PFD report

Celia Marion PHILLIPS · Prevention of Future Deaths report

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Issued 26 Nov 2025•Birmingham and Solihull

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised3

  1. Lack of carer understanding of the need for repositioning to mitigate pressure sores
    Part of recurring concern: Inadequate management of pressure ulcers
  2. Failure to undertake frequent repositioning of a bed-bound person
    Part of recurring concern: Failure to reliably reposition patients at required intervals
  3. Lack of carer training on pressure sores, skin assessment or repositioning
    Part of recurring concern: Inadequate management of pressure ulcersPart of recurring concern: Inadequate training and competence assurance for carers providing care
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

    Conduct competency spot checks of staff after the training period.

    Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
  2. Action

    Provide further training in wound prevention.

    Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
  3. Action

    Explore working with Access Group to establish skin-check and repositioning options in daily digital records where needed.

    Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.

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

  1. Position

    Staff state that they understood the importance of repositioning bed-bound service users and had appropriate skills or training to support Celia.

    Stated by Inspire You Care LtdDisputes 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

Lack of carer understanding of the need for repositioning to mitigate pressure sores

Wider context from the report

“1. The deceased was bed bound. 2. On the 12th March the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day. 3. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning. 4. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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 undertake frequent repositioning of a bed-bound person

Wider context from the report

“1. The deceased was bed bound. 2. On the 12th March the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day. 3. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning. 4. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore. ”

Is this part of a recurring concern?

Yes — Failure to reliably reposition patients at required intervals.

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 carer training on pressure sores, skin assessment or repositioning

Wider context from the report

“1. The deceased was bed bound. 2. On the 12th March the deceased's GP documented that she had pressure sores and stressed the importance of frequent repositioning, noting that she had carers who attended four times a day. 3. In both written, oral and documentary evidence provided by the carers there was no indication that repositioning had been undertaken; that there was any understanding of the need for repositioning to mitigate against the development of pressure sores; or that there had been training on pressure scores, skin assessment or re-positioning. 4. Whilst not causative of or contributory to death when admitted to hospital on the 27th April 2025 it was noted that the deceased had a DTI and a grade 1 pressure sore. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers; Inadequate training and competence assurance for carers providing care.

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

Conduct competency spot checks of staff after the training period.

Verbatim wording from the response

“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location

Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 2025

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 further training in wound prevention.

Verbatim wording from the response

“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location

Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 2025

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

Explore working with Access Group to establish skin-check and repositioning options in daily digital records where needed.

Verbatim wording from the response

“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location

Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 2025

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

Staff state that they understood the importance of repositioning bed-bound service users and had appropriate skills or training to support Celia.

Verbatim wording from the response

“– Carers informed the management team that they were aware Celia was bed bound as they read her care plan. Carers said they had the appropriate skills/training to support her whilst she was in bed. This includes the importance of repositioning her at an appropriate interval when they attended their care calls. They also understood that if there were any concerns around Celia skin then this should be immediately informed to the district nurses. – When staff were asked that it was not reported in the daily logs that Celia was repositioned, staff admitted that this was their failing part due to poor record keeping and not mentioning this important information in the daily notes.”

Source location

Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 2025

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

Staff state that Celia was repositioned during all four daily care visits, despite repositioning not being recorded in daily logs.

Verbatim wording from the response

“– Staff stated that as mentioned before they did reposition Celia at all four daily visits as this would have to take place due to them having to complete personal care tasks for Celia at each visit.”

Source location

Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 2025

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.2

  1. 1

    Provide refresher training on record keeping and communication.

    Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
  2. 2

    Meet individually with staff in supervision to discuss the importance of detailed and accurate daily recording.

    Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.

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 refresher training on record keeping and communication.

Verbatim wording from the response

“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location

Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 2025

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

Meet individually with staff in supervision to discuss the importance of detailed and accurate daily recording.

Verbatim wording from the response

“– Team managers will meet with all staff individually in their supervision and discuss the importance of detailed and accurate daily recording. – Staff will undergo refresher training on Record Keeping and Communication. – Staff will also undertake further training in Wound Prevention. – These trainings will be completed within a four-week (19th January 2026 – 15th February 2026) timeframe and then care coordinators will carry out competency spot checks on the staff members. – Management team will also look into working with digital recording provider (Access Group) and set up options of skin check / repositioning for clients where needed as a check in item on the daily recording element.”

Source location

Response from Inspire You Care Ltd
Page 2 · response
Published 2 December 2025

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