Recurring concern

Failure to involve families and carers in safety-critical care decisions

First to latest report 2 Dec 2014 — 2 May 2026

Reports that mention this concern
16
Times this concern has been raised
18
Stated actions linked to this concern
31

What this concern includes

Includes failures to consider, seek, enable or appropriately use family or carer involvement in safety-critical care planning, risk management or consequential care decisions where their information, support or protective role is materially relevant; include the anchor's failure to consider and advocate for family contact and comparable failures involving family participation in risk management and planning.

What is not included
  • Excludes routine family communication, updates or contact where no safety-critical care decision, risk-management arrangement or protective-support need is involved.
  • Excludes professional-to-professional communication and generic advocacy failures where family or carer involvement is not the bounded safety control.
  • Excludes cases where family or carer involvement is inappropriate, refused, legally restricted or not materially relevant because of consent, confidentiality, capacity or safeguarding considerations.
  • Excludes failures limited to discharge, mental-health-specific family involvement or family complaints where an existing narrower named process provides the more faithful boundary.

Reports and published responses 16 reports

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

  1. East London

    AI-generated summary

    Somtera Bibi · 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

    Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.

    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 respond adequately to attempts to formulate a family safety plan

    Wider context from the report

    “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour. Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically: (i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family (ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020 (iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened (iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members (v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members (vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse ”

    Source location

    Somtera Bibi · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Circulate Trust-wide expectations for contacting and communicating with police.

    Verbatim wording from the response

    “7. On 21 April 2026 communication was circulated Trust-wide including expectations around contacting the police.”

    Source location

    Response from East London Foundation NHS Trust
    Page 2 · response
    Published 10 July 2026

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    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

    Integrate safeguarding work with Local Authority colleagues through joint case-review and planning forums.

    Verbatim wording from the response

    “14. Since this tragic incident, the Trust’s Newham Mental Health Service has made great efforts to integrate our safeguarding work with Local Authority colleagues through the introduction and bolstering of joint forums where cases are reviewed and plans are agreed.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

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    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 and strengthen risk assessment and management processes, including clinical-recording-system changes and staff training.

    Verbatim wording from the response

    “16. The Trust has a large piece of work underway reviewing and strengthening risk assessment and management processes. This will involve changes to our clinical recording system as well as staff training. This is intended to create processes that are more focused on risk formulation, based on current factors and historical risk. For clarity, these processes would always be expected to involve the service user and also family/carers where this is relevant.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

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    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 staff guidance and regular advice to service users and carers on safeguarding, community safety and police routes for mitigating identified risks.

    Verbatim wording from the response

    “19. In relation to the specific risks relating to this case, the relevant actions are those around risk formulation in terms of identifying risks (as per concern 5). In terms of mitigating identified risks, these should flow from the risk assessment and include the home environment where relevant. In relation to family or carer safety, the appropriate actions will predominantly relate to either safeguarding processes (DASH assessment/ MARAC referral etc) or community safety/police liaison processes. Learning for these is covered in relation to concerns 1, 3 and 4 as per the learning statements.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Family and community safety risks should be addressed through safeguarding, community safety pathways or police liaison rather than direct health responses.

    Verbatim wording from the response

    “19. In relation to the specific risks relating to this case, the relevant actions are those around risk formulation in terms of identifying risks (as per concern 5). In terms of mitigating identified risks, these should flow from the risk assessment and include the home environment where relevant. In relation to family or carer safety, the appropriate actions will predominantly relate to either safeguarding processes (DASH assessment/ MARAC referral etc) or community safety/police liaison processes. Learning for these is covered in relation to concerns 1, 3 and 4 as per the learning statements.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

    Open published response

  2. West Sussex, Brighton and Hove

    AI-generated summary

    Amy Clare CHAPMAN · 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

    Amy Clare Chapman, who was experiencing a mental health crisis and assessed as at high risk of suicide, was admitted to the Haven Unit at Millview Hospital on 23 March 2025. On 27 March, she was permitted to leave the unit twice without adequate checking of her records, family contact, or documentation, and later jumped from a bridge, dying from her injuries. The principal concerns included insufficient risk assessment and planning for trips out, failures to read and record notes, inadequate family involvement, uncertainty over care and safety plans, and gaps in training, alerts, checklists, and auditing.

    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 family involvement in risk management and planning

    Wider context from the report

    “6. The lack of family involvement in risk management and planning is a breach of policy, and would have been straightforward in this case. ”

    Source location

    Amy Clare CHAPMAN · Prevention of Future Deaths report
    Page 2 · concerns

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    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 Triangle of Care training and carer-involvement simulation sessions for Brighton Haven staff.

