Recurring concern

Failure to reliably identify and escalate self-neglect risks

First to latest report 30 Dec 2016 — 24 Nov 2024

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
14

What this concern includes

Includes failures in processes specifically dedicated to identifying, assessing, escalating or coordinating responses to self-neglect, including escalation of deteriorating health, use of self-neglect assessment tools, risk-management meetings and safeguarding escalation routes.

What is not included
  • Excludes generic clinical deterioration or care-escalation failures where self-neglect is not a material part of the asserted concern.
  • Excludes generic safeguarding, communication or multi-agency coordination deficiencies that do not specifically concern self-neglect risks.
  • Excludes failures limited to provision of care, housing clearance or treatment after self-neglect risks have been reliably identified and escalated.
  • Excludes ordinary neglect or abuse concerns without a self-neglect component.

Reports and published responses 5 reports

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

  1. East Riding and Hull

    AI-generated summary

    Colin Wiles · 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

    Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance 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

    Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect

    Wider context from the report

    “(1) No Vulnerable Adult Risk Management meeting was held despite multifactorial concerns with Mr Wiles’ comorbidities and self neglect leading to poor living conditions and increased risk to his safety ”

    Source location

    Colin Wiles · Prevention of Future Deaths report
    Page 3 · 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

    Review and renew the VARM procedure into a more contemporary, seamless and accessible Multi Agency Risk Management meeting procedure.

    Verbatim wording from the response

    “The current VARM procedure is available to all professionals and people in the east riding on the ERSAB website and guides them through the processes and paperwork involved (included as appendix 1). Training is provided to practitioners across the health and care system in the east riding on the use of VARM both through the ERSAB and the local authorities internal learning and skills team. To enable development in this area, the ERSAB and ASCH have collaborated with Hull City Council’s safeguarding adults board and Adult Services to review and renew the VARM procedure to contemporise the approach and develop a more seamless and accessible procedure in this geographical area.”

    Source location

    Response from East Riding of Yorkshire Council
    Page 1 · response
    Published 2 December 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

    Relaunch risk-management training after the new Multi Agency Risk Management procedure is finalised.

    Verbatim wording from the response

    “The VARM training is therefore currently under review and will be relaunched following the completion of this work to ensure and enable effective roll out of the new procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be considered by the service at our practice development board which is chaired by our Head of Service for Safeguarding and Quality Assurance.”

    Source location

    Response from East Riding of Yorkshire Council
    Page 1 · response
    Published 2 December 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

    Consider making Multi Agency Risk Management training mandatory for adult social care and health practitioners through the practice development board.

    Verbatim wording from the response

    “The VARM training is therefore currently under review and will be relaunched following the completion of this work to ensure and enable effective roll out of the new procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be considered by the service at our practice development board which is chaired by our Head of Service for Safeguarding and Quality Assurance.”

    Source location

    Response from East Riding of Yorkshire Council
    Page 1 · response
    Published 2 December 2024

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    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 and system concerns fall outside NHS England’s national policy and programme remit.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

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    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 organisations should address the local and system concerns raised in the report.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    Open published response

  2. Dorset

    AI-generated summary

    Neville Stephen Abbott · 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

    Neville Stephen Abbott, who lived alone and was known to Adult Social Care and Community Mental Health Services, was found deceased at home on 8 February 2022. He had schizophrenia and atrial fibrillation, and declined prescribed anticoagulant medication. The report raises concerns that Adult Social Care practitioners did not use the Professionals Checklist to assess potential self-neglect or consider convening a Multi-Agency Risk Management Meeting.

