Feb – Apr 2026

Prevention of Future Deaths reports are never comfortable reading, and they are not meant to be. Their purpose is to identify where something has gone badly wrong and where a coroner has seen a risk that could lead to further deaths unless action is taken.

Looking across a recent selection of social care-relevant reports, the themes are depressingly familiar: choking risk, fire risk, falls, unsafe discharge, missed escalation, poor record-keeping, hydration and bowel care, pressure damage, catheter care, no-access procedures and multi-agency drift. Our “usual suspects”.

The important point for providers is that most of these risks were not mysterious. In many cases, the person was already known to be vulnerable: frail, cognitively impaired, immobile, smoking while unable to self-rescue, dependent on insulin, catheter-dependent, PEG-fed, on anticoagulants, or known to have eating and drinking risks.

This month’s big theme for me is:

A risk is not managed just because something has been written down somewhere. It is managed when staff know what to do, when to escalate, who to contact, and can identify an urgent or emergency situation quickly.

DNACPR does not mean “do nothing”

One of the starkest reports concerned the death of Bonita Cleary, who died after choking in a nursing home. She had dementia, severe frailty and a history of episodes where her jaw could clench or lock. She was being supported by staff while eating when she began choking.

A DNACPR authorisation was in place. However, the coroner was concerned that staff did not fully understand that CPR can still be appropriate where there is a potentially reversible cause, such as choking. The coroner stated that, notwithstanding the DNACPR, CPR ought to have commenced and raised concern about a wider lack of awareness among care and nursing staff.

This is an important training point. A DNACPR decision is about whether CPR should be attempted in the event of cardiac or respiratory arrest. It is not a blanket instruction to withhold emergency action. Where the cause may be reversible, staff must know what to do.

For care services, choking response training should explicitly cover DNACPR. Staff should understand the difference between respecting a person’s end-of-life wishes and failing to respond to an emergency that may be reversible.

Choking and dysphagia: plans must follow the person

Another report concerned Emma Turner, who had profound disabilities, lacked capacity and had been advised to eat only pureed food. She died after eating cake, when her airway became obstructed. The report raised wider concerns about information sharing, safeguarding follow-up, lack of face-to-face review and poor multi-agency oversight.

Eating and drinking guidance has to follow the person across services, settings, staff teams and family care arrangements. If a person is at risk, everyone involved must understand what the plan is, why it matters, and what may happen if it is not followed.

Where someone lacks capacity, there also needs to be proper best interests decision-making. Families may be deeply loving and committed, but that does not remove the responsibility of professionals to support, guide, challenge and safeguard where necessary.

Smoking, fire risk and the danger of “noted but not acted on”

Two of the reports involved people who died in fires after smoking.

Jacqueline Joseph was a known smoker with limited mobility following a stroke. She had care and support needs and received four care visits a day. She died after being found in an armchair, unable to extinguish the fire or self-rescue. The premises had no careline provision, no previous Home Fire Safety Visit referral, and the coroner raised concern about incorrectly installed smoke alarms.

Paul Hutchinson died in a fire in extra care sheltered accommodation. He had limited mobility, speech difficulties, incontinence and cognitive difficulties following a stroke. A Person Centred Fire Risk Assessment had rated him as high risk. There were multiple burn marks on clothing, carpets and furnishings from smoking, but the coroner found there were no adequate control or mitigating measures, and no action to notify a local Fire Officer.

On the day of the fire, his smoke detector activated but was silenced by a member of staff, as were other detectors. The first call to London Fire Brigade was made eight minutes after the detector activated, and the manager did not contact LFB until fifteen minutes after activation.

Burn marks from smoking are evidence of an immediate and serious risk.

If a person smokes and cannot reliably manage the risks or self-rescue, a fire risk assessment must result in action. That may include referral to the local Fire and Rescue Service, review of smoking arrangements, supervision, fire-retardant products, telecare, alarm response protocols, PEEPs, evacuation planning, staff training and family discussion.

This is also where I am obviously going to return to one of my recurrent soapbox issues: emollients and personal fire safety.

In the smoker-fire reports reviewed here, the focus was on smoking, alarms, Home Fire Safety Visit referrals, Person Centred Fire Risk Assessments, burn marks and evacuation. I did not see emollients mentioned in the reports. That does not mean emollients were relevant in those individual cases; the reports can only reflect the evidence before the coroner. However, it does mean providers should not wait for a coroner to spell it out before including emollients in their own fire risk thinking.

The MHRA has been clear that clothing, bedding, dressings and other fabrics contaminated with emollient residue can ignite more easily, and that the risk is not limited to high-paraffin products. Risk advice now extends to paraffin-containing and paraffin-free emollients. CQC also identifies unsafe use of emollient creams as a cause of serious or fatal fire injuries in adult social care.

For my money, every smoking fire risk assessment should ask: Does this person use emollients, barrier creams, ointments, dressings, continence products, oxygen, airflow equipment, pressure-relieving equipment, or bedding/clothing likely to be contaminated with flammable residue?