    Verbatim wording from the response

    “A number of actions have also been taken to improve family involvement, including, as part of a specific Brighton Haven Team training day, reaffirming the principles of the Triangle of Care and conducting carer involvement simulation sessions to improve practice. Triangle of Care is a nationally recognised, collaborative framework that involves the patient, their carer, and professionals working together to support recovery, safety, and wellbeing. Adherence to the framework will be monitored.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 4 · response
    Published 29 June 2026

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  3. Worcestershire

    AI-generated summary

    Surendrakumar Patel · 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

    Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.

    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 consider and advocate for family contact

    Wider context from the report

    “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy: a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began b. Failure to consider hospital transfer for prisoners severely weakened by weight loss c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival d. Failure to consider and advocate for family contact 2. Prison staff lacked awareness of HMP Hewell food refusal policy, including: • Not informing Next of Kin of the prisoner’s decision to refuse food/fluids • Not asking the prisoner whether such information should be shared ”

    Source location

    Surendrakumar Patel · Prevention of Future Deaths report
    Page 2 · concerns

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    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 a joint review of HMP Hewell’s food refusal policy to clarify consideration of next-of-kin contact where serious health risks are identified.

    Verbatim wording from the response

    “HMPPS recognises the importance of family involvement at times of increased vulnerability including where a prisoner is refusing food and/or fluid. A joint review of HMP Hewell’s food refusal policy has since been undertaken in partnership with healthcare colleagues. This review has strengthened clarity around the consideration of contact with next of kin when a healthcare professional identifies a serious risk to an individual’s health. Following the completion of the review, awareness sessions will be delivered to prison and healthcare staff involved in managing and supporting prisoners who refuse food, including contact with the next of kin, to support consistent, compassionate, and informed practice.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 12 March 2026

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    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 awareness sessions to prison and healthcare staff on supporting prisoners who refuse food, including contact with next of kin.

    Verbatim wording from the response

    “HMPPS recognises the importance of family involvement at times of increased vulnerability including where a prisoner is refusing food and/or fluid. A joint review of HMP Hewell’s food refusal policy has since been undertaken in partnership with healthcare colleagues. This review has strengthened clarity around the consideration of contact with next of kin when a healthcare professional identifies a serious risk to an individual’s health. Following the completion of the review, awareness sessions will be delivered to prison and healthcare staff involved in managing and supporting prisoners who refuse food, including contact with the next of kin, to support consistent, compassionate, and informed practice.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 12 March 2026

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.

    Verbatim wording from the response

    “Following evidence heard at the inquest you raised concerns directed to both HMPPS and Practice Plus Group (PPG). I understand PPG will respond to those issues relating to the delivery of healthcare at HMP Hewell, for which they are responsible. I am therefore responding to the issue relating to HMPPS.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 12 March 2026

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.

    Verbatim wording from the response

    “This does not mean that Practice Plus Group has not reflected on this case. The outcome of the Inquest follows a period whereupon the food and fluid refusal pathway has robustly been tested and, as a result, Practice Plus Group considers it to be robust and fit for purpose regardless of the”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 12 March 2026

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Family advocacy was not considered necessary because the patient did not request family support and no benefit from contact was identified.

    Verbatim wording from the response

    “So far as Practice Plus Group is concerned, Mr Patel did not request any family support. Mr Patel told the nursing staff that his only external support had been his wife and that he was not in contact with his daughter at the time he entered HMP Hewell. Therefore, the need to act as an advocate for family contact did not arise in this specific case.”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 12 March 2026

    Open published response

  4. West Sussex, Brighton and Hove

    AI-generated summary

    Joanna Chamberlain · 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

    Joanna Chamberlain took her own life at home on 23 January 2025 after a recent overdose, other self-harm incidents and an assessment that she was at moderate risk. The report raises concerns about the lack of safe, supportive spaces for people needing more support than home treatment teams can provide, and about clinicians seeking and including family or other relevant input when care plans depend on protective factors.

    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 clear guidance and protocols for clinicians to seek and include family or other relevant views in care and safety planning

    Wider context from the report

    “Equally, whilst I recognise the importance and value in clinicians rapidly assessing a patient’s risk of self-harm, using their individual professional judgement, and forming an immediate care and safety plan, there is a potential need for clearer national guidance on, direction to and protocols for clinicians to appropriately seek and include the views and input of family members, or others (e.g. GP), reinforcing the triangle of care, and especially where the delivery or assurance of a care and safety plan depends on them. This appears even more necessary where such individuals themselves are a key protective factor. ”

    Source location

    Joanna Chamberlain · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Publish national best-practice guidance promoting proactive involvement of trusted others in safety assessment and management.

