PFD report

Sheila Margaret Gaskin · Prevention of Future Deaths report

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Issued 27 Jul 2017•South Wales Central

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
2

Of 2 recipients

Stated actions
2

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. Failure to prohibit carers assisting the service user to smoke in bed
    Part of recurring concern: Inadequate management of smoking-related fire risks in vulnerable people
  2. Lack of effective day-to-day oversight of care provision
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

    Issue general guidance to care providers on assessing and mitigating smoking-related health and fire risks, including expectations for assisting service users to smoke.

    Stated by Care Inspectorate WalesStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
  2. Action

    Continue reviewing regulated providers’ risk-management systems through inspections to identify unsafe care and care-plan breaches.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    A blanket prohibition lacks stakeholder support and could compromise service users' choice and control.

    Stated by Care Inspectorate WalesDisputes 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

Failure to prohibit carers assisting the service user to smoke in bed

Wider context from the report

“(1) The evidence revealed that there was an identified risk in the deceased's Care Plan of her smoking in bed. The Fire Service had been involved in risk assessing the situation and have provided flame retardant bedding and linen. Despite this obvious risk having been identified and implemented into the Care Plan there was nothing prohibiting carers assisting the deceased to smoke in bed which, the evidence revealed, was a regular occurrence. (2) Management of the care provided accepted that there was no effective oversight by them on a day-to-day basis and they were unaware that carers were assisting the deceased in this way. They agreed that what was required was a blanket prohibition on carers assisting the service user in smoking which would have given greater degree of clarity. ”

Is this part of a recurring concern?

Yes — Inadequate management of smoking-related fire risks in vulnerable people.

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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 effective day-to-day oversight of care provision

Wider context from the report

“(1) The evidence revealed that there was an identified risk in the deceased's Care Plan of her smoking in bed. The Fire Service had been involved in risk assessing the situation and have provided flame retardant bedding and linen. Despite this obvious risk having been identified and implemented into the Care Plan there was nothing prohibiting carers assisting the deceased to smoke in bed which, the evidence revealed, was a regular occurrence. (2) Management of the care provided accepted that there was no effective oversight by them on a day-to-day basis and they were unaware that carers were assisting the deceased in this way. They agreed that what was required was a blanket prohibition on carers assisting the service user in smoking which would have given greater degree of clarity. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Issue general guidance to care providers on assessing and mitigating smoking-related health and fire risks, including expectations for assisting service users to smoke.

Verbatim wording from the response

“We do want to respond positively to your recommendation and have agreed to issue general guidance to care providers on the following lines.”

Source location

2017-0328-Response-by-CSSIW
Page 2 · response
Published 2 December 2017

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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

Continue reviewing regulated providers’ risk-management systems through inspections to identify unsafe care and care-plan breaches.

Verbatim wording from the response

“However, that does not remove the requirement placed on providers and registered managers to ensure that they are delivering care in a safe way and doing all that is practicable to mitigate any risks. CQC will continue to review through its inspection processes the systems and processes being operated by those services it regulates and will challenge and if appropriate take enforcement action against the registered person where it finds that care is being provided in an unsafe way and is being provided contrary to the care plan.”

Source location

2017-0328-Response-by-Care-Quality-Commission
Page 5 · response
Published 2 December 2017

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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

A blanket prohibition lacks stakeholder support and could compromise service users' choice and control.

Verbatim wording from the response

“Whilst people completely understand the reasons for your recommendation there is no support for the proposal to place a blanket prohibition on care workers assisting service users to smoke. It was considered such a ban would compromise choice and control of people who use services. What our discussions did reveal was a deep concern for care staff and the risks of passive smoking.”

Source location

2017-0328-Response-by-CSSIW
Page 1 · response
Published 2 December 2017

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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

A blanket smoking-assistance ban cannot be imposed because the regulator lacks power to make law or issue statutory guidance.

Verbatim wording from the response

“CSSIW regulates and inspects on behalf of Welsh Ministers. We do not have the power to make law nor issue formal statutory guidance. Therefore we are unable to impose such a ban. We have discussed your recommendation with a number of key agencies including Welsh Government policy officials, Social Care Wales which regulates the work force, the UKHCA and Care Forum Wales the two leading provider associations as well as Heath and Safety bodies and the Fire Service.”

Source location

2017-0328-Response-by-CSSIW
Page 1 · response
Published 2 December 2017

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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

A blanket prohibition on assisting smoking is not considered appropriate because person-centred care requires case-by-case risk assessment.

Verbatim wording from the response

“With regard to the suggestion of a blanket prohibition on care workers assisting service users smoking, we are concerned that this approach is not consistent with the person-centred approach to care planning that we would expect to see. A blanket ban on this activity could inadvertently lead to a person’s care and support needs not being met in a way that promotes their needs and preferences; we would prefer that prohibition is risk assessed as appropriate on a case-by-case basis.”

Source location

2017-0328-Response-by-Care-Quality-Commission
Page 5 · response
Published 2 December 2017

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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

Existing inspection, governance and oversight processes are considered sufficient to identify key risks and ensure appropriate mitigation when operated effectively.

Verbatim wording from the response

“Part of our current methodology includes inspectors making an assessment of the provider’s governance systems and how these are used to ensure that risks are managed and mitigated and the quality of assessment is under appropriate scrutiny by the registered person. Governance systems should include “spot checks” by the registered manager or delegated person to ensure that staff in the field are working in accordance with individuals’ care plans. This also enables the registered person to assess specific risks and offer guidance and support to their staff.”

Source location

2017-0328-Response-by-Care-Quality-Commission
Page 4 · response
Published 2 December 2017

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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 service was not CQC-regulated, so notification and oversight fell under CSSIW rather than CQC.

Verbatim wording from the response

“We can confirm that we did not receive any statutory notification regarding Ms Gaskin’s death but we would not have expected to do so. This is because Ms Gaskin was being provided with care from Affinity Homecare Newtown, a service which is not regulated by CQC, rather falling under the jurisdiction of the Care and Social Services Inspectorate Wales (CSSIW). There would, therefore, have been no requirement placed on the service provider Affinity Homecare Newtown to inform CQC in this instance.”

Source location

2017-0328-Response-by-Care-Quality-Commission
Page 1 · response
Published 2 December 2017

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    CQC cannot pathway-track or visit every service user because its inspection resources are limited.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

CQC cannot pathway-track or visit every service user because its inspection resources are limited.

Verbatim wording from the response

“In line with Inspection methodology how many people the inspector or inspection team need to make contact with is dependent on the size of the service. Inspectors are not able to pathway track all the people using the service. (As with all public bodies) we have limited resources. We seek to maximise these in terms of our ability to obtain service user feedback, by sending questionnaires to service users prior to the inspection and speaking with a number of service users or their relatives by phone. We are also able to visit a number of people using the service but given that they are living in their own homes and not all together in one place, as is the case when we inspect care homes, we do not have the resources to visit everybody.”

Source location

2017-0328-Response-by-Care-Quality-Commission
Page 3 · response
Published 2 December 2017

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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