Recurring concern

Failure to maintain clear ownership of multi-agency support and care

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First reported 16 Oct 2015•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures to designate, retain or exercise overall ownership for coordinated multi-agency support and care, including absence of a lead person or agency, unclear responsibility between agencies, and loss of a single point of contact for people with complex or uncertain needs.

Not included

  • Excludes generic failures of communication, information sharing or multi-agency meetings where no deficiency in overall ownership or accountability for support and care is identified.
  • Excludes failures belonging to a separately named pathway, service or safeguarding system unless the report specifically identifies the absence of overall ownership within that system.
  • Excludes isolated failures to appoint a case manager where no broader multi-agency ownership or coordination concern is supported.
  • Excludes generic organisational accountability or leadership deficiencies unrelated to coordinating support and care across multiple agencies.
Reports
15

Distinct published reports

Individual concerns
18

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
15

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.

Department of Health and Social Care8
NHS England2
Cornwall Council1
Derbyshire County Council1
Derbyshire Healthcare NHS Foundation Trust1
Gloucestershire County Council1
Greater Manchester Health and Social Care Partnership1
Home Office1
Kent and Medway Mental Health NHS Trust1
Ministry of Housing, Communities and Local Government1
Ministry of Justice1
NHS Gloucestershire Clinical Commissioning Group1
NHS Greater Manchester Integrated Care Board1
Norfolk and Suffolk NHS Foundation Trust1
South West Yorkshire Partnership Teaching NHS Foundation Trust1

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. West Sussex, Brighton and Hove

    AI-generated summary

    Alex Ganski · 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 Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.

    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 designated lead with oversight and authority over coordinated care

    Wider context from the report

    “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”

    Source location

    Alex Ganski · 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

    Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.

    Verbatim wording from the response

    “As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 August 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.

    Verbatim wording from the response

    “NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 14 August 2026

    Open published response

  2. West Sussex, Brighton and Hove

    AI-generated summary

    Alex Ganski · 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 Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.

    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 designated lead with full oversight and authority over coordinated care

    Wider context from the report

    “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”

    Source location

    Alex Ganski · 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

    Share the draft Personalised Care Framework with NHS organisations ahead of publication.

    Verbatim wording from the response

    “The Personalised Care Framework also looks to improve continuity, clarity and safety by ensuring people experiencing serious mental illness have a named professional coordinating their care, a care plan that reflects their needs now, quicker re-access to support when things deteriorate, and more consistent standards of good care wherever they live. The Personalised Care Framework has been shared in draft with NHS organisations ahead of its expected publication.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 2 April 2026

    Open published response

  3. Kent and Medway

    AI-generated summary

    Stephen Taylor · 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 Taylor experienced worsening mental distress linked to work and financial concerns, with escalating risk indicators and repeated contact with health services. He died on 26 May 2025 after deliberately jumping from Louisa Bay Cliffs. The principal concerns were the lack of coordinated escalation and ownership of risk across services, reliance on his denial of immediate intent despite other risk indicators, routine rather than urgent referrals, and the absence of a same-day urgent face-to-face assessment despite family concerns.

    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 assign ownership of urgent risk management across services

    Wider context from the report

    “(5) Responsibility for escalation became diffuse across multiple services, creating a foreseeable risk that no single service took ownership of urgent risk management. ”

    Source location

    Stephen Taylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. West Sussex, Brighton and Hove

    AI-generated summary

    Axel Price · 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

    Axel Price, who had recently turned 18, died by a ligature at some time between 15 and 23 April 2021 after discharge from hospital and Police custody into temporary accommodation. The report identified concerns about unclear agency responsibility and inadequate support during his transition from child and adolescent mental health services to adult services, including failures relating to discharge planning, risk assessment, capacity assessment and ongoing engagement.

    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 national guidance and support for the multi-agency transition approach

    Wider context from the report

    “This case identified that there is a lack of clear understanding of the risk or accountability between the agencies when a young person transitions from CAMBS services at the age of 18 to adult services. The expert who provided evidence in this case said that this was a well-recognised problem and whilst services across the country had tried to address this, there was a lack of national guidance and provision. In this particular case Axel was particularly vulnerable. He was born Yasmin Price but identified as a male from a young age. He had struggled emotionally during his teens and had indulged with alcohol and drugs. He had been detained on a number of occasions due to his mental health. At the age of 18 he transitioned to adult services but there was a lack of a recognised pathway for him. In the lead up to his death he had been discharged from a mental health provision following his arrest for criminal offences. He was then discharged from the hospital and subsequently the Police station to temporary accommodation. There was little shared understanding between agencies of how Axel should best be supported and therefore he appeared to fall between the services. Substantial changes have been made locally by Sussex Partnership Foundation NHS Trust around the transition of those from CAMBS to Adult health services but looking at other Prevention of Future Death Reports this is not just a local issue. There is a lack of national guidance and support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services. Unless this is addressed nationally, sadly other deaths will occur. ”