    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 knowledge and use of the Professionals Checklist for assessing potential self-neglect

    Wider context from the report

    “i. The lack of knowledge of, and use of the “Professionals Checklist” by ASC practitioners risks adults known to ASC not being assessed where there is a potential risk of self-neglect, including the perhaps less obvious aspects of self-neglect such as declining prescribed medication. Consequently, the requirement to consider calling a MARM, mandated by the “Professional Checklist”, in order to share information, assess risk and to formulate a plan to mitigate risk, may be missed. ”

    Source location

    Neville Stephen Abbott · Prevention of Future Deaths report
    Page 3 · 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

    Disseminate awareness of the Self-Neglect Checklist and Multi-Agency Risk Management framework through management and frontline staff channels.

    Verbatim wording from the response

    “k) Prompted discussion within Locality and Acute Hospital Services to raise awareness of the Self-Neglect checklist, MARM framework and to encourage their use were discussed at the service managers planning meeting. This has led to service managers discussing in their team managers meeting and further cascading to front line staff. This included raising awareness of available self-neglect/hoarding training and MARM Training.”

    Source location

    Response from BCP Council
    Page 2 · response
    Published 14 May 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

    Instruct Adult Social Care operational staff to complete the Self-Neglect Checklist for allocated people who find engaging with services challenging.

    Verbatim wording from the response

    “a. On 6 June, we instructed all operational staff in ASC via email to complete the Self-Neglect Checklist when they are allocated a person who appears to find engaging with services challenging. We will update our own ‘Managing Risk and Engagement Guidance’, to include this information.”

    Source location

    Response from BCP Council
    Page 3 · response
    Published 14 May 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

    Update Managing Risk and Engagement Guidance to include the Self-Neglect Checklist requirement.

    Verbatim wording from the response

    “a. On 6 June, we instructed all operational staff in ASC via email to complete the Self-Neglect Checklist when they are allocated a person who appears to find engaging with services challenging. We will update our own ‘Managing Risk and Engagement Guidance’, to include this information.”

    Source location

    Response from BCP Council
    Page 3 · response
    Published 14 May 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

    Make the Self-Neglect Checklist prominent on the updated Adult Social Care intranet.

    Verbatim wording from the response

    “b. The Self-Neglect Checklist is now much more prominent on our updated Adult Social Care intranet site, to help raise awareness in the future.”

    Source location

    Response from BCP Council
    Page 3 · response
    Published 14 May 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

    Deliver a mandatory staff webinar on self-neglect, checklist use, risk assessment, management escalation and the Multi-Agency Risk Management framework.

    Verbatim wording from the response

    “c. Based on the above instruction, we will also be holding a mandatory webinar for all staff on 26 June 2024. The purpose of this webinar is to further highlight what constitutes self-neglect, to highlight the guidance that is available in the Safeguarding Adults Board (SAB) Procedures and our own guidance, including the requirement to use the Self-Neglect Checklist. We will remind practitioners that they are required to undertake a Risk Assessment if a person ‘declines an assessment, services or support’ and to discuss this issue with their line manager. We will promote the use of the MARM framework in supporting the formulation of a multi-agency risk assessment and management plan.”

    Source location

    Response from BCP Council
    Page 3 · response
    Published 14 May 2024

    Open published response

  3. East London

    AI-generated summary

    Donna Levy · 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

    Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.

    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 escalate care in response to deteriorating health and self-neglect risks

    Wider context from the report

    “2. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect. ”

    Source location

    Donna Levy · 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

    Review, revise and disseminate the risk-escalation process to health and social care staff.

    Verbatim wording from the response

    “• Review, revise and disseminate the risk escalation process with health and social care staff.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 8 September 2023

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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

    Devise a standard operating procedure for district nurses’ daily handovers.

