Recurring concern

Unreliable escalation of assessed safety risk levels

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First reported 25 Jul 2014•Latest report 26 Jul 2024

Definition

What this concern includes

Includes failures of controls governing the escalation, updating or consistent assignment of assessed safety risk levels, including inhibiting policy wording, approval barriers, inconsistent level-setting and failure to maintain current risk-level information when these directly affect risk recognition.

Not included

Excludes generic risk-assessment deficiencies where the specific issue is not escalation, updating or consistent assignment of risk levels.
Excludes failures to communicate or record risk information where the underlying risk level was reliably assessed and escalated.
Excludes failures of a separately named hazard-specific risk system unless that system is the supported parent boundary.
Excludes generic staffing, training or senior-oversight deficiencies unless they directly prevent appropriate escalation or updating of assessed risk levels.

Reports: 4
Individual concerns: 4
Date range: 2014–2024
Stated actions: 3

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.

Dovecote Lodge1

HM Prison and Probation Service1

Home Office1

London Borough of Redbridge1

Metropolitan Police Service1

Milton Keynes University Hospital1

Ministry of Justice1

North East London 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.

26 Jul2024
East London
Concerns raised1
1. Obstacles inhibiting increases in assessed risk levels
This report raised 24 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
  Remove the statement discouraging risk-level inflation during the next risk-assessment policy review.
  Stated by HM Prison and Probation ServiceStated planned
Respondent positions 1
1. Position
  There is no evidence of a widespread reluctance to seek approval for increased risk or that the policy statement inhibits justified risk escalation.
  Stated by HM Prison and Probation ServiceDisputes the concern
AI-generated summary

Zara Natasha Aleena · 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

Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.

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
Obstacles inhibiting increases in assessed risk levels
Wider context from the report
“(9) There may be obstacles to increasing risk levels. The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team. The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase risk. ”
Source location
Zara Natasha Aleena · 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
Remove the statement discouraging risk-level inflation during the next risk-assessment policy review.

Verbatim wording from the response
“9.1. We do not have any evidence of a widespread problem of Probation Officers being reluctant to ask SPOs to approve formal increases in assessed risk, or that this particular statement in policy is inhibiting staff from raising their assessment of an offender’s risk level, where that would be justified based on the available evidence. The percentage of those assessed as ‘high risk of serious harm’ has increased in recent years from 19.9% in 2018 to 25% in 2022. PARG’s annual sentence management audit confirms agreement with the risk level in most assessments. To avoid any misinterpretation, this statement will be removed in the next review, due by November.”

Source location
Response from HMPPS and MoJ
Page 8 · response
Published 2 August 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
There is no evidence of a widespread reluctance to seek approval for increased risk or that the policy statement inhibits justified risk escalation.

Verbatim wording from the response
“9.1. We do not have any evidence of a widespread problem of Probation Officers being reluctant to ask SPOs to approve formal increases in assessed risk, or that this particular statement in policy is inhibiting staff from raising their assessment of an offender’s risk level, where that would be justified based on the available evidence. The percentage of those assessed as ‘high risk of serious harm’ has increased in recent years from 19.9% in 2018 to 25% in 2022. PARG’s annual sentence management audit confirms agreement with the risk level in most assessments. To avoid any misinterpretation, this statement will be removed in the next review, due by November.”

Source location
Response from HMPPS and MoJ
Page 8 · response
Published 2 August 2024
Open published response
28 Mar2021
Milton Keynes
Concerns raised1
1. Failure to follow NICE sepsis risk stratification guidance for lactate levels above 2
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 1
1. Action
  Update the MKUH sepsis policy at its scheduled November 2021 review.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The patient was not suspected of sepsis and lacked high-risk criteria, so guidelines did not mandate repeat lactate measurement or imply likely clinical benefit.
  Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concern
AI-generated summary

Nicholas Rousseau · 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

Nicholas Rousseau attended Milton Keynes University Hospital on 3 and 5 October 2019 and died at home on 9 October 2019, aged 47. During his first attendance, his lactate level was 3.9 and he was discharged. The report identified conflicting views among senior Accident and Emergency staff about the significance of elevated lactate and whether it should be repeated, with concern that disregarding the NICE guidelines posed a threat to patients with sepsis and elevated lactate levels.

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 follow NICE sepsis risk stratification guidance for lactate levels above 2
Wider context from the report
“(1) In the course of oral evidence Dr ████████ and ████████ ████████, both Consultants in Accident and Emergency Medicine at the hospital gave conflicting accounts of how much importance they would ascribe to the lactate level which was nearly twice the upper limit of normal and whether they would repeat it before discharge. ████████ told me he would not repeat it because he saw lots of patients with elevated lactate and with the resources he had available he would be spending a disproportionate amount of time checking lactate levels in patients who ultimately would be fine. We spent some time on the point and with reference to the NICE Sepsis Risk Stratification Tools. The Guideline is clear that if a lactate is above 2 then the patient should be escalated to high risk. ████████ was challenged several times on his position that irrespective of the guidelines he would not routinely repeat the lactate level dismissing it as an unnecessary burden. He maintained that position. Dr ███ took a flatly contrary view and said that she would repeat it irrespective of the burden of work it may generate. These contrasting opinions indicate a degree of confusion amongst the senior staff at Milton Keynes University Hospital Accident and Emergency Department which in my view poses a threat to patients with sepsis and with elevated lactate levels. The disregarding of the NICE Guidelines simply because it is inconvenient is disturbing. ”
Source location
Nicholas Rousseau · 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
Update the MKUH sepsis policy at its scheduled November 2021 review.

Verbatim wording from the response
“• Maintains a local MKUH policy that is consistent with national guidance (including NG51). The current policy is due for scheduled review in November 2021.”

Source location
2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
Page 3 · response
Published 30 March 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The patient was not suspected of sepsis and lacked high-risk criteria, so guidelines did not mandate repeat lactate measurement or imply likely clinical benefit.

Verbatim wording from the response
“Before coming to the substantive matter of blood lactate levels, I would like to take this opportunity to extend my condolences and sympathies to Mr Rousseau’s family. I am conscious that any sense of divergence in view, at Inquest, between HM Coroner and attending physicians will have added to the family’s distress. I am not clear from the Regulation 28 report whether you consider that an alternative course of action regarding the measurement of blood lactate might have afforded an opportunity to alter the subsequent clinical course and Mr Rousseau’s ultimately death. For avoidance of doubt, we do not consider this likely.”

Source location
2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
Page 1 · response
Published 30 March 2021
Open published response
25 Nov2020
East London
Concerns raised1
1. Failure to consult the referring general practitioner before downgrading suicide risk
This report raised 2 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
  Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.
  Stated by North East London NHS Foundation TrustStated planned
AI-generated summary

Trinder Kaur Birdi · 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

Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.

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 consult the referring general practitioner before downgrading suicide risk
Wider context from the report
“The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional. It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor. ”
Source location
Trinder Kaur Birdi · 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
Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.

Verbatim wording from the response
“1. A requirement will be introduced for a referral to the on-call psychiatrist to be completed where the presenting risk is significantly different to that of another clinician (including GP) who has reviewed the patient on the same day.”

Source location
2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
Page 3 · response
Published 29 December 2020
Open published response
25 Jul2014
West Yorkshire (Western)
Concerns raised1
1. Lack of clear and consistent identification of falling risk levels in records
This report raised 2 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Edna Bulmer · 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

Edna Bulmer, who had a history of falls, suffered an unwitnessed fall on 10 September 2013 and was later found unconscious in bed. She died in