    Source location

    Axel Price · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a recognised multi-agency transition pathway with clear risk, accountability and support arrangements

    Wider context from the report

    “This case identified that there is a lack of clear understanding of the risk or accountability between the agencies when a young person transitions from CAMBS services at the age of 18 to adult services. The expert who provided evidence in this case said that this was a well-recognised problem and whilst services across the country had tried to address this, there was a lack of national guidance and provision. In this particular case Axel was particularly vulnerable. He was born Yasmin Price but identified as a male from a young age. He had struggled emotionally during his teens and had indulged with alcohol and drugs. He had been detained on a number of occasions due to his mental health. At the age of 18 he transitioned to adult services but there was a lack of a recognised pathway for him. In the lead up to his death he had been discharged from a mental health provision following his arrest for criminal offences. He was then discharged from the hospital and subsequently the Police station to temporary accommodation. There was little shared understanding between agencies of how Axel should best be supported and therefore he appeared to fall between the services. Substantial changes have been made locally by Sussex Partnership Foundation NHS Trust around the transition of those from CAMBS to Adult health services but looking at other Prevention of Future Death Reports this is not just a local issue. There is a lack of national guidance and support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services. Unless this is addressed nationally, sadly other deaths will occur. ”

    Source location

    Axel Price · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Tobias Ryse Mannering-Jones · 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

    Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.

    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 overall ownership for coordinated multi-agency support

    Wider context from the report

    “5. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support. ”

    Source location

    Tobias Ryse Mannering-Jones · 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

    Provide dedicated youth homelessness advisers to support local authorities with joint protocols between housing and children’s services.

    Verbatim wording from the response

    “I am committed to embedding fully the Homelessness Reduction Act 2017 and as part of this, I have also put in place bespoke support through DLUHC’s Homelessness Advice and Support Team, which includes dedicated youth homelessness advisers that work with LAs to promote positive joint working across housing authorities and children’s services. In carrying out their statutory duties, LAs must have regard to statutory guidance, including ‘Prevention of Homelessness and Provision of accommodation for 16 and 17 year olds who may be homeless and/or require accommodation’²; which sets a clear expectation that LAs implement joint protocols between housing and children’s services.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 3 · response
    Published 20 March 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

    Coordinate Changing Futures pilots to improve joined-up local support for people experiencing multiple disadvantages.

    Verbatim wording from the response

    “Secondly, my Department is co-ordinating a cross-government initiative to improve the way local public services engage and support people experiencing multiple disadvantages. ‘Changing Futures’ is a £77 million programme piloting innovative approaches across 15 local areas (covering 34 top-tier LAs in England), to join-up local systems and more effectively respond to the needs of people who are experiencing combinations of homelessness, substance misuse, mental health issues, domestic abuse and contact with the criminal justice system. The programme runs to March 2025 with an evaluation underway. I will publish the final learnings and outcomes from the pilots in 2025, and in the meantime interim evaluation reports and learning are published online to help disseminate learning⁷.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 5 · response
    Published 20 March 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

    Existing systems ensure people with multiple disadvantages known to services have an appropriately experienced lead professional coordinating their support.

    Verbatim wording from the response

    “As an immediate measure, to address concerns relating to the multi-agency co-ordination of support to vulnerable young adults in Tameside, TASPB asked agencies to audit their ████████ young adults already known to services. This was with a view to ensuring that an appropriately experienced lead professional has or is given responsibility for coordinating services to the young person and is supporting their engagement. In response to this request, TASPB are assured systems are in place across organisations to ensure people who experience multi-disadvantage that are known to services do have a lead professional allocated. This will support people who are known to services and rely on services from the homeless shelter.”

    Source location

    Response from Greater Mnachester Integrated Care
    Page 6 · response
    Published 20 March 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

    Manchester Integrated Care Board is expected to provide further information on integrating local services for coordinated support.

    Verbatim wording from the response

    “I expect Manchester Integrated Care Board to provide more information on the integration of local services related to this matter of concern in their response.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 5 · response
    Published 20 March 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

    Greater Manchester Integrated Care Board should address the local lack of ownership or responsibility among agencies.

