PFD report

Angela Marietta Carpos · Prevention of Future Deaths report

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Issued 22 Apr 2024•Inner North 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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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 raised4

  1. Lack of assurance about company trainer qualifications
  2. Lack of clarity about carers’ aspiration pneumonia training
    Part of recurring concern: Inadequate training and competence assurance for carers providing care
  3. Failure of carers to recognise aspiration pneumonia
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.6

  1. Action

    Launch the further updated refresher training with additional clarity on aspiration and choking.

    Stated by MiHomecare LimitedStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
  2. Action

    Launch redesigned annual Care Professional Development training covering choking, aspiration and related care-safety topics.

    Stated by MiHomecare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
  3. Action

    Update themed choking supervision to include aspiration and aspiration pneumonia, and release the revised version.

    Stated by MiHomecare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Medical concerns requiring professional assessment or emergency intervention are escalated to GPs, district nurses, NHS 111 or 999.

    Stated by MiHomecare LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Lack of assurance about company trainer qualifications

Wider context from the report

“In Angela’s case, her daughter recognised very quickly that there was a problem and called an ambulance immediately. However, the carers (who knew Angela well, and cared for her with diligence) were unable to recognise aspiration pneumonia and were unclear about whether they had received any training on it, were unclear about what training they do receive, or how often they receive it. The PFD witness was unable to say what qualifications the company’s trainers have and did not know the contents of the company’s policies. ”

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

Lack of clarity about carers’ aspiration pneumonia training

Wider context from the report

“In Angela’s case, her daughter recognised very quickly that there was a problem and called an ambulance immediately. However, the carers (who knew Angela well, and cared for her with diligence) were unable to recognise aspiration pneumonia and were unclear about whether they had received any training on it, were unclear about what training they do receive, or how often they receive it. The PFD witness was unable to say what qualifications the company’s trainers have and did not know the contents of the company’s policies. ”

Is this part of a recurring concern?

Yes — Inadequate training and competence assurance for carers providing 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 of carers to recognise aspiration pneumonia

Wider context from the report

“In Angela’s case, her daughter recognised very quickly that there was a problem and called an ambulance immediately. However, the carers (who knew Angela well, and cared for her with diligence) were unable to recognise aspiration pneumonia and were unclear about whether they had received any training on it, were unclear about what training they do receive, or how often they receive it. The PFD witness was unable to say what qualifications the company’s trainers have and did not know the contents of the company’s policies. ”

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

Lack of knowledge of company policy contents

Wider context from the report

“In Angela’s case, her daughter recognised very quickly that there was a problem and called an ambulance immediately. However, the carers (who knew Angela well, and cared for her with diligence) were unable to recognise aspiration pneumonia and were unclear about whether they had received any training on it, were unclear about what training they do receive, or how often they receive it. The PFD witness was unable to say what qualifications the company’s trainers have and did not know the contents of the company’s policies. ”

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

Launch the further updated refresher training with additional clarity on aspiration and choking.

Verbatim wording from the response

“4.3. CCH Group had also updated its induction and refresher training from October 2022 (starting with the induction training and then moving to the refresher training) to include more detail on choking and aspiration. This version of the training was completed by the two care workers on shift on the evening on 25 December 2022, in June and August 2023. Our training on choking and aspiration has since been further updated and launched to include additional clarity around aspiration (again, starting with the induction training and then moving to the refresher training, the updated version of which is due to go live this week). I have appended a printout of the materials from the most recently updated [induction / refresher] training at Appendix 2 to demonstrate the topics covered.”

Source location

Response from Mi Homecare
Page 6 · response
Published 29 April 2024

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

Launch redesigned annual Care Professional Development training covering choking, aspiration and related care-safety topics.