If yes, the plan should say what is being done about it. That may include laundry routines, clothing and bedding changes, advice to the person and family, smoking controls, staff prompts, Fire and Rescue referral, and clear recording on the care plan, MAR and fire risk assessment.

Right Care Right Person: guidelines must not become tramlines

The report into the death of Lisa Taylor-Penny is particularly relevant to providers navigating Right Care Right Person.

Carers and social workers had been outside her home for hours, repeatedly trying to obtain assistance to enter the premises. After nearly seven hours, a police officer made the operational decision to enter and she was found deceased. The coroner was concerned that Right Care Right Person was being implemented rigidly, as “tramlines not guidelines”, and that there was insufficient scope for call handlers to escalate for senior professional judgment where professionals were saying they needed police attendance to secure entry and were concerned for life and limb.

As I have previously noted, care providers need to be confident when asserting risk in this situation. If you feel the right person is the fastest person who can get there with lawful powers of entry, say so clearly.

That does not mean demanding police attendance for every welfare concern. It means being able to explain, calmly and explicitly: why you believe there is an immediate risk to life or serious harm; what is known about the person’s vulnerabilities; what attempts have already been made; why waiting is unsafe; why access is required; and why the person or agency being contacted is needed.

Right Care Right Person should not leave care staff, social workers or clinicians standing outside a door for hours while everyone agrees someone else is probably responsible.

Services should review their no-access and welfare concern procedures now. There should be a timed escalation pathway, especially where the missed visit involves insulin, essential medication, food, fluids, personal care, known suicidal ideation, severe frailty, cognitive impairment or inability to self-rescue.

Unsafe discharge and reablement: the home test matters

Several reports also raised familiar concerns around discharge, reablement and falls.

Lesley Krommendijk was discharged home after a fall and fractured hip. The hospital team described her as mobile and fit for discharge, but her family gave a very different account. Her son said she needed help from family and neighbours to transfer from bed to commode. The coroner preferred the family’s evidence and was concerned that the discharge was too early and potentially unsafe.

This is a recurring problem. Medically fit is not the same as safe at home. A person may be clinically stable but still unable to manage safely between calls. Family evidence should be taken seriously, especially where it differs from professional optimism.

Reablement must not become a period where deterioration is normalised. Pain, reduced mobility, inability to transfer, confusion, poor intake and repeated falls should trigger review, not simply more visits recorded as completed.

Falls, anticoagulants and escalation

John Hay’s case is another example of risk factors sitting in plain sight. He lived alone, had dementia, osteoporosis, atrial fibrillation and was taking anticoagulant medication. After a fall, he declined paramedics, but his son was not consulted. Later that day he was found on the floor and staff contacted his son rather than 111 or 999.

For providers, the learning is straightforward: falls protocols must reflect the person’s actual risks. A person on blood thinners who has fallen, especially where the fall is unwitnessed or there may be head injury, is not a routine monitor-and-record situation.

Where a person with dementia refuses medical attention, staff should be trained to think about capacity, risk, escalation and family or professional consultation. The person declined is not always the end of the matter.

Basic care is clinical risk

Patrick Griffin’s report is a painful reminder that hydration, nutrition, bowel care and personal care are not basic in the sense of being low risk. They are basic in the sense of being fundamental.

Mr Griffin had advanced dementia and entered a care home for respite. He needed support with dietary and fluid intake and full assistance with hygiene and personal care. When admitted to hospital, he was dehydrated and had not opened his bowels for seven days. The care provider’s response included training on communication, documentation, nutrition, malnutrition and dehydration, along with policy refreshers and additional handover sections for dietary intake, fluid consumption and elimination.

Fluid intake, food intake and bowel activity should be visible in handover, daily walk rounds, audits and escalation systems. If a person has advanced dementia, they may not be able to seek help, explain discomfort, request drinks or report constipation.

Catheter care and commissioned tasks

Peter Pettit’s report concerned catheter displacement, urinary retention, infection, deterioration and poor care records. The report identified a lack of evidence of catheter management by the care company in the days leading up to hospital attendance. It also raised wider issues around medication compliance, stockpiles of medication, reporting to commissioners or GPs, and formal training arrangements for commissioned care tasks.

This is an important point for domiciliary care providers. If a task is in the care plan, the provider must be able to show staff understand it, complete it, record it and escalate concerns. Catheter care is not just personal care. It carries infection, retention, pain, dignity and hospital admission risks.

Commissioners also need to be clear about what they are asking providers to do, and providers need to be honest about whether staff are trained and competent to do it.

Pressure damage: deterioration must be escalated immediately

Albert Bellingham died from infection arising from a sacral pressure sore. The coroner described a really serious failure to provide appropriate nursing care, with a preventable sacral pressure sore allowed to deteriorate until he returned to hospital with black/grey tissue and foul-smelling exudate.