    Verbatim wording from the response

    “Finally, turning to your concern around a lack of overall ownership or responsibility among the different agencies involved. This should be addressed in full by Greater Manchester ICB, as this is a local context, I can confirm that, at a national level, the Government champions joined-up multi-disciplinary approaches. For example, through the 10-year drug strategy, ‘From Harm To Hope’ we have committed to developing a Joint Action Plan to improve mental health treatment for people using drugs and alcohol. The plan focuses on improving join-up between addiction and mental health services, ensuring that everyone can get the care and support they need. It is due to be published later this year and will improve the join up between substance misuse services and mental health services.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 20 March 2024

    Open published response

  6. Manchester South

    AI-generated summary

    Jordan Peter Clare · 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

    Jordan Peter Clare, who had complex mental health, behavioural and substance-misuse-related needs, died on 26 August 2020 after suspending himself by a ligature at his home while distressed about an unresolved dispute with a neighbour. The principal concern was the absence of a single person or agency to coordinate care, support, information-sharing and safeguarding for vulnerable adults with complex needs who do not fall within existing social care or formal mental health frameworks.

    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 provision for vulnerable adults with complex needs outside existing care and supervision frameworks

    Wider context from the report

    “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision. The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis. ”

    Source location

    Jordan Peter Clare · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of an identifiable single point of contact for vulnerable adults with complex needs

    Wider context from the report

    “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision. The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis. ”

    Source location

    Jordan Peter Clare · 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

    Absence of arrangements for contact, information sharing and coordinated deployment of services, support or safeguarding

    Wider context from the report

    “The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision. The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care co-ordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis. ”

    Source location

    Jordan Peter Clare · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. West Yorkshire Eastern

    AI-generated summary

    Daniel Clements · 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

    Daniel Clements, aged 27, was taken to hospital by police for a psychiatric assessment on 19 July 2021 and was discharged to his GP after being deemed not to have a mental illness. Later that evening, he ran into the path of a fast-moving train and sustained fatal injuries. The principal concerns were how to keep people displaying suicidal ideation safe when they are not considered mentally ill, and whether agencies adequately supported Mr Clements, who was described as vulnerable and had experienced homelessness and difficulties accessing support and medication.

    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 provide coordinated continuing support for people with suicidal feelings without overt psychiatric illness

    Wider context from the report

    “(4) Mr Clements was passed between agencies without any lasting benefit. This tragic situation illustrates the void in relation to those with suicidal feelings without any overt psychiatric illness. ”

    Source location

    Daniel Clements · 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

    Meet quarterly with partner organisations to resolve service-interface issues, maintain care pathways and update systems for service changes.

    Verbatim wording from the response

    “The Trust’s services meet with partner organisations referred to above on a quarterly basis, the purpose of which is to resolve service interface issues, ensure smooth care pathways and the updating of the system to reflect any service changes. In addition to these meetings, the Trust will propose a meeting with its social care partner, Wakefield Local Authority, to raise with them the contents of your report.”

    Source location

    Response from South West Yorkshire Partnership
    Page 3 · response
    Published 27 September 2022

    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

    Social problems beyond secondary mental health services’ scope cannot be resolved by the Trust, which instead supports access to appropriate partner services.

    Verbatim wording from the response

    “Where an intervention capable of reducing the risk of suicide can be provided by the Trust, we aim to achieve excellence in this regard, for example in the treatment of mood disorders. However, where resolution of a problem lies beyond the scope of services provided by the Trust, we endeavour to ensure that the person and their carers are offered support in accessing an appropriate service, often involving partner organisations.”

    Source location

    Response from South West Yorkshire Partnership
    Page 1 · response
    Published 27 September 2022

    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

    For people below the detention threshold, crisis needs should be met through community partnerships between local authorities, NHS organisations and voluntary-sector organisations.

    Verbatim wording from the response

    “Where individuals are not experiencing mental illness of a severity that makes detention under the Mental Health Act appropriate, their needs should be met in the community where partnership between Local Authorities, NHS organisations and Voluntary sector organisations is so critical. Local Authorities hold a range of duties under the Care Act 2014 to promote individual wellbeing, provide information and advice, safeguard adults from abuse and neglect as well as promote the integration of health and care services for those in need of care and support. The expansion of crisis services in the NHS Long Term Plan, backed up by £150m of additional capital funding for crisis centres, will support this aim alongside system partners.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 27 September 2022

    Open published response

  8. East Riding and Hull

    AI-generated summary

    Jessica Louise LAVERACK “Jessie” · 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

    Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.

    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 single point of contact for information collation, assessment and coordinated proactive action

    Wider context from the report

    “(4) There is no single point of contact to oversee the collation of all information, to appropriate assess it and to coordinate a structured proactive approach to people with dual or multi diagnosis. This is in both MARAC and for those who are vulnerable but do not meet the “high risk” criteria. ”

    Source location

    Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Manchester South

    AI-generated summary

    Matthew McManus · 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

    Matthew McManus, who had complex mental health and social care needs, died at the scene after sustaining multiple injuries on 9 November 2020. The report concluded suicide and identified a lack of coordinated care, information sharing, joint assessment and risk planning across the agencies supporting him. It raised concern that without a clear pathway for jointly assessing and coordinating care for adults with complex mental health and social care needs, future deaths may occur.

