Recurring concern

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

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First reported 2 Dec 2014•Latest report 2 May 2026

Definition

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.

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
16

Distinct published reports

Individual concerns
18

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
31

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England3
Nottinghamshire Healthcare NHS Foundation Trust2
Betsi Cadwaladr University LHB1
Bluebird Care (Bromsgrove & Redditch)1
Care Quality Commission1
Cookham Wood Prison1
County Durham and Darlington NHS Foundation Trust1
Divine Health Services Limited1
Durham County Council1
East London NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Government Legal Department1
Greater Manchester Mental Health NHS Foundation Trust1
Herefordshire and Worcestershire Health and Care NHS Trust1
HM Prison and Probation Service1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. East London

    AI-generated summary

    Vijaykumar Girishbhai Gadhavi · 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

    Vijaykumar Girishbhai Gadhavi died from a drug overdose while an in-patient at Whipps Cross Hospital under enhanced one-to-one care. The report raised concerns about breaches of the Enhanced Care Policy, the absence of an alert or risk-management plan, inadequate recording of property and medication, insufficient family involvement, and a lack of evidence that learning from earlier self-harming incidents had been implemented.

    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

    Insufficient involvement of family in learning disability care recommendations

    Wider context from the report

    “4. The recommendation by the learning disability nurse were not fully put into practice. In particular, there was insufficient involvement of his family. ”

    Source location

    Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Stephen Thurm · 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

    Stephen Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.

    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 incorporate main carers' care needs into long-term plans

    Wider context from the report

    “3. ████████ expressed they were both suffering with a severe effect on their mental health but their care needs as the main carers was not built in to any long term plan. ”

    Source location

    Stephen Thurm · 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 incorporate family information into care plans and risk assessments

    Wider context from the report

    “1. The inquest heard that information regarding the risk of self-harm to Stephen was passed by his family to his treating clinicians and his care coordinator but this was not taken into account as Stephen denied a recent attempt to take his own life. What steps could be taken to ensure family information is taken into account in the relevant care plan and risk assessments. ”

    Source location

    Stephen Thurm · 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

    Publish an updated Care Programme Approach Position Statement setting expectations for involving and supporting carers in care and support planning.

    Verbatim wording from the response

    “Carers are often vital in supporting people with severe mental health problems in the community. There was existing national CPA guidance which sets clear expectations around carer involvement, however, there was a need to bring this guidance (although helpful) up to date. As part of the newly published Care Programme Approach Position Statement, NHS England and NHS Improvement has set out clear expectations for systems to provide support for carers of people with severe mental health problems and to better involve carers in care and support planning from April 2021. Specifically, to use Long Term Plan funding to develop and implement plans to improve the lives of carers of people with severe mental health problems and also to look at specific inequalities’ carers may face.”

    Source location

    2021-0155-Response-from-NHS-Improvement_Published
    Page 2 · response
    Published 18 May 2021

    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

    Update the Clinical Risk Assessment Policy to address confidentiality breaches where necessary to manage risks of serious harm.

    Verbatim wording from the response

    “GMMH Trust Clinical Risk Assessment Policy has been updated in March 2021 to include circumstances when staff may be required to breach someone’s confidentiality in respect of risk to self or others.”

    Source location

    2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 18 May 2021

    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 and update Trust-wide clinical risk training to require gathering and corroborating risk information from family, friends and other professionals.

    Verbatim wording from the response

    “Alongside the updated Clinical Risk Policy the Trust wide clinical risk training has also been reviewed and updated in March 2021 to include the need for staff to gather information from other sources and not just the service user when undertaking assessment of risk. The use of professional curiosity is raised within the training and the need not to take things at face value but to corroborate information with other professionals, friends and family. The training makes it clear to staff that you do not require consent from a service user to receive information from others.”

    Source location

    2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 18 May 2021

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Stanley Langdon · 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

    Stanley Langdon died at Dipton Manor Care Home on 21 May 2017 from complications arising from a periprosthetic left femoral fracture sustained while carers assisted him to climb onto a minibus. The report states that he would not have sustained the fracture if he had been transferred in a wheelchair using the available hydraulic lift. The principal concerns were that services began without an adequate care plan or needs assessment, and that care planning was not based on complete information or agreed with his family, creating a risk of similar accidents and deaths in future.

    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 discuss and agree care plans and needs assessments with service users’ families

    Wider context from the report

    “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user. (5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users. (6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day) (7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day). ”

    Source location

    Stanley Langdon · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Essex

    AI-generated summary

    Dean Gary Saunders · 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

    Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.

    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 meaningfully involve families in the ACCT process

    Wider context from the report

    “6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family. ”

    Source location

    Dean Gary Saunders · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  5. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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 involve outside agencies and carers in safeguarding

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · 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

    Introduce a more rigorous ACCT quality-assurance process with individual feedback to case managers.

    Verbatim wording from the response

    “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

    Source location

    2014-0555-Response-by-Ministry-of-Justice
    Page 5 · response
    Published 28 December 2014

    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 Cookham Wood case workers to facilitate regular community visits, significant-incident updates, and community and parental participation in ACCT reviews.

    Verbatim wording from the response

    “Point 3,a; The arrangements now in place, require Case Workers at Cookham Wood, to encourage the external YOT and Social Workers (where a Looked After Child (LAC)) to visit young persons in custody at least monthly, to meet with the young”

    Source location

    2014-0555-Response-by-Medway-Youth-Offending-Service
    Page 3 · response
    Published 28 December 2014

    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 ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.

    Verbatim wording from the response

    “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

    Source location

    2014-0555-Response-by-Ministry-of-Justice
    Page 5 · response
    Published 28 December 2014

    Open published response

  6. North Wales (East and Central)

    AI-generated summary

    Anthony Gwyn Williams · 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

    On 9 February 2014, Anthony Gwyn Williams, whose mental health was declining, went to Pentwmpath Woods and took his own life with a ligature while his balance of mind was disturbed. Concerns included insufficient guidance on when staff could deviate from the recognised psychiatric assessment pathway, lack of continuous access to patients’ medical records, and the need for greater engagement with families and carers about care and treatment plans.

    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

    Insufficient engagement with family and carers about patients' Care and Treatment Plans

    Wider context from the report

    “3. There should be greater engagement with family and carers of patients (with patient consent) to ensure that they are aware of the contents of patient's Care and Treatment Plan especially with regard to the options which may exist in times of crisis. ”

    Source location

    Anthony Gwyn Williams · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Family and carer involvement in care planning is legally limited where patients with capacity do not consent, unless overriding public interest justifies disclosure.

    Verbatim wording from the response

    “general principal if a patient has capacity to make decisions about whether family members or carers are involved in a patient’s care planning and care, then services are obliged to respect that decision unless there is an overriding public interest, which merits disclosure of information. Where the involvement of family and carer’s is accepted by the patient, the sharing of the Care and Treatment Plan would be appropriate. I am assured that all patients are provided with a copy of their Care and Treatment Plans. If a patient lacks capacity to make decisions about the involvement of family or carers there should follow a best interest decision. I would suspect in the majority of cases the involvement of family and carers would be in a person’s best interest.”

    Source location

    2014-0523-Response-by-University-Health-Board
    Page 2 · response
    Published 2 December 2014

    Open published response
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Data last updated 7 September 2026