Care UK

PFD Addressee
Reports: 26 Earliest: Dec 2013 Latest: 14 Oct 2025
Response Status (last 2 years, 2 reports)
Responded 2
AI Classification
Action Taken 65%
Action Planned 24%
Noted 8%
Disputed 3%
Based on 37 classified responses
PFD Reports Received by Quarter
PFD Reports
26 results
Thompson Elliott
All Responded
2025-0515 14 Oct 2025 Sunderland
Care Home Health related deaths
Concerns summary (AI summary) Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.
Action Taken (AI summary) Care UK has reinforced training, updated documentation, emphasized communication requirements, and improved medication knowledge among staff. They have updated the care home's contact list to include on-call numbers for team leaders and emphasized the need for hospital staff to ensure its return with the resident on discharge.
Marion Jones
All Responded
2025-0413 7 Aug 2025 Manchester South
Care Home Health related deaths
Concerns summary (AI summary) A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, resulting in a fall that contributed to her decline.
Action Taken (AI summary) Care UK has updated its admission checklist, care plan forms, and audit processes to ensure pre-admission assessments for bed rails are completed and documented, and that care plans are comprehensive and up-to-date. They also clarified falls management and prevention policy and high/low beds should be considered as an alternative to bed rails.
Jennifer Rackley
Historic (No Identified Response)
2023-0305 6 Jun 2023 Berkshire
Care Home Health related deaths
Concerns summary (AI summary) A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, and involved staff could not be identified.
John Gregory
Partially Responded
2020-0073 20 Mar 2020 London Inner North
Care Home Health related deaths
Concerns summary (AI summary) Inadequate staff standards, inconsistent encouragement of fluid intake, and failure to monitor and respond to a patient's deteriorating condition, including inaccurate record-keeping, contributed to significant neglect.
Action Taken (AI summary) Care UK's Muriel Street reviewed manual handling training and improved it with a specific section on wheelchair safety guidance, including 1:1 supervision/training and laminated guides. They have also increased staffing levels and implemented updated welfare check documentation.
Robert Ginn
Partially Responded
2019-0372 30 Oct 2019 London Inner (North)
State Custody related deaths
Concerns summary (AI summary) Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, alongside conflicting assessments of the patient's body temperature.
Noted (AI summary) Care UK expresses condolences and addresses the coroner's concerns regarding first aid quality at HMP Pentonville. They discuss training, national changes to resuscitation procedures, and staff safety, but ultimately do not support bodycams for nurses due to concerns about patient trust and rapport.
Daniel Davey
Partially Responded
2019-0267 16 May 2019 Oxford
State Custody related deaths
Concerns summary (AI summary) Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.
Action Taken (AI summary) Care UK updated its Local Operating Procedure in February 2019 to ensure a member of healthcare staff attends planned ACCT reviews daily. In-possession risk assessments are completed at various points and random spot checks are undertaken to reduce the risk of stockpiling. The Safer Custody Governor is recommending awareness of in-possession medication risks is included in case manager training. HMP Bullingdon implemented a new ACCT case management system with a case manager assigned to each case. The prison issued guidance stating in-possession medication is a topic for ACCT reviews, with risk assessments informed by healthcare. A safety briefing on in-possession medication has been distributed and ACCT case manager training will cover stockpiling medication. The Trust has reminded staff to update Medication In Possession risk assessments, ensuring updates feed into the ACCT. Staff were reminded that changes in presentation regarding serious self-harm should trigger opening an ACCT. The case was reviewed with involved staff, and learning shared.
Tyrone Givans
Partially Responded
2019-0028 23 Jan 2019 London Inner (North)
State Custody related deaths
Concerns summary (AI summary) Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to significant safety concerns within the prison.
Action Planned (AI summary) Care UK provides healthcare services at HMP Pentonville, and they are committed to working with partner agencies in tackling illicit substance supply and trading. A new Health and Wellbeing model was implemented on May 14, 2018, acting as an additional safety net for patients coming into prison. HMPPS published a national Prison Drugs Strategy in April and is revising and republishing its local drug strategy. A new equality policy framework with guidance on reasonable adjustments will be published in June, and a resource tool is being developed to digitally collect more personalized information from prisoners, aiming for implementation in June/July 2019.
Andrew Craig
Partially Responded
2018-0194 25 Jun 2018 Dorset
State Custody related deaths
Concerns summary (AI summary) Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.
