Celia Phillips

Investigation Report: Celia Marion Phillips 

Date: 15th January 2026 

Introduction   

This document provides Inspire You Care Ltd.'s formal response to the Coroner’s report. Following receipt of 
the report, we undertook an immediate and thorough internal investigation to understand the concerns raised in 
the care provided to Celia Phillips. This report details our findings, and the comprehensive actions we are 
taking to prevent any recurrence of these concerns raised. We accept the coroner's findings and express our 
profound condolences and apologies to the family of Celia Phillips. 

Below are the concerns that were raised and have been investigated. Thereafter actions will be set out by 
Inspire You Care Ltd. 

1.  Celia Phillips was bed bound. / On the 12th March 2025 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. 

2.  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. 

3.  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. 

What measures have been taken to reduce risk in future and internal investigation 

Inspire You Care Ltd - Management team opened an investigation upon receiving these concerns, this included 
meeting and speaking with the core staffing team that worked with CP in her last two weeks of receiving care. 
The below report outlines the summary findings of the investigation, staff responses, agreed actions, and 
learning outcomes.   

1.  Celia Phillips was bed bound. / On the 12th March 2025 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. 

Concern Raised  

The concern raised was that Celia was bed bound; this is a part of her care plan and the subsequent care that 
she would require.  

Investigation – Fact Find:     

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 −  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. 

Findings:   

−  There is some evidence of staff not understanding their role of caring for Celia whilst in bed as when 

asked to document how they cared for Celia they did not mention key information. 

−  Staff do agree that they failed to include important information in their daily logs which could now be 

seen as they did not reposition Celia accordingly.  

Agreed Actions:   

−  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. 

2. 

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. 

Concern Raised:   

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. 

Staff 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. 

 
 
 
 
 
 
 
 
  
 
 
 
 
 −  Staff were asked in the investigation if they understood the importance of repositioning and all the staff 
responded in the affirmative that yes, they understand with the primary concern being the development 
of pressure sores if repositioning does not take place. 

−  Staff accepted that their record keeping had been poor and due to this it may appear that repositioning 
did not take place. Staff said in their written evidence also they detailed the care that Celia received 
but again they failed to be accurately detailed to also include information around repositioning Celia. 

Findings:   

−  Staff response clearly shows that they do understand the importance of repositioning service users 

who are bed bound as this will then reduce the likelihood of pressure sores developing. 

−  Staff agree with their failing on not being detailed enough when making their daily records and when 

giving their written evidence for care provided to Celia. 

Agreed Actions:   

−  Staff have been informed through the investigation that they must go through a refresher training 
programme around record keeping / communication training alongside also completing a training 
module 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. 

3.  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. 

Concern Raised:   

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. 

Staff Response:   

−  Staff stated that they mentioned the pressure sore to the family of Celia and also reported to the 

management team who subsequently reported this to the district nurse team. 

−  Staff said they understand the importance of pressure sores and that they must be attended too and 

reported to the appropriate professionals. 

Findings:   

−  Staff did understand the importance of pressure sores and that they must be reported to the 

appropriate professionals. 

−  Staff through their written evidence did not mention repositioning Celia, which could make pressure 

sores worse. 

Agreed Actions:   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 −  Staff have been informed through the investigation that they must go through a refresher training 
programme around record keeping / communication training alongside also completing a training 
module 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 

Conclusion  

The concerns raised by the coroners report and, while concerning, have provided an opportunity to reflect on 
our practices and identify areas for learning and growth. By addressing these concerns with transparency, and 
a commitment to improvement, we can ensure that all our service users receive the highest standard of care. 
This investigation reaffirms our dedication to safeguarding the well-being of those we serve and upholding the 
values of trust, respect, and professionalism that define Inspire You Care Ltd. 

Prepared by
Position: Nominated Individual   
Date: 15th January 2026