PFD report

Margaret O’Brien · Prevention of Future Deaths report

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Issued 11 Dec 2015•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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. Lack of specific, prescribed staff training on carrying out observations of residents
  2. Lack of specific, prescribed staff training on recording observations of residents
    Part of recurring concern: Inadequate staff training for clinical and care record keeping
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.1

  1. Action

    Create and introduce a competency-based observation assessment for care and nursing colleagues to complete during induction, covering policy knowledge and recording requirements.

    Stated by Care UK, Residential Care Services (RCSStated plannedThe respondent said that this action was planned when they made their response on 11 December 2015.

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

  1. Position

    Revised observation policy and the proposed induction competency assessment are considered sufficient to address staff training and recording concerns.

    Stated by Care UK, Residential Care Services (RCSExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 specific, prescribed staff training on carrying out observations of residents

Wider context from the report

“There appeared to be an absence of specific, prescribed training of staff on how to carry out and record observations of residents. ”

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 specific, prescribed staff training on recording observations of residents

Wider context from the report

“There appeared to be an absence of specific, prescribed training of staff on how to carry out and record observations of residents. ”

Is this part of a recurring concern?

Yes — Inadequate staff training for clinical and care record keeping.

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

Create and introduce a competency-based observation assessment for care and nursing colleagues to complete during induction, covering policy knowledge and recording requirements.

Verbatim wording from the response

“The Care UK, RCS Learning & Development function is also looking to create a competency based assessment, which care and nursing colleagues would complete during their induction to the company. This will be aligned to the policy and guidance provided around observation of residents/patients in our care.”

Source location

Response from Care UK
Page 1 · response
Published 11 December 2015

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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

Revised observation policy and the proposed induction competency assessment are considered sufficient to address staff training and recording concerns.

Verbatim wording from the response

“I trust that you will accept that the actions taken in revising our observation policy and the proposal to introduce a competency based assessment, for completion at induction, meet your directions in relation to improving our service and specifically in the carrying out and recording of observations.”

Source location

Response from Care UK
Page 2 · response
Published 11 December 2015

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.1

  1. 1

    Revise the resident-observation policy and guidance to specify observation practice, frequency, interaction, record-keeping and responses to deviations.

    Stated by Care UK, Residential Care Services (RCSStated completedThe respondent said that this action was complete when they made their response on 11 December 2015.

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

Revise the resident-observation policy and guidance to specify observation practice, frequency, interaction, record-keeping and responses to deviations.

Verbatim wording from the response

“Since the death of Mrs O’Brien Care UK, RCS has reviewed its internal policy on the observation of residents and revised the guidance provided to colleagues working with residents/patients in our care.”

Source location

Response from Care UK
Page 1 · response
Published 11 December 2015

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