PFD report

ALBERT FLYNN · Prevention of Future Deaths report

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Issued 2 Jul 2014•Manchester South

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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. Failure to provide food and fluid during prolonged care periods
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
  2. Failure to administer prescribed medication
    Part of recurring concern: Failure to provide required medication promptly when clinically neededPart of recurring concern: Unsafe medication administration
  3. Insufficient staff training and qualification for assessment and treatment decisions
    Part of recurring concern: Unsafe assignment of staff without the required qualifications or competence to care work
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.4

  1. Action

    Re-emphasise the need to seek qualified advice during induction training for new staff.

    Stated by Hc-One LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 July 2014.
  2. Action

    Provide additional training and competency assessment to the senior carer involved in the incident.

    Stated by Hc-One LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 July 2014.
  3. Action

    Re-emphasise earlier help-seeking and intervention to the care staff involved through supervision.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 2 July 2014.

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

  1. Position

    Qualified nursing input for residential clients would normally be provided by the district nursing service, rather than residential care staff.

    Stated by Hc-One 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

Failure to provide food and fluid during prolonged care periods

Wider context from the report

“1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated. 2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours. 3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day. 4. The staff did not seem to appreciate the importance of administering prescribed medication. ”

Is this part of a recurring concern?

Yes — Inadequate management of patients' nutrition and hydration needs.

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 administer prescribed medication

Wider context from the report

“1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated. 2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours. 3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day. 4. The staff did not seem to appreciate the importance of administering prescribed medication. ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed; Unsafe medication administration.

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

Insufficient staff training and qualification for assessment and treatment decisions

Wider context from the report

“1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated. 2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours. 3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day. 4. The staff did not seem to appreciate the importance of administering prescribed medication. ”

Is this part of a recurring concern?

Yes — Unsafe assignment of staff without the required qualifications or competence to care work.

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 account for recent blood-thinning medication in assessment

Wider context from the report

“1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated. 2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours. 3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day. 4. The staff did not seem to appreciate the importance of administering prescribed medication. ”

Is this part of a recurring concern?

Yes — Inadequate controls for bleeding risk in patients taking antithrombotic medication.

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

Re-emphasise the need to seek qualified advice during induction training for new staff.

Verbatim wording from the response

“On this particular occasion the care staff members were experienced care assistants, some of whom had undergone NVQ training and had also undertaken mandatory training courses in relation to certain aspects of the delivery of care. As a matter of routine all care staff receive training in essential elements of care and these include Safer people handling; Safeguarding; Emergency procedures; Falls awareness; Promoting healthy skin. It is accepted that in this particular case Mr Flynn was left undisturbed for too long before qualified assistance was sought and during induction training for new staff, the need to call for qualified advice will be re-emphasised.”

Source location

2014-0308-Response-by-Lester-Aldridge-LLP
Page 1 · response
Published 2 July 2014

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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

Provide additional training and competency assessment to the senior carer involved in the incident.

Verbatim wording from the response

“The importance of medication being provided at the appropriate time is something that is contained in the routine training and competency assessments undertaken by staff and repeated at annual intervals but conducted more frequently should individual concerns be raised. Senior carer staff involved in this incident will undergo additional training and competency assessment to support her awareness.”

Source location

2014-0308-Response-by-Lester-Aldridge-LLP
Page 2 · response
Published 2 July 2014

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

Re-emphasise earlier help-seeking and intervention to the care staff involved through supervision.

Verbatim wording from the response

“The circumstances surrounding the care staff’s failure to alert the qualified nurse on duty of Mr Flynn’s condition is regrettable and with the balance of hindsight is accepted by them as having been regrettable. The need to seek earlier help and intervention has been re-emphasised to all the care staff involved in this case during the course of supervision and this case will also serve as a reminder to all care staff working within the company to alert more senior staff should they have any cause for concern about the condition of a resident which is unexpected or extraordinary.”

Source location

2014-0308-Response-by-Lester-Aldridge-LLP
Page 3 · response
Published 2 July 2014

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

Use the case as a reminder to all company care staff to alert senior staff about unexpected or extraordinary resident conditions.

Verbatim wording from the response

“The circumstances surrounding the care staff’s failure to alert the qualified nurse on duty of Mr Flynn’s condition is regrettable and with the balance of hindsight is accepted by them as having been regrettable. The need to seek earlier help and intervention has been re-emphasised to all the care staff involved in this case during the course of supervision and this case will also serve as a reminder to all care staff working within the company to alert more senior staff should they have any cause for concern about the condition of a resident which is unexpected or extraordinary.”

Source location

2014-0308-Response-by-Lester-Aldridge-LLP
Page 3 · response
Published 2 July 2014

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

Qualified nursing input for residential clients would normally be provided by the district nursing service, rather than residential care staff.

Verbatim wording from the response

“Mr Flynn’s condition should have been addressed at that stage. The nurse on duty would then have been able to attribute proper weight to the fact that Mr Flynn had received blood thinning drugs the previous day and his state of consciousness was cause for concern. The hospital did not provide any cautionary advice for the care team upon discharge back to the home on the evening of 14th March 2014 following the administration of anti-coagulation therapy, nor did the hospital initiate district nursing input across the weekend. Mr Flynn was accommodated as a residential client and so his day to day care would not have been provided by qualified nurses but by care assistants. The nursing input would normally be provided by the district nursing service.”

Source location

2014-0308-Response-by-Lester-Aldridge-LLP
Page 2 · response
Published 2 July 2014

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