Verbatim wording from the response

“2.5. In terms of refresher training, our revised Care Professional Development training (CPD training) has just been launched. This annual update training has been redesigned and now includes relevant updates alongside scenarios to enhance understanding around the impact and consequences of decisions made by our care staff. It looks to expand knowledge as our care workers progress and to bring our training to life, linking these to outcomes for people under our care. This is an online modular course covering the following topics: Health and Safety; First Aid Awareness (which covers choking and aspiration); Moving and Assisting; Infection Prevention and control; Food Safety; Medication administration; Handling Information (GDPR); Record Keeping and internal communications; and Dementia Awareness.”

Source location

Response from Mi Homecare
Page 2 · response
Published 29 April 2024

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

Update themed choking supervision to include aspiration and aspiration pneumonia, and release the revised version.

Verbatim wording from the response

“2.6. Care workers receive supervisions at their relevant Branch Office every 3 months. We have a specific type of supervision called a themed supervision – one of the available themed supervisions covers choking (and is in the process of being updated to cover aspiration / aspiration pneumonia – see paragraph 4.4.1). In a themed supervision, there will be scenarios that care workers need to answer and then Branch Office staff will discuss the answers with them. Staff can raise their concerns regarding a client in the supervision as well. They will be provided with clear and accurate guidance.”

Source location

Response from Mi Homecare
Page 3 · response
Published 29 April 2024

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

Launch the CCH Connect app to provide staff with immediate access to policies, learning initiatives and organisational news.

Verbatim wording from the response

“2.10. We have recently launched a new CCH Group app – called CCH Connect. Operational and care staff have instant access to key policies through this app. We believe this innovation will give our teams better visibility and in particular, it gives another platform in which to reach out to the teams and keep them informed of organisational learning, policies, procedures, and resources.”

Source location

Response from Mi Homecare
Page 3 · response
Published 29 April 2024

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

Update induction training with additional clarity on aspiration and choking.

Verbatim wording from the response

“4.3. CCH Group had also updated its induction and refresher training from October 2022 (starting with the induction training and then moving to the refresher training) to include more detail on choking and aspiration. This version of the training was completed by the two care workers on shift on the evening on 25 December 2022, in June and August 2023. Our training on choking and aspiration has since been further updated and launched to include additional clarity around aspiration (again, starting with the induction training and then moving to the refresher training, the updated version of which is due to go live this week). I have appended a printout of the materials from the most recently updated [induction / refresher] training at Appendix 2 to demonstrate the topics covered.”

Source location

Response from Mi Homecare
Page 6 · response
Published 29 April 2024

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

Launch a choking and aspiration campaign with an updated staff prompt card through CCH Connect and branch team meetings.

Verbatim wording from the response

“4.4.1. CCH Group’s Best Practice Forum has considered the circumstances surrounding Ms Carpos’ death as part of a serious incident review. A number of actions have been prompted by this review. For example, the themed supervision relating to choking (see paragraph 2.6) is being updated to include more detail on aspiration / aspiration pneumonia and the updated version is due to be released by the end of July. In addition, there is also a campaign initiative that has been created to highlight both choking risks and management alongside aspiration and the differences in presentation. This initiative is expected to be launched prior to the end of June 2024 and will be included on our new CCH Connect app as a “Talking Head” discussion, along with an updated prompt card for staff. Please see the latest version of this updated prompt card at Appendix 1.”

Source location

Response from Mi Homecare
Page 6 · response
Published 29 April 2024

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

Medical concerns requiring professional assessment or emergency intervention are escalated to GPs, district nurses, NHS 111 or 999.

Verbatim wording from the response

“3.4. The fundamental message care workers receive from their training is that if they have any concerns about an individual’s health and wellbeing these should be escalated as appropriate – e.g., to the Branch Office, the GP, the District Nurses,”

Source location

Response from Mi Homecare
Page 4 · response
Published 29 April 2024

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 provider does not provide nursing care, and its care workers are not trained medical professionals.