    Verbatim wording from the response

    “NHS England published the Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management on 4 April 2025. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. One of its 10 overarching principles of approach is that of 'involving others: encourage the involvement of trusted others, where possible and as appropriate'. The guidance applies to all mental health practitioners and promotes the proactive engagement of trusted others within legal limits, highlighting that "in the case of immediate risk to life, the duty to share information overrides confidentiality". This guidance therefore clarifies previous national guidance.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 14 November 2025

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    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

    Launch nationally available e-learning training complementing the suicide-safety guidance for mental health practitioners.

    Verbatim wording from the response

    “NHS England has also launched an e-learning session, which is designed to complement our Staying Safe from Suicide Guidance. The Staying Safe from Suicide: Best practice guidance e-learning session is now available for all mental health practitioners across the country. The guidance and the training both cover sections on confidentiality and the law, and refer to the Consensus statement for information sharing and suicide prevention.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 14 November 2025

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    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

    Share draft personalised-care guidance with Integrated Care Boards on involving families, carers and support networks in care and safety planning.

    Verbatim wording from the response

    “Personalised Care Framework”

    Source location

    Response from NHS England
    Page 4 · response
    Published 14 November 2025

    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

    Published suicide safety guidance clarifies national expectations for proactively involving trusted others in safety planning.

    Verbatim wording from the response

    “NHS England published the Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management on 4 April 2025. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. One of its 10 overarching principles of approach is that of 'involving others: encourage the involvement of trusted others, where possible and as appropriate'. The guidance applies to all mental health practitioners and promotes the proactive engagement of trusted others within legal limits, highlighting that "in the case of immediate risk to life, the duty to share information overrides confidentiality". This guidance therefore clarifies previous national guidance.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 14 November 2025

    Open published response

  5. County Durham and Darlington

    AI-generated summary

    Esther Jane Lancaster Byrne · 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

    Esther Jane Lancaster Byrne, who had vascular dementia and was extremely frail, died at her care home on 18 December 2024 after deterioration following a fall, a neck of femur fracture, surgery and discharge back to the care home. Concerns included poor communication with the family and power-of-attorney holder, misunderstandings about her baseline and mobility affecting discharge planning, failure to arrange follow-up, and doubts about the quality and accuracy of outsourced radiological reporting.

    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 communicate diagnosis, treatment options, rationale and discharge plans with family representatives

    Wider context from the report

    “1. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased's baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan. ”

    Source location

    Esther Jane Lancaster Byrne · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Allocate a multidisciplinary team member on ward rounds to update families about all aspects of patient care.

    Verbatim wording from the response

    “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.”

    Source location

    Response from County Durham and Darlington NHS Foundation Trust
    Page 2 · response
    Published 11 June 2025

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    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

    Conduct regular retrospective clinical-record audits to monitor compliance with family communication standards.

    Verbatim wording from the response

    “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.”

    Source location

    Response from County Durham and Darlington NHS Foundation Trust
    Page 2 · response
    Published 11 June 2025

    Open published response

  6. Nottinghamshire

    AI-generated summary

    Kenneth Stanley Baylis · 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

    Kenneth Stanley Baylis took his own life on 23 January 2023 while on unescorted leave as an informal inpatient on Kingsley Ward. The report identified concerns including inadequate suicide risk assessment and mitigation, insufficient family involvement, failure to follow planned-leave procedures, and inadequate review and investigation after serious suicide attempts or a death.

    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 routinely involve family in patients' risk assessment, care planning and safety planning

    Wider context from the report

    “1. Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning. ”

    Source location

    Kenneth Stanley Baylis · 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 each patient with a named nurse who agrees at least weekly family or carer contact and audits involvement in care planning and risk assessment.

    Verbatim wording from the response

    “The wards within MHSOP have reviewed their processes for involving family members in care and treatment and the following is now routinely in place on all wards:”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 6 March 2024

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    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

    Invite families and carers to ward multidisciplinary meetings using a standard template and audit invitations and involvement.