Action Taken (AI summary) The plan to upgrade the cell windows has now been approved and is provisionally on Ministry of Justice programme for delivery in 2019/20. Additionally, a number of measures to reduce prisoner access to non-prescribed medication have been introduced including assigning responsibility for medication queue management to one person, marking the dispensary floor for security and privacy, using CCTV, providing staff with attendee lists, and implementing a medication management practice where certain drugs are dispensed by healthcare. Care UK provides healthcare services at HMP Guys Marsh. In response to concerns about drug use, they have provided first aid training by prison staff and sourced posters highlighting the risks of NPS. They state a commitment to implementing lessons across Care UK's services.
Craig Royce
Partially Responded
2017-0379 20 Dec 2017 Essex
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.
Action Taken (AI summary) Since taking over prison healthcare services in 2017, Essex Partnership University NHS Foundation Trust has implemented a robust documentary system for referral of prisoners to mental health care, including widening the availability of a referral form to all prison staff.
Stephen Shaylor
Partially Responded
2017-0380 18 Dec 2017 Exeter and Greater Devon
State Custody related deaths
Concerns summary (AI summary) Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to detect self-harm, requiring continuous monitoring.
Noted (AI summary) Care UK clarified that night welfare checks are conducted by HCAs, with a nurse available for assistance, and that the nurse from the Integrated Substance Misuse Service reviews the welfare check list daily; they reiterate that ACCT documentation is the responsibility of prison staff and the welfare checks don't replace it, and that the MPCCC clinic is held weekly.
Mark Doyle
Partially Responded
2017-0375 18 Dec 2017 London Inner (North)
State Custody related deaths
Concerns summary (AI summary) Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
Action Taken (AI summary) Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared with the prison; additionally, prisoners admitted to the Substance Misuse Unit will remain for a minimum of two weeks, with senior manager and clinical lead reviews before any moves.
John Williams
Partially Responded
2017-0094 28 Mar 2017 London Inner (North)
State Custody related deaths
Concerns summary (AI summary) Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for improved referral systems.
Action Taken (AI summary) Care UK has reminded the nurse involved about giving evidence at an inquest and provided further support. The First Reception Health Screen template has been changed to include a mandatory field for mental health referrals, with electronic referrals made directly to the mental health in-reach team.
Daphne Cherry
All Responded
2017-0080 13 Mar 2017 Gloucestershire
Care Home Health related deaths
Concerns summary (AI summary) Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Action Taken (AI summary) Care UK has taken actions including training the home manager, deputy, and unit leaders in early recognition of deteriorating patients, delivering training to all staff, introducing daily meetings and walkarounds to discuss residents, and CQC has acknowledged the implemented changes.
Tedros Kahssay
Partially Responded
2016-0437 6 Dec 2016 London Inner (North)
State Custody related deaths Suicide
Concerns summary (AI summary) Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.
Action Taken (AI summary) Care UK has changed the reception screening template to include mandatory PER review, seeks consent for GP records during screening, and reinforced Code Red/Blue training with staff and displayed posters. All clinical staff receive mandatory ILS training, and guidance on resuscitation with rigor mortis present has been circulated.
Warren Sampson
Partially Responded
2016-0320 6 Sep 2016 Essex
State Custody related deaths
Concerns summary (AI summary) Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Action Taken (AI summary) Discipline staff now email healthcare each day with the ACCT reviews they are intending to hold and invite the appropriate healthcare professional to input into the process. A Second Health Screen is undertaken within 72 hours of an inmate arriving to ensure matters such as consent for obtaining GP records has been sought.
Terence Adams
Partially Responded
2016-wp25340 26 Jul 2016 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Action Planned (AI summary) Care UK will remind staff to check they have had sight of the core record and any accompanying information including the PER, relating to history, index offence, sentence status, clinical history and possible warnings. They have also agreed that the prison Governor will automatically receive (redacted) copies of RCAs going forward.
Alan Stead
All Responded
2016-0261 22 Jul 2016 Staffordshire (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Action Taken (AI summary) Care UK implemented a training program for nurses and HCAs in phlebotomy at HMP Dovegate, completed in March 2016, to ensure timely blood tests. The Governance team also shared learning from the case at a National Quality and Improvement Meeting.
Samuel Blair
Partially Responded
2016-0196 19 May 2016 London Inner (North)
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.
