This is my second post about Prevention of Future Death reports published in 2023 relating to learning disabled and autistic people. You can read the first one, which includes an explanation of what PFDs are here. In this post I’ll cover the PFDs issued following the deaths of Owen Garnett, Steven Duquemin and Matthew Dale […]
Eighteen months ago, in July 2022, I started curating on this website reports published by CQC into care and support for learning disabled and autistic people, that was rated as outstanding or inadequate. In this post I’ll share some of the recently published low lights. One of the things I feel that needs acknowledging before […]
There were so many issues that emerged during the court of Peter’s second inquest. I can’t blog about all of them, but I wanted to just focus on record keeping and decision making at Oaks & Woodcroft, before the final post which will focus on the Prevention of Future Deaths evidence given by the Director […]
I’ve written a number of posts reporting Peter’s second inquest now, a quick recap incase this is the first one you’re coming to. There’s one about how he came to be in the care of the Priory Group here, one about support worker Siobhan Cator and her understanding of 1-1 supervision and refusal to have […]
Peter’s Eating, Drinking and Swallowing Care Plan has been referenced throughout his second inquest (and was also a key feature of his first inquest). There’s a post detailing it’s content, how the Speech and Language Therapist Ms Debbage assessed his swallow, and the staff’s understanding of it here: Peter’s SALT plan ends with clear instructions […]