    Verbatim wording from the response

    “• Devise a standardised operating procedure relating to how District Nurses conduct their daily handovers.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 8 September 2023

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Floyd Everton CARRUTHERS · 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

    Floyd Everton Carruthers was detained at HMP Birmingham and died in hospital on 14 June 2021 after developing infective endocarditis, cardiac tamponade, and multi-organ failure. The report raises concerns about inadequate safeguarding training and escalation processes, insufficient record keeping and handover, and failures to refer him to healthcare despite missed meals and not leaving his cell. The jury concluded that his 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

    Inadequate safeguarding escalation process for non-violent, non-self-harm-related injurious activity

    Wider context from the report

    “2. While evidence was heard from prison staff detailing a number of potential escalation routes for what might be termed 'social isolation' (an instance, as with Mr Carruthers, where they had not left their cell for a period of days but had not been observed to have were self isolating), notably ACCT and CISP, none of the officers appeared aware of a corresponding process for raising safeguarding issues. The known escalation routes (ACCT and CISP) are more focussed on violence and self-harm, leaving at the very least a conceptual gap in how best to deal with injurious activity which is neither violent nor directly/obviously contributory to self-harm, such as self-neglect. My concern is that the existing safeguarding escalation process is either inadequate, inappropriately trained or both ”

    Source location

    Floyd Everton CARRUTHERS · Prevention of Future Deaths report
    Page 3 · 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

    Issue staff notice clarifying safeguarding responsibilities and escalation routes for prisoners experiencing self-neglect.

    Verbatim wording from the response

    “On 9 March 2023, the Governor at HMP Birmingham issued a notice to staff on the subject of safeguarding, stating very clearly that when a prisoner is found to be neglecting their own welfare it is the responsibility of staff to ensure that appropriate action is taken to ensure that their needs are met using relevant processes and to provide ongoing support. Staff are reminded to report such instances to the prison safeguarding lead (the Head of Safer Custody) who will consider the suitability of making a referral for a social care assessment.”

    Source location

    Response from HM Prison and Probation Services
    Page 1 · response
    Published 9 January 2023

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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

    Instruct suicide and self-harm prevention trainers to place greater emphasis on self-neglect.

    Verbatim wording from the response

    “In addition to this, safeguarding is now a standing item at the weekly Governing Governor’s briefing at HMP Birmingham. The establishment’s suicide and self-harm prevention trainers have been instructed to place more emphasis on issues relating to self-neglect, and from December 2023 a HMPPS training programme focused specifically on safeguarding will become available.”

    Source location

    Response from HM Prison and Probation Services
    Page 1 · response
    Published 9 January 2023

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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

    Issue a learning bulletin reminding staff to identify and refer prisoners who appear to be self-neglecting and support them appropriately.

    Verbatim wording from the response

    “In the meantime, HMPPS will issue a learning bulletin that will remind staff of the existing requirements to identify and refer for assessment prisoners who appear to be self-neglecting, and describe the actions that staff can take to support prisoners in such circumstances.”

    Source location

    Response from HM Prison and Probation Services
    Page 2 · response
    Published 9 January 2023

    Open published response

  5. Manchester City

    AI-generated summary

    Raymond David SHEPHERD · 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

    Raymond David SHEPHERD had chronic ill health, severely limited mobility and a high risk of falls and self-neglect. In January 2016, care records noted repeated falls, poor appetite and a deterioration in his condition, but referrals to a GP or ambulance service were not made; he later sustained a femur fracture after a further fall and died in hospital on 30 January 2016. The principal concerns were poor care record-keeping, missed care visits, failure to escalate reported or observed falls and deterioration, and the absence of a mental capacity 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 respond to indicators of self-neglect and inadequate nutrition

    Wider context from the report

    “5. The deceased was a service user with chronic health problems which affected his mobility and was at high risk of suffering a fall as well as self-neglect. He reported not wishing to eat anything over a period of days which again should have triggered some concern. ”

    Source location

    Raymond David SHEPHERD · 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

    Implement the new care plan incorporating falls management, capacity, substance and alcohol misuse, and food and nutrition risks.

    Verbatim wording from the response

    “4.2 A new care plan was already in development and a section was added about risks of falls and falls management. This was introduced to the wider Organisation on 1st December 2016.”

    Source location

    2016-0467-Response-by-Human-Support-Group.pdf
    Page 2 · response
    Published 30 December 2016

    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