Verbatim wording from the response

“3.2. MiHomecare is a homecare provider that provides care and support to people within their own homes in the community. The care and support MiHomecare provides to individuals is varied and will depend on the package of care commissioned, usually, by the local authority. Care and support tasks completed by MiHomecare care workers can include assistance with personal care (for example, assistance with washing, dressing and toileting), assistance with administering medication, assistance with meal preparation, and support with shopping and domestic activities (such as hoovering). MiHomecare does not provide nursing care and whilst care workers receive basic first aid training, they are not trained medical professionals.”

Source location

Response from Mi Homecare
Page 4 · response
Published 29 April 2024

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.4

  1. 1

    Review care-planning tools to consider adding specific risk-management references to aspiration alongside eating and drinking difficulties.

    Stated by MiHomecare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
  2. 2

    Restructure the Best Practice Forum under an experienced Head of Quality to review incidents and trends and drive organisational learning.

    Stated by MiHomecare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
  3. 3

    Integrate the Learning and Development team into the CCH Group Quality Team for closer clinically led collaboration.

    Stated by MiHomecare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
  4. 4

    Complete a serious incident review of the circumstances surrounding Ms Carpos’ death and use it to prompt safety actions.

    Stated by MiHomecare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.

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 care-planning tools to consider adding specific risk-management references to aspiration alongside eating and drinking difficulties.

Verbatim wording from the response

“4.4.2. Our care planning tools are also being reviewed and as a part of this extensive project, the risk management around difficulties with eating and drinking (and hence the risks surrounding aspiration) will be considered. This project is still ongoing (expected to be concluded before the end of summer), but it is expected that one of the amendments made will be to ensure the tools include particular reference to aspiration rather than just swallowing difficulties more generally.”

Source location

Response from Mi Homecare
Page 6 · response
Published 29 April 2024

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

Restructure the Best Practice Forum under an experienced Head of Quality to review incidents and trends and drive organisational learning.

Verbatim wording from the response

“Additionally, we have restructured our Best Practice Forum, and since March 2024, this is now led by an experienced Head of Quality, Craig McCall. This Forum undertakes best practice reviews from all areas of our organisation to ensure that we review serious incidents and trends and take action to learn from these incidents or trends. This includes reviews of policy, ways of working, improvements to documentation or systems and training initiatives. Nicola Brown sits as a standing participant in these reviews to ensure that any learning from the Forum / reviews is reflected in / used to enhance training for our teams.”

Source location

Response from Mi Homecare
Page 2 · response
Published 29 April 2024

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

Integrate the Learning and Development team into the CCH Group Quality Team for closer clinically led collaboration.

Verbatim wording from the response

“2.2.1. 3 Learning Content specialists – who are responsible for the design and implementation of learning materials. They are managed by an experienced Head of Quality, who is also a Registered Nurse, ████████, and supported by experts in digital learning program design. Since January 2024, this team now sits as a part of the CCH Group Quality Team. This structural change means that there is close collaboration with our learning content that is not only operationally but clinically led.”

Source location

Response from Mi Homecare
Page 1 · response
Published 29 April 2024

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

Complete a serious incident review of the circumstances surrounding Ms Carpos’ death and use it to prompt safety actions.

Verbatim wording from the response

“4.4.1. CCH Group’s Best Practice Forum has considered the circumstances surrounding Ms Carpos’ death as part of a serious incident review. A number of actions have been prompted by this review. For example, the themed supervision relating to choking (see paragraph 2.6) is being updated to include more detail on aspiration / aspiration pneumonia and the updated version is due to be released by the end of July. In addition, there is also a campaign initiative that has been created to highlight both choking risks and management alongside aspiration and the differences in presentation. This initiative is expected to be launched prior to the end of June 2024 and will be included on our new CCH Connect app as a “Talking Head” discussion, along with an updated prompt card for staff. Please see the latest version of this updated prompt card at Appendix 1.”

Source location

Response from Mi Homecare
Page 6 · response
Published 29 April 2024

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