PFD report

Marjorie Wood · Prevention of Future Deaths report

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Issued 25 Apr 2016•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
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised1

  1. Lack of clarity or knowledge about the legal status of individuals in care homes
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.3

  1. Action

    Undertake further MCA and DoLS training for the staff member.

    Stated by Kingsley Care HomesStated plannedThe respondent said that this action was planned when they made their response on 25 April 2016.
  2. Action

    Check written DoLS applications, reasons and authorisations during home audits and make the information available to line managers on a shared file.

    Stated by Kingsley Care HomesStated completedThe respondent said that this action was complete when they made their response on 25 April 2016.
  3. Action

    Provide line-management supervision addressing the identified MCA and DoLS concerns.

    Stated by Kingsley Care HomesStated completedThe respondent said that this action was complete when they made their response on 25 April 2016.

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 or knowledge about the legal status of individuals in care homes

Wider context from the report

“Whilst there was no evidence in this case that the lack of clarity or knowledge in this particular case made a difference to the deceased, it is important that there is a full understanding of the legal status of an individual who is in a care home as this may impact on their care and treatment needs. ”

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

Undertake further MCA and DoLS training for the staff member.

Verbatim wording from the response

“Ms Cank had previously completed training in relation to MCA and DoLS. She has undergone supervision with her line manager in respect of the concerns raised by your investigation and is due to undertake further training.”

Source location

2016-0161-Response-by-Kingsley-Healthcare-Group
Page 3 · response
Published 25 April 2016

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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

Check written DoLS applications, reasons and authorisations during home audits and make the information available to line managers on a shared file.

Verbatim wording from the response

“Timperley had failed to follow policy and keep a written record of each application, reasons for the request and authorisation.”

Source location

2016-0161-Response-by-Kingsley-Healthcare-Group
Page 3 · response
Published 25 April 2016

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

Provide line-management supervision addressing the identified MCA and DoLS concerns.

Verbatim wording from the response

“Ms Cank had previously completed training in relation to MCA and DoLS. She has undergone supervision with her line manager in respect of the concerns raised by your investigation and is due to undertake further training.”

Source location

2016-0161-Response-by-Kingsley-Healthcare-Group
Page 3 · response
Published 25 April 2016

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

Official responses located
1/2

Data last updated 7 September 2026