Action Planned (AI summary) The London Ambulance Service updated its Computerised Gazetteer to include multiple entrances to HMP Pentonville, and included specific reference to HMP Pentonville in refresher training for EOC staff, requiring confirmation of the gate to attend at the start of a call. They have also held meetings with senior prison staff to promote effective communication. Care UK refers to the response provided by BEH-MHT for some concerns, and states they will collaborate with them to ensure their action plan is implemented. They have implemented a training plan to ensure most healthcare staff will be ILS trained by December 2016, with yearly refresher trainings. NOMS states that the local risk assessment at Pentonville is up to date, and there is a sufficient number of staff trained in first aid. Prison control room staff have been briefed to provide the prison gate location at the beginning of calls to the London Ambulance Service.
Ernest Higgs
All Responded
2016-0181 27 Apr 2016 Surrey
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.
Action Planned (AI summary) The Trust will include a statement within the newsletter sent to GPs within the Trust's catchment area reminding them of 24-hour access to the Trust's pathology department. They will also be sending a letter to each of their three local CCGs requesting that this information is passed on to all registered care homes in their area. The CCG's Quality Committee has undertaken an in-depth analysis of the issues relating to nursing and residential care home quality, which will lead to changes in the way they commission and assure quality of services. They are at the final stages of developing a nursing home Primary Care Standard, recruiting a specialist dietician and the CHC team will raise concerns should they find poor documentation either from the nursing/residential home andlor poorly documented communication between general practitioner and care home staff. The practice has drafted a policy regarding telephone advice to nursing homes, and will audit responses to nursing home phone requests 6 months after implementation. They are waiting for BMA clarity on multi-disciplinary notes before committing to a stance, but are in agreement with the nursing home regarding contemporaneous notes.
Derek Thomas
Partially Responded
2015-0502 15 Dec 2015 County Durham and Darlington
State Custody related deaths
Concerns summary (AI summary) Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting understanding between prison and escort staff regarding critical safety form procedures.
Noted (AI summary) Nursing staff have been instructed to review all documents when completing reception screening, and staff have been reminded of the importance of ensuring all paperwork accompanies an individual. All initial healthcare assessments are undertaken by qualified mental health nurses, unless circumstances prevent this. The prison has implemented mandatory verbal handover of SASH form information from reception staff to healthcare staff. All staff working in reception must complete an online training course, managed by their line manager and monitored through the staff appraisal system. Care UK is no longer the healthcare provider at HMP Durham. It will forward the concerns to heads of healthcare at other facilities where it interacts with GEO Amey and the prison service. GEOAmey provided refresher training to over 90% of their officers regarding the completion of Prisoner Escort Records (PER) and Self Harm and Suicide Warning Forms (SASH Forms), following concerns raised about procedures and training.
Margaret O’Brien
Historic (No Identified Response)
11 Dec 2015 London (West)
Care Home Health related deaths
Concerns summary (AI summary) Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.
Alois Piska
Partially Responded
2014-0553 23 Dec 2014 Portsmouth & South East Hampshire
Care Home Health related deaths
Concerns summary (AI summary) The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.
Disputed (AI summary) Care UK disputes the coroner's concerns, stating that staffing levels at Harry Sotnick House were adequate and that staff are trained not to catch residents who fall to prevent injury. They also state Mr Piska was classified as low risk for falls.
Geraldine Kilborn
All Responded
2014-0532 10 Dec 2014 County Durham & Darlington
State Custody related deaths
Concerns summary (AI summary) There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.
Action Planned (AI summary) An amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team. From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model. Daily reviews will be undertaken by a member of the mental health team, as on any patient allocated for, Healthcare with mental health issues: In addition all complex ACCT cases will be discussed at morning handover to increase staff awareness. A registered nurse with previous knowledge of the patient will be in attendance at an ACCT review. TEWV has already made changes to the availability of Mental Health Team staff over the weekend. Staff are on duty between 9.30 am - 1230pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support. Staff were reminded to read all the relevant information in the ACCT document and on System One notes.
Edward Devlin
Partially Responded
2014-0335 22 Jul 2014 County Durham & Darlington
State Custody related deaths
Concerns summary (AI summary) Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Action Planned (AI summary) Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat of violence.
Michaela Christoforou
All Responded
2014-0285 25 May 2014 London (North)
Care Home Health related deaths
Concerns summary (AI summary) All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Action Planned (AI summary) Care UK has now located nine sets of ligature cutters throughout Rhodes Farm. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014 and a protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters.