Recurring concern

Untimely or incomplete community care assessments

First to latest report 30 Aug 2013 — 18 Nov 2025

Reports that mention this concern
18
Times this concern has been raised
20
Stated actions linked to this concern
30

What this concern includes

Includes delayed, missing or materially inadequate assessments of a person's community care, support or treatment needs where the assessment is part of community care planning, discharge or referral.

What is not included
  • Excludes generic staffing, communication or documentation deficiencies unless they directly constitute failure of the community care assessment.
  • Excludes hospital diagnostic, custody, deprivation-of-liberty and mental-capacity assessments unless the assertion explicitly concerns a community care needs assessment.
  • Excludes failures to provide care packages or placements after an assessment has been completed.

Reports and published responses 18 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Barry Wayne Preston · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Placement without a clear understanding of the person's needs

    Wider context from the report

    “7. His placement at Laburnum Lodge was made without a clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital. ”

    Source location

    Barry Wayne Preston · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a competency framework for identifying and assessing patients with complex health, social and onward care needs.

    Verbatim wording from the response

    “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.”

    Source location

    2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
    Page 3 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a Home First competency framework for recommending appropriate intermediate-care placements.

    Verbatim wording from the response

    “The Home First team are a therapy based team which aims to support those patients in the ED and assessment wards to return home without a longer period of hospital admission. It has been identified that there is a skills gap within this team and a competency framework has been developed to support staff in making the appropriate recommendation for placement at intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily basis by a member of the nursing team within the IDT.”

    Source location

    2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review transfers to intermediate care daily through an Integrated Discharge Team nurse.

    Verbatim wording from the response

    “The Home First team are a therapy based team which aims to support those patients in the ED and assessment wards to return home without a longer period of hospital admission. It has been identified that there is a skills gap within this team and a competency framework has been developed to support staff in making the appropriate recommendation for placement at intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily basis by a member of the nursing team within the IDT.”

    Source location

    2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require ward managers to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before transfer of care.

    Verbatim wording from the response

    “• Ward Managers have been instructed that any patient with complex needs should be escalated to the IDT for a full MDT meeting where any transfer of care is being considered.”

    Source location

    2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.

    Verbatim wording from the response

    “At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals identify those patients who had existing social care needs prior to admission to hospital. The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.”

    Source location

    2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
    Page 2 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a skills and competency framework for Integrated Discharge Team members to identify patients with complex onward needs.

    Verbatim wording from the response

    “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 Response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.”

    Source location

    2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
    Page 2 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver additional training to existing Integrated Discharge Team staff on identifying patients with complex onward needs.

    Verbatim wording from the response

    “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 Response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.”

    Source location

    2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
    Page 2 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.

    Verbatim wording from the response

    “Actions taken by Bolton Council and BNFT”

    Source location

    2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
    Page 3 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Local Authority will provide a further response on actions concerning safe placement and transfers of care.

    Verbatim wording from the response

    “Section 5 (7): His placement at Laburnum Lodge was made without clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.”

    Source location

    2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 9 June 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.

    Verbatim wording from the response

    “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.”

    Source location

    2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 1 · response
    Published 9 June 2020

    Open published response

  2. Manchester South

    AI-generated summary

    Maria Katarina HRYNIW · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Maria Katarina HRYNIW, who was PEG fed following a stroke and had very limited mobility, developed bronchopneumonia and died at The Lakes Care centre on 14 April 2018. Concerns included the lack of assessment of the suitability and volume of continued PEG feeding near the end of life, continued administration despite reported difficulty coping with the prescribed volume, and unclear responsibilities between the SALT team and care home regarding assessment and decision-making.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess the suitability and volume of continued PEG feeding in the community

    Wider context from the report

    “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding. ”

    Source location

    Maria Katarina HRYNIW · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.

    Verbatim wording from the response

    “We look at how people’s end of life needs are met under Assessment Framework key question “Is the service Responsive?” The framework has ‘Key Lines of Enquiry’ (KLOEs) for inspectors to follow when answering the key questions. One of the KLOEs for ‘Responsive’ asks: How are people supported at the end of their life to have a comfortable, dignified and pain-free death? Inspectors explore how people, and their family, friends and other carers are involved in planning, managing and making decisions about their end of life care, and how people’s pain and other symptoms are assessed and managed effectively, including having access to specialised support.”

    Source location

    2018-0398-Response-by-CQC
    Page 2 · response
    Published 20 December 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.

    Verbatim wording from the response

    “In accordance with CQC’s regulatory remit, as with other regulators, we highlight breaches of the regulations to a Provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the Provider and/or Registered Manager (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. We expect registered persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.”

    Source location

    2018-0398-Response-by-CQC
    Page 2 · response
    Published 20 December 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.

    Verbatim wording from the response

    “In accordance with CQC’s regulatory remit, as with other regulators, we highlight breaches of the regulations to a Provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the Provider and/or Registered Manager (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. We expect registered persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.”

    Source location

    2018-0398-Response-by-CQC
    Page 2 · response
    Published 20 December 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.

    Verbatim wording from the response

    “You will appreciate that I am not in a position to comment on the quality of end of life care provided by the nursing home and others to Ms Hryniw. I expect the Care Quality Commission to respond to you as regulator of health and adult social care in England on its consideration of the matters of concern raised with regard to the provision of services in this case.”

    Source location

    2018-0398-Response-by-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 20 December 2018

    Open published response

  3. Norfolk

    AI-generated summary

    DARREN HAYES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Darren Hayes had significant physical health problems, opiate dependence and alcohol abuse, and was losing weight, struggling with nutrition and personal care, living alone without a cooker. He died on 11 March 2014 before a planned community care assessment could take place; the inquest recorded poisoning by morphine and benzodiazepines, with empyema of the gallbladder. Concerns included delayed and inadequately documented attempts to contact him, insufficient consideration of the risks he presented, and failure to contact other relevant services when he did not respond.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to fully consider identified risks in assessment

    Wider context from the report

    “(3) The risks with which Mr Hayes were not fully considered ie his diabetes being “out of control”, weighing less than 7 stone, lacking motivation, struggling to manage at home, living alone and having no cooker. He was no longer receiving 3 daily visits from NFRS. The evidence was that Mr Hayes had a microwave and could swallow small pieces “a hot drink”. ”

    Source location

    DARREN HAYES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Lincolnshire

    AI-generated summary

    Elaine Marilyn GILES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elaine Marilyn GILES, a 66-year-old woman, died from fat embolism after falling while descending the stairs at home five days after discharge following hip replacement surgery. The principal concern was that she had been assessed as safe on stairs before discharge but could not safely negotiate the stairs at home, highlighting the need for detailed assessment of likely function in the home and adequate support after discharge.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of detailed assessment of likely functional performance in home circumstances after discharge

    Wider context from the report

    “Whilst assessed as "safe" on stairs prior to discharge from Peterborough City Hospital, it is very clear that Elaine could not negotiate stairs safely when she got home. This tragic case draws attention to the need for detailed assessments of a patient's likely functional performance in their home circumstances after discharge and the importance of ensuring adequate support is available in the home environment. ”

    Source location

    Elaine Marilyn GILES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Norfolk

    AI-generated summary

    JOHN HENRY WILSHER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Wilsher, a resident of Springdale Care Home, deteriorated after falls and was found to have extradural and subdural haemorrhages. He died on 21 December 2013 after discharge from hospital to the care home, which quickly became unable to cope with his mobility. Concerns included inaccurate discharge information, inadequate communication about his care needs and prior referral, and delays or gaps in care assessments.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in NCC Community Services assessments

    Wider context from the report

    “(3) An assessment was carried out by NCC Community Services on 13 December 2013 by which time Mr Wilsher had been admitted to NNUH and discharged and plans were already in place for his transfer to a nursing home. ”

    Source location

    JOHN HENRY WILSHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Derby and Derbyshire

    AI-generated summary

    William Leonard Beckwith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Leonard Beckwith sustained a cervical spine fracture after a fall at home, was discharged from hospital without the fracture being diagnosed, and died on 11 October 2013 after readmission with acute stridor and subsequent deterioration. The principal concern was that, despite his age and history of falls, he was discharged home in the early hours without formal assessment of his abilities, his home environment, or his wife’s ability to care for him, and without post-discharge planning or needs assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to undertake post-discharge planning and assessment of follow-up care needs

    Wider context from the report

    “A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning. ”

    Source location

    William Leonard Beckwith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester West

    AI-generated summary

    Keith Samuel Peters · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Keith Samuel Peters lived alone with Type II diabetes, chronic pancreatitis and alcohol dependence, and was admitted to hospital after his sister became concerned about his condition; he died on 12 September 2013. Concerns included delays and lack of prioritisation in assessing his social care needs, and the absence of a system to reallocate cases when an assessment could not be completed within the required period.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to prioritise assessments approaching or exceeding the twenty-eight-day completion period

    Wider context from the report

    “Brief circumstances of matters of concern (1) Mr Peters’ case was allocated to a Community Assessment Officer who was on annual leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters’ assessment within the required period. (2) During the periods when the Community Assessment Officer was available there is no evidence of Mr Peters’ case being prioritised, neither when the twenty eight day period allowed for the assessment to be completed was approaching expiry, nor when that period had expired. (3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight days required. ”

    Source location

    Keith Samuel Peters · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a system for referring overdue assessments for reallocation to another officer

    Wider context from the report

    “Brief circumstances of matters of concern (1) Mr Peters’ case was allocated to a Community Assessment Officer who was on annual leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters’ assessment within the required period. (2) During the periods when the Community Assessment Officer was available there is no evidence of Mr Peters’ case being prioritised, neither when the twenty eight day period allowed for the assessment to be completed was approaching expiry, nor when that period had expired. (3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight days required. ”

    Source location

    Keith Samuel Peters · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide six-weekly formal supervision and daily case discussions where required, supported by a systematic approach to reprioritisation or reallocation.

    Verbatim wording from the response

    “Action Staff to receive formal supervision on a 6 weekly basis and case discussions on a daily basis if required. The service does accept that a more systematic approach would be of benefit to managers and staff to enable reaching the 28 day period to enable reprioritisation/reallocation as necessary.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 3 · response
    Published 20 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop electronic monitoring and trigger functions to alert staff and managers to assessment timescales requiring prioritisation or reallocation.

    Verbatim wording from the response

    “The service will develop a monitoring and trigger function within the electronic system for staff and managers to be alerted to timescales for risk assessment prioritisation or reallocation as necessary.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 3 · response
    Published 20 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Communicate staff and manager responsibilities for alerting case managers when assessment timescales may not be met.

    Verbatim wording from the response

    “Action Staff to be reminded of personal responsibilities to alert their case manager to cases where timescales may not be met.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 2 · response
    Published 20 December 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Unavailable referral information did not identify risks requiring prioritisation, while daily welfare checks found no concerns or increasing risks.

    Verbatim wording from the response

    “Service Response The service considers that there was significant information that was not shared at the point of referral that could have highlighted risks to the case worker and manager to prioritise casework.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 3 · response
    Published 20 December 2013

    Open published response

  8. South Yorkshire (Western)

    AI-generated summary

    Mrs May Gibson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain community care assessments

    Wider context from the report

    “1) the failure to obtain the community care assessment and to take proper account of this in developing a care plan; ”

    Source location

    Mrs May Gibson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026