Recurring concern

Failure to reliably identify and escalate self-neglect risks

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First reported 30 Dec 2016•Latest report 24 Nov 2024

Definition

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.

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: 5
Individual concerns: 5
Date range: 2016–2024
Stated actions: 14

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Bournemouth, Christchurch and Poole Council1

Department of Health and Social Care1

East Riding of Yorkshire Council1

HM Prison and Probation Service1

Hull University Teaching Hospitals NHS Trust1

London Borough of Redbridge1

Ministry of Justice1

NHS England1

North East London NHS Foundation Trust1

The Human Support Group Limited1

Trafford Borough Council1

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.

24 Nov2024
East Riding and Hull
Concerns raised1
1. Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review and renew the VARM procedure into a more contemporary, seamless and accessible Multi Agency Risk Management meeting procedure.
  Stated by East Riding of Yorkshire CouncilStated in progress
2. Action
  Relaunch risk-management training after the new Multi Agency Risk Management procedure is finalised.
  Stated by East Riding of Yorkshire CouncilStated planned
3. Action
  Consider making Multi Agency Risk Management training mandatory for adult social care and health practitioners through the practice development board.
  Stated by East Riding of Yorkshire CouncilStated planned
Respondent positions 2
1. Position
  Local and system concerns fall outside NHS England’s national policy and programme remit.
  Stated by NHS EnglandOutside remit
1. Position
  Local organisations should address the local and system concerns raised in the report.
  Stated by NHS EnglandRedirects responsibility
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
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
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
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
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
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
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
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Local 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
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Local 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
3 May2024
Dorset
Concerns raised1
1. Lack of knowledge and use of the Professionals Checklist for assessing potential self-neglect
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Disseminate awareness of the Self-Neglect Checklist and Multi-Agency Risk Management framework through management and frontline staff channels.
  Stated by Bournemouth, Christchurch and Poole CouncilStated completed
2. Action
  Instruct Adult Social Care operational staff to complete the Self-Neglect Checklist for allocated people who find engaging with services challenging.
  Stated by Bournemouth, Christchurch and Poole CouncilStated completed
3. Action
  Update Managing Risk and Engagement Guidance to include the Self-Neglect Checklist requirement.
  Stated by Bournemouth, Christchurch and Poole CouncilStated planned
1. Action
  Make the Self-Neglect Checklist prominent on the updated Adult Social Care intranet.
  Stated by Bournemouth, Christchurch and Poole CouncilStated completed
2. Action
  Deliver a mandatory staff webinar on self-neglect, checklist use, risk assessment, management escalation and the Multi-Agency Risk Management framework.
  Stated by Bournemouth, Christchurch and Poole CouncilStated planned
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
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
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
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
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
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 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
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
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
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 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
31 Aug2023
East London
Concerns raised1
1. Failure to escalate care in response to deteriorating health and self-neglect risks
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review, revise and disseminate the risk-escalation process to health and social care staff.
  Stated by North East London NHS Foundation TrustStated planned
2. Action
  Devise a standard operating procedure for district nurses’ daily handovers.
  Stated by North East London NHS Foundation TrustStated planned
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
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
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
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
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
5 Jan2023
Birmingham and Solihull
Concerns raised1
1. Inadequate safeguarding escalation process for non-violent, non-self-harm-related injurious activity
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Issue staff notice clarifying safeguarding responsibilities and escalation routes for prisoners experiencing self-neglect.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Instruct suicide and self-harm prevention trainers to place greater emphasis on self-neglect.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Issue a learning bulletin reminding staff to identify and refer prisoners who appear to be self-neglecting and support them appropriately.
  Stated by HM Prison and Probation ServiceStated planned
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
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
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
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
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
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
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
30 Dec2016
Manchester City
Concerns raised1
1. Failure to respond to indicators of self-neglect and inadequate nutrition
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement the new care plan incorporating falls management, capacity, substance and alcohol misuse, and food and nutrition risks.
  Stated by Human Support GroupStated completed
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to respond to indicators of self-neglect and inadequate nutrition

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 3

Respondent positions 2

Actions described in response 5

Actions described in response 2

Actions described in response 3

Actions described in response 1