreting clinical observations
  3. Failure of physical health observations to produce and support reliable interpretation of results
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 document physical health observations

Wider context from the report

“(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”

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

Failure to provide and verify support workers’ training and competence for physical health checks

Wider context from the report

“(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in conducting and interpreting clinical observations.

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 of physical health observations to produce and support reliable interpretation of results

Wider context from the report

“(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”

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

Failure of qualified staff to recognise support workers’ lack of knowledge

Wider context from the report

“(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”

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

Unavailability of a functioning thermometer

Wider context from the report

“(1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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