    Verbatim wording from the response

    “• In addition to this, weekly/fortnightly multi-disciplinary meetings (MDT) take place on each ward and families and carers are routinely invited which is audited on a weekly basis. There is a universal MDT template (Appendix 3) which is used for documenting the meetings and it specifically asks if family members were invited and details their involvement in care and treatment.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 6 March 2024

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    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

    Introduce collaborative care-planning conversations with every newly admitted patient and their relative or carer.

    Verbatim wording from the response

    “• Kingsley Ward during March 2024 ran a patient and carer survey to ask about involvement in care planning and risk assessment and which they plan to continue to monitor effectiveness of changes made and identify further improvements required. This initial survey has informed the introduction of a collaborative care planning conversation with every newly admitted patient and their relative/carer to all MHSOP ward. This includes a structured conversation to co-produce the care plans for each patient as they are admitted to the in-patient ward.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 6 March 2024

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    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

    Strengthen SAFETool training with family and carer involvement content and reflective case studies.

    Verbatim wording from the response

    “• The training will be facilitated by one of the Trusts Clinical Educators for Suicide Prevention who also has an extensive clinical background within MHSOP. The training already incorporates family/carer involvement within risk assessment and care planning, but this has been further strengthened and includes case studies to enable staff to undertake reflection and learning during the training session.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 4 · response
    Published 6 March 2024

    Open published response

  7. Manchester South

    AI-generated summary

    Susan Wendy Bracegirdle · 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

    Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.

    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 a communication strategy supporting joint working and family involvement in pressure-ulcer care

    Wider context from the report

    “2. There was no communication strategy in place as a consequence of an approach that did not promote team /joint working. The inquest heard that as a consequence the family were unsighted on the condition of Mrs Bracegirdle until shortly before her admission to hospital. This meant that the family could not support the work to reduce the risk of the pressure ulcers deteriorating further and were not able to be a proactive about the care she was receiving increasing the risk of her pressure ulcers deteriorating ”

    Source location

    Susan Wendy Bracegirdle · 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

    Develop an information leaflet explaining how families can contact District Nursing for pressure-area-care advice.

    Verbatim wording from the response

    “In undertaking this review there was evidence of verbal communication with the care home staff and written notes within the communication book at the care home. However, an information leaflet will be developed to promote communication.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 4 · response
    Published 12 February 2024

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    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

    Include joint-working Quality Statements in the service’s next assessment and follow up actions addressing previously identified communication shortfalls.

    Verbatim wording from the response

    “At our last inspection of Stable Steps Care Centre on 8 and 19 June 2023 we found that improvements were needed to ensure communication worked effectively within the home. Feedback from people living at the home and their families was mixed with some people feeling staff were responsive to their needs, whilst others gave examples of where they felt there had been delays in receiving treatment. Families also told us communication between healthcare services and the home could be difficult, staff were not always able to identify deterioration in people and that liaison and referrals with external services could be improved.”

    Source location

    Response from Care Quality Commission
    Page 5 · response
    Published 12 February 2024

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    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

    Follow up the registered manager’s investigation into failures to keep families informed and seek assurance that resulting actions mitigate communication risks.

    Verbatim wording from the response

    “We would expect, as parties to general reviews of care whilst at the home, a person’s family to be involved and informed, with the consent of the individual, regarding their care, treatment and progress. We note that the registered manager in her statement, advised that she had apologised to the family for the failure to keep them informed regarding Mrs Bracegirdle’s pressure ulcers and that she had committed to investigating this shortfall. We will follow up on the outcome of the investigation to seek assurance that any actions arising from the investigation will mitigate further risks that families are not kept informed where appropriate within acceptable timeframes.”

    Source location

    Response from Care Quality Commission
    Page 6 · response
    Published 12 February 2024

    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 home provider is responsible for keeping family members updated about residents’ health, including pressure ulcer management and nursing advice.

    Verbatim wording from the response

    “The care home provider would be expected to keep family members updated in relation to all aspects of a resident’s health and wellbeing as a matter of course, using the information from the communications book, and from direct conversations with the attending district nurses. In the event of further questions from the family then it would be expected for the care home staff to liaise with the attending team to obtain information to address those questions. This would include information about pressure ulcer management and any advice from community colleagues (District Nursing Team) or the TVN Team.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 4 · response
    Published 12 February 2024

    Open published response

  8. Worcestershire

    AI-generated summary

    Anthony John Friend · 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

    Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.

    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 ensure carers' participation in sling assessments

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

    Source location

    Anthony John Friend · 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

    Failure to discuss sling use with new carers

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

    Source location

    Anthony John Friend · 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

    Introduce a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.

