Recurring concern

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

First to latest report 16 Oct 2015 — 15 Jun 2026

Reports that mention this concern
15
Times this concern has been raised
18
Stated actions linked to this concern
15

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.

What is 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 and published responses 15 reports

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

  1. Suffolk

    AI-generated summary

    May Adalaid Miller · 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

    May Adalaid Miller, aged 95, was attacked by another resident while asleep at Beech House Residential Care Home on 9 February 2020 and died from natural causes precipitated by the assault. The report raised concerns about the lack of safeguarding information sharing between agencies and care facilities, including the absence of a system to share information about the other resident’s risk factors.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unclear central point of contact for investigative agencies and care homes

    Wider context from the report

    “In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of ████████. At no time was the family of Mr ████████ asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes. It was established during the evidence that multiple investigative agencies may have been aware of Mr ████████’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible. Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller. ”

    Source location

    May Adalaid Miller · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Norfolk

    AI-generated summary

    BENJAMIN THOMAS GOODRUM · 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

    Benjamin Thomas Goodrum, who had schizophrenia and Asperger’s syndrome and lived in the community with support from several organisations and his parents, was found clearly deceased in his flat on 27 June 2016. Concerns included the absence of a person with overall responsibility for him, the failure to appoint a replacement Care Co-Ordinator, and the incomplete implementation of an investigation recommendation concerning allocation of a Lead Care Professional or Care Co-Ordinator.

    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 allocate a specific individual Care Co-Ordinator or Lead Care Professional to service users receiving active treatment

    Wider context from the report

    “(1) Although there was evidence of good communication between the various organisations involved with Mr Goodrum and attempts were ongoing to retain contact with him, there was no person taking overall responsibility for Mr Goodrum. (2) Mr Goodrum had originally been allocated a Care Co-Ordinator but on this person leaving, no new Care Co-Ordinator was appointed. (3) The Serious Incident Investigation recommended all service users receiving active treatment should be allocated a Lead Care Professional or a Care Co-Ordinator and this action was to be completed by 30/04/2017. At the time of the inquest this action had not been put in place and the Action Plan was regarded as complete. (4) Evidence was heard that alternative measures have been taken within the various teams to ameliorate the lack of sufficient Care Co-Ordinators for service users, for instance using a team-based approach, but that such measures are not as effective as services having a specific individual appointed as a Care Co-Ordinator. ”

    Source location

    BENJAMIN THOMAS GOODRUM · Prevention of Future Deaths report
    Page 1 · 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

    Recruit to fill the Central Norfolk Long Term Treatment Team’s band 5 vacancy.

    Verbatim wording from the response

    “The clinical team involved in the case (Central Norfolk Long Term Treatment Team) currently has one band 5 vacancy which is being recruited to.”

    Source location

    2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 11 February 2018

    Open published response

  3. Gloucestershire

    AI-generated summary

    Anielka Agnes Grace Marie Jennings · 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

    Anielka Agnes Grace Marie Jennings, aged 17, was found hanging from a banister at home on 5 February 2015 and was pronounced deceased at 1510 hours. The principal concern was that, when numerous agencies care for a child transitioning to adult services, the absence of a lead or key professional can lead to communication breakdown between agencies.

    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 an identified lead professional for individuals receiving care from numerous agencies

    Wider context from the report

    “(1) When an individual is being cared for by numerous agencies, in particular when said individual is a child transitioning to adult services, there is no lead/ key professional identified, which can result in a breakdown of communication between the agencies. ”

    Source location

    Anielka Agnes Grace Marie Jennings · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Cornwall

    AI-generated summary

    Colin Keith Williams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Colin Williams was found dead at his home on 9 April 2013, where he had been lying on the kitchen floor in a state of decomposition. He was known to numerous agencies as a vulnerable adult with complex needs, alcohol misuse and a tendency to self-neglect, but his body was not found for some weeks. Evidence at the inquest described difficulties arising from the number of agencies involved, variable mental capacity and complex or unavailable funding arrangements, which hindered his access to support.

    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 of services to provide clear, accessible routes to care and funding for people with complex health and social needs

    Wider context from the report

    “Mr Colin Williams was known to numerous agencies and personnel. At inquest evidence was given from Ocean Housing, Adult care, Health and Wellbeing, Taylors of Grampound, the Police, Royal Cornwall Hospital (together with minutes of Complex planning meetings arranged by Cornwall Council on 11.11.12, 13.03.12) the extent of his complex needs and tendency to self-neglect, particularly when under the influence of alcohol. Despite being known to have complex needs his body was not found for some weeks. Those at inquest gave evidence that due to the large number of potential agencies involved in his care, his age (below 65), and the fact he had variable mental capacity due to his chronic alcoholism (no mental health diagnosis) it made it difficult for Mr Williams to know which agency provided what service and whether they were free or not. This led to agency “blindness” preventing him from accessing help/funding particularly at a time of crisis (especially when he lacked capacity due to alcoholism). An example was given by Ocean Housing who had been involved with Mr Williams since 2011. Initially he was provided support through his tenancy which was funded by Cornwall Council supporting people budget. In 2011 the way funding was provided was changed and Mr Williams no longer qualified. An independent living service was set up in lieu which clients had to contribute towards. From this time forward Mr Williams did not engage as he had difficulty in understanding the structure. His funding was made more complicated by hospital admissions/care home placements which meant on occasions he was left without funds due to the necessary paperwork being completed – which he was unable to complete or understand on his own. Those at inquest considered that this was not an uncommon scenario; particular when a client had both health and social issues and this was made even more difficult if they were drug and/or alcohol dependant. ”

    Source location

    Colin Keith Williams · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Derby and Derbyshire

    AI-generated summary

    Louise Sharon Henry · 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

    Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities

    Wider context from the report

    “1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co-ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co-ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity. ”

    Source location

    Louise Sharon Henry · 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 clarify the respective roles and responsibilities of mental health and social care workers at the Service Manager Interface Meeting.

    Verbatim wording from the response

    “In order to address these concerns the Council and DCHFT intend to review:-”

    Source location

    2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
    Page 3 · response
    Published 16 January 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update the Care Programme Approach Policy with clearer guidance on the relationship between CPA and Self-Directed Support.

    Verbatim wording from the response

    “2. Preliminary discussions have already taken place between Health and Social Care senior managers about the interface between CPA and SDS. Both organisations are clear that the two policies are intended to be complementary. It is acknowledged there may be cases where the individual is subject to CPA but where a social worker is the lead practitioner. The Council is clear that in following SDS, this will also fulfil the requirements of CPA. A plan involving senior managers from both organisations has been agreed to update the DCHFT Care Programme Approach Policy to provide clearer updated guidance upon this issue.”

    Source location

    2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 January 2015

    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

    Cascade the Service Manager Interface Meeting's role-clarification outcomes to staff through line-management supervision.

    Verbatim wording from the response

    “4. The Council has also established that there is still some work to be done in terms of education for health and social care workers on the expectations of each service pathway. The outcomes of the Service Manager Interface Meeting described above will be cascaded down to staff via line management supervision.”

    Source location

    2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 January 2015

    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