Pressure damage is another area where care services must avoid passive recording. A pressure sore is not just a wound. It can become a route to sepsis and death.

Care homes need clear escalation triggers: deterioration in colour, odour, exudate, pain, fever, refusal of care, deterioration in mobility, reduced nutrition, reduced hydration, or failure of the current plan. There should be named clinical oversight and evidence of challenge where external support is delayed or ineffective.

Communication after hospital procedures

John Ioannou was a non-verbal man living in a residential care home and fed via PEG. He attended hospital for manipulation of a PEG problem and was discharged back to the care home without a written discharge summary. He later became agitated and appeared to be in pain, then died from peritonitis linked to infection at the PEG site.

For care providers, the learning is that discharge back to a care home after an invasive or semi-invasive procedure must include written instructions, red flags and escalation routes. If the person is non-verbal, agitation, distress or behavioural change after a procedure should be treated as signs of possible physical deterioration.

Practical audit prompts for providers

Care providers should consider using these reports as a prompt to review critical aspects of their service, including paperwork checks and raising discussion points at team meetings and supervisions. Key matters arising are:

• Whether staff understand that DNACPR does not prevent emergency action for reversible causes such as choking.
• Whether choking and eating/drinking plans are current, followed, and understood by staff and families.
• Whether every smoker with dexterity, mobility, cognition or self-rescue issues has a meaningful personal fire risk assessment.
• Whether emollients, barrier creams, ointments and contaminated fabrics are included in smoking and fire risk assessments.
• Whether burn marks trigger immediate escalation, not just recording.
• Whether no-access procedures include timed escalation and clear routes to family, clinicians, ambulance, police, fire, housing or safeguarding.
• Whether staff are confident challenging rigid interpretations of Right Care Right Person where there is concern for life and limb.
• Whether discharge and reablement decisions reflect the person’s real ability to function at home between visits.
• Whether falls protocols account for anticoagulants, dementia, osteoporosis, head injury, long lies and unwitnessed falls.
• Whether hydration, nutrition, bowel care, catheter care and medication support are audited as delivered care, not just planned care.
• Whether pressure damage escalation is quick and done correctly, with quick follow up if a timely response is not received.
• Whether hospital discharge information is always obtained and understood before accepting someone back after a procedure, and if not, if this is being escalated to the commissioners, and how the service safely supports people returning from hospital who turn out to have inadequate or misleading information.

Final thought

The common thread is not a shocking new risk. It is visible risk that did not become visible action quickly enough. That is the governance test – not whether the risk appeared somewhere in the paperwork, but whether anyone acted on it in time.

A burn mark should change the plan. A missed insulin visit should change the plan. A fall in a person on anticoagulants should change the plan. A displaced catheter should change the plan. A pressure sore that changes colour or smell should change the plan. A person with dysphagia eating unsuitable food should change the plan. A locked door, with a high-risk person behind it, should change the plan. And the plan should then be shared with the people who have to follow it, and it should be ensured it is being followed correctly.

Reports

• Regulation 28 report: Bonita Cleary, Prevention of Future Deaths report 2026-0067.
• Regulation 28 report and response: Jacqueline Joseph, Prevention of Future Deaths report 2026-0102, and response from Squared.
• Regulation 28 report: Lesley Krommendijk, Prevention of Future Deaths report 2026-0109.
• Regulation 28 report: John Franklin, Prevention of Future Deaths report 2026-0110.
• Regulation 28 report and response: Patrick Griffin, Prevention of Future Deaths report 2026-0114, and response from Caring UK.
• Regulation 28 report: Emma Turner, Prevention of Future Deaths report 2026-0115.
• Regulation 28 report: Asher Blackman, Prevention of Future Deaths report 2026-0133.
• Regulation 28 report: John Ioannou, Prevention of Future Deaths report 2026-0137.
• Regulation 28 report: Albert Bellingham, Prevention of Future Deaths report 2026-0176.
• Regulation 28 report: John Hay, Prevention of Future Deaths report 2026-0189.
• Regulation 28 report: Peter Pettit, Prevention of Future Deaths report 2026-0196.
• Regulation 28 report: Roman Barr, Prevention of Future Deaths report 2026-0197.
• Regulation 28 report: Susan Toft, Prevention of Future Deaths report 2026-0214.
• Regulation 28 report: Catherine Oliver, Prevention of Future Deaths report 2026-0215.
• Regulation 28 report: Kiefer Fraser-Phillips, Prevention of Future Deaths report 2026-0216.
• Regulation 28 report: Lisa Taylor-Penny, Prevention of Future Deaths report 2026-0220.
• Regulation 28 report: Paul Hutchinson, Prevention of Future Deaths report 2026-0223.

External guidance

• MHRA Drug Safety Update: Emollients – new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients.
• MHRA: Emollients and risk of severe and fatal burns – new resources available.
• CQC Learning from safety incidents, Issue 3: Fire risk from use of emollient creams.