Jack Brown
PFD Report
All Responded
Ref: 2025-0593
All 1 response received
· Deadline: 13 Jan 2026
Coroner's Concerns (AI summary)
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic checks.
View full coroner's concerns
At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activites of such agencies are therefore not inspected or checked to ensure that they have rigerous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur.
Responses
Action Taken
The Department for Health and Social Care is supporting the professionalisation of the workforce through the revised Care Workforce Pathway, and the Adult Social Care Learning and Development Support Scheme including the new Level 2 Adult Social Care Certificate. (AI summary)
The Department for Health and Social Care is supporting the professionalisation of the workforce through the revised Care Workforce Pathway, and the Adult Social Care Learning and Development Support Scheme including the new Level 2 Adult Social Care Certificate. (AI summary)
View full response
Dear Ms Lomas,
Thank you for the Regulation 28 report of 18 November 2025 sent to the Secretary of State of the Department of Health and Social Care about the death of Mr Jack Richard Brown. I am replying as the Minister with responsibility for Adult Social Care (ASC).
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Brown’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
Your report raises concerns that because care agencies, who supply agency care staff to care and nursing homes, are not regulated by the Care Quality Commission (CQC), there is a risk that agency care staff “are providing care to vulnerable people without basic checks as to experience and suitability”, which “places service users at risk of harm”.
In preparing this response, my officials have made enquiries with the CQC to ensure we adequately address your concerns.
Matters of concern:
• At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff,
who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur.
Care providers are required to be registered with the CQC where they carry out a regulated activity – as described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, employment agencies do not usually carry out regulated activity and as such do not typically need to be registered.
Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.
Providers must also ensure staff receive appropriate training and supervision, and are supported to obtain further qualifications. Staff who are registered with a health care or social care regulator, including health care professionals, social workers or other professionals, must be supported to provide evidence to the appropriate regulator to show that they meet the professional standards needed to continue to practise. Whilst individual care workers, including agency staff, are expected to act competently and in line with regulations, the legal duty to comply with CQC regulations sits with the registered provider and registered manager. CQC cannot prosecute for a breach of Regulation 18, but CQC can take regulatory action such as issuing a warning notice to the provider to make improvements.
Further to those regulatory safeguards, the department is committed to enhancing the skills of staff working in adult social care, including those employed by agencies. It is vital to ensure that the care provided is of good quality, fair, personalised, and accessible. The department is supporting the professionalisation of the workforce through a range of activities which agencies can access for their employees. We recently revised and expanded the Care Workforce Pathway, the first national career structure for adult social care. This sets out the knowledge, skills, values, and behaviours needed to work in the sector and provides a framework for progression and development.
The department also launched the Adult Social Care Learning and Development Support Scheme in September 2024, backed by up to £12 million this financial year for eligible care staff to undertake courses and qualifications, including the new Level 2 Adult Social Care Certificate. Developed from the Care Certificate standards, the Level 2 Adult Social Care
Certificate has been designed to support people in care roles to have the most up to date knowledge and baseline skills required to support people to succeed in their roles. To ensure training undertaken is of good quality, we also launched the Quality Assured Care Learning Service which supports individuals and employers to easily identify trusted learning and development opportunities which meet the needs of the sector.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 18 November 2025 sent to the Secretary of State of the Department of Health and Social Care about the death of Mr Jack Richard Brown. I am replying as the Minister with responsibility for Adult Social Care (ASC).
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Brown’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
Your report raises concerns that because care agencies, who supply agency care staff to care and nursing homes, are not regulated by the Care Quality Commission (CQC), there is a risk that agency care staff “are providing care to vulnerable people without basic checks as to experience and suitability”, which “places service users at risk of harm”.
In preparing this response, my officials have made enquiries with the CQC to ensure we adequately address your concerns.
Matters of concern:
• At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff,
who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur.
Care providers are required to be registered with the CQC where they carry out a regulated activity – as described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, employment agencies do not usually carry out regulated activity and as such do not typically need to be registered.
Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.
Providers must also ensure staff receive appropriate training and supervision, and are supported to obtain further qualifications. Staff who are registered with a health care or social care regulator, including health care professionals, social workers or other professionals, must be supported to provide evidence to the appropriate regulator to show that they meet the professional standards needed to continue to practise. Whilst individual care workers, including agency staff, are expected to act competently and in line with regulations, the legal duty to comply with CQC regulations sits with the registered provider and registered manager. CQC cannot prosecute for a breach of Regulation 18, but CQC can take regulatory action such as issuing a warning notice to the provider to make improvements.
Further to those regulatory safeguards, the department is committed to enhancing the skills of staff working in adult social care, including those employed by agencies. It is vital to ensure that the care provided is of good quality, fair, personalised, and accessible. The department is supporting the professionalisation of the workforce through a range of activities which agencies can access for their employees. We recently revised and expanded the Care Workforce Pathway, the first national career structure for adult social care. This sets out the knowledge, skills, values, and behaviours needed to work in the sector and provides a framework for progression and development.
The department also launched the Adult Social Care Learning and Development Support Scheme in September 2024, backed by up to £12 million this financial year for eligible care staff to undertake courses and qualifications, including the new Level 2 Adult Social Care Certificate. Developed from the Care Certificate standards, the Level 2 Adult Social Care
Certificate has been designed to support people in care roles to have the most up to date knowledge and baseline skills required to support people to succeed in their roles. To ensure training undertaken is of good quality, we also launched the Quality Assured Care Learning Service which supports individuals and employers to easily identify trusted learning and development opportunities which meet the needs of the sector.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
13 Jan 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 10 February 2023 I commenced an investigation into the death of Jack Richard BROWN aged 86. The investigation concluded at the end of the inquest on 24 October 2025. The conclusion of the inquest was that Mr Brown died due to natural causes.
Circumstances of the Death
Mr Brown was an 86 year old gentleman who had been admitted to a care home following a hospital stay for heart failure and hyponatraemia. He was suffering from delirium and required constant 1:1 observations, along with help with all activities of daily living. Against that background, on the evening of 25th January 2023 Jack was assisted to the toilet by the night carer. He was sleepy and indicated that he wanted to stay on the toilet. He remained on the toilet asleep between approximately 9.30pm and 7.30am. Attempts were made during that time to rouse him but he remained asleep. At 8am on 26th January 2023 a handover of care staff took place and the day carer raised a concern that Mr Brown was unresponsive. Further staff checked Mr Brown and recognised that he had sadly died. His death was confirmed by paramedics who attended the scene. A post-mortem examination concluded that Mr Brown had died due to ischemic heart disease.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.