    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 coordinated support and care with a single point of contact

    Wider context from the report

    “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means. ████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk. Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur. A copy of the SSAB Safeguarding Adult Review can be found at this link https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf ”

    Source location

    Matthew McManus · Prevention of Future Deaths report
    Page 4 · 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 Community Mental Health Framework with named keyworkers, multidisciplinary teams and joined-up personalised care planning.

    Verbatim wording from the response

    “I would like to assure you that we are, through the development and implementation in local areas of the Community Mental Health Framework (CMHF), working to improve the way people with mental health conditions access joined-up support across health and social care, as well other parts of local systems. I would also like to assure you that more broadly we are bringing a broad range of local services closer together through the Health and Care Act 2022 and the integrated care systems (ICSs) that were formed as a result.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 14 February 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

    Operate the GM Care Record across Greater Manchester health and mental health providers, GPs and hospitals to share information for care coordination.

    Verbatim wording from the response

    “Additionally, Greater Manchester has accelerated use of the GM Care Record (GMCR) to support data sharing between health and care professionals across the region. It now means that all professionals involved in a patient’s care can share vital information across different organisations, settings and localities. As well as informing clinical decision making at the point of care, the GMCR is also being further enhanced to support joined up care planning and coordination through a range of clinical use cases. GMCR is now active between the two GM mental health trusts, GPs, and the hospital trusts within Greater Manchester. The inclusion of social care data feeds is also underway to further support care planning and coordination. Access to the GMCR can be made available to all relevant organisations that would have a requirement to access data, i.e.”

    Source location

    Response from Greater Manchester Combined Authority
    Page 2 · response
    Published 14 February 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

    Add social care data feeds to the GM Care Record to support care planning and coordination.

    Verbatim wording from the response

    “Additionally, Greater Manchester has accelerated use of the GM Care Record (GMCR) to support data sharing between health and care professionals across the region. It now means that all professionals involved in a patient’s care can share vital information across different organisations, settings and localities. As well as informing clinical decision making at the point of care, the GMCR is also being further enhanced to support joined up care planning and coordination through a range of clinical use cases. GMCR is now active between the two GM mental health trusts, GPs, and the hospital trusts within Greater Manchester. The inclusion of social care data feeds is also underway to further support care planning and coordination. Access to the GMCR can be made available to all relevant organisations that would have a requirement to access data, i.e.”

    Source location

    Response from Greater Manchester Combined Authority
    Page 2 · response
    Published 14 February 2022

    Open published response

  10. Manchester South

    AI-generated summary

    Irene Ann Esaw · 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

    Irene Ann Esaw, who had dementia and was dependent on her grandson for all nutritional, mobility, hygiene and personal care, was discharged from hospital without a formal care package or community referrals. She was later found deceased at home in an emaciated state, with severe untreated pressure sores, tissue damage and widespread sepsis. The principal concerns were failures to assess mental capacity, recognise clinical signs of neglect, and ensure effective multi-agency assessment and working.

    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 clarify multi-agency responsibility for capacity and needs assessments

    Wider context from the report

    “3. Multi-agency Working – My findings reveal that in the treatment of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments. The effect of this was that there was never an adequate assessment of her needs completed. ████████, the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking. I am concerned that this continues to need to be addressed. ”

    Source location

    Irene Ann Esaw · 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

    Establish a multi-agency Mental Capacity Act group with the local authority to review and benchmark policies, procedures, strategy and training.

    Verbatim wording from the response

    “In partnership with the Local authority we have taken the lead in establishing a multi-agency group focused on the application of the MCA with a view to a collective review and benchmarking of our policies and procedures in order to develop a multi-agency strategy, policy and training on the application of the Mental Capacity Act across the multiagency system, to promote a shared approach and understanding.”

    Source location

    Response from Tameside and Glossop NHS England
    Page 2 · response
    Published 17 September 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

    Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.

    Verbatim wording from the response

    “Integral to this, is ensuring that the multidisciplinary team have a good understanding of one another’s roles and responsibilities. Work will take place to ensure that this is embedded in practice. This will include ensuring that roles and responsibilities feature in the induction of all staff, in ongoing clinical supervision and in multiagency procedures and standards. A multiagency review and refresh of the Mental Capacity Act procedures and training regarding adults with care needs on discharge, will take place.”

    Source location

    Response from Tameside and Glossop NHS England
    Page 11 · response
    Published 17 September 2021

    Open published response
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Data last updated 7 September 2026