    Verbatim wording from the response

    “We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 3 · response
    Published 18 September 2023

    Open published response

  9. Nottinghamshire

    AI-generated summary

    Gerard Murray · 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

    Gerard Murray died on 16 July 2022 after leaving the mental health ward at Bassetlaw Hospital on unescorted leave and being found deceased later that day. The report identifies concerns about limited risk assessment and management, inadequate monitoring of patients returning from leave, limited family and carer involvement, and staff awareness of the ligature risk reduction pathway.

    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

    Extremely limited family and carer involvement in care planning and ward rounds

    Wider context from the report

    “3. There was extremely limited family and carer involvement in Gerard’s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward ”

    Source location

    Gerard Murray · 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

    Complete Triangle of Care self-assessments across Adult Mental Health inpatient areas and review findings to agree improvement actions.

    Verbatim wording from the response

    “The involvement of patient’s family, friends and carers is vital when planning and delivering the patients care and treatment. We recognise that at times, we have got this wrong. To understand how to improve in this area, all Adult Mental Health inpatient areas have completed the Triangle of Care Self-Assessment.”

    Source location

    Response from Nottingham Heathcare
    Page 3 · response
    Published 30 October 2023

    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

    Recruit and deploy a Carer Peer Support Worker for acute wards to strengthen liaison with patients, families, carers, and multidisciplinary teams.

    Verbatim wording from the response

    “To aid and support this partnership, all-acute wards have recruited a Carer Peer Support worker whose working week is dedicated to liaising with patients and their families/carers and ensuring the link with MDT members, and clinical discussions is strong. This person will also support the patients and their family/carers in Ward round discussions and ensure that follow up actions are completed and communicated effectively.”

    Source location

    Response from Nottingham Heathcare
    Page 4 · response
    Published 30 October 2023

    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

    Introduce admission-based Carer Contact Plans recording patients’ preferences for family and carer involvement and information sharing.

    Verbatim wording from the response

    “To enhance the work of the Carer Peer Support Worker, it is planned that all patients will on admission complete a carer contact plan. This will include who the patient would like to be involved in their care and care discussions, and what level of information should be shared. The Carer Contact Plan is in the final stage of agreement and should be used through the in-patient wards by the end of December 2023. The use of the Carer Contact Plan will be reviewed in Quarter 4 of 2023/34.”

    Source location

    Response from Nottingham Heathcare
    Page 4 · response
    Published 30 October 2023

    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 bespoke family-intervention training to the Beech Ward multidisciplinary team.

    Verbatim wording from the response

    “Finally, the family intervention team have devised a bespoke one-day training package which all of the Beech ward team including the MDT are booked on to attend. A copy of the training program is included below, and is scheduled to start in January 2023, with roll out through to June 2024.”

    Source location

    Response from Nottingham Heathcare
    Page 4 · response
    Published 30 October 2023

    Open published response

  10. Norfolk

    AI-generated summary

    Janice HOPPER · 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

    Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

    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 prepare care plans with relevant family input

    Wider context from the report

    “1. Mrs Hopper had dementia. The Care Plan was not prepared with input from Mrs Hopper's husband. ”

    Source location

    Janice HOPPER · 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

    Use an in-person pre-admission form documenting resident and family input, with family involvement subject to the resident’s consent where they have capacity.

    Verbatim wording from the response

    “New pre admission form has been developed and now includes detailed information regarding resident and family input, all pre admissions will be completed in person and not over the phone, families will be involved as part of the pre-admission process irrespective of resident capacity as long as the resident with capacity consents, this will be documented on the form.”

    Source location

    Response from Runwood Homes
    Page 1 · response
    Published 1 December 2022

    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

    Complete new-resident risk assessments within 24 hours and care plans within seven days, prioritising high-risk assessments within six hours and reviewing plans with families and when needs change.

    Verbatim wording from the response

    “New residents’ risk assessments will be completed in co-ordination within 24 hours and care plans within 7 days, although priority will be given within the first 6 hours to the highest risks to residents, e.g. choking, falls, pressure ulcers, evacuation during a fire, nutrition/hydration and any other specific ones such as pain, epilepsy, diabetes, moving and handling, absconding. This will allow staff to be able to assess the resident and gain further knowledge of their needs. All families will be invited to attend after 6 weeks to review these and then sign, these will be followed up monthly during the “Resident Of The Day” process and a full review will be undertaken at 6 months of the resident’s care plan and risk assessments, or if needs change they will be reviewed sooner.”

    Source location

    Response from Runwood Homes
    Page 1 · response
    Published 1 December 2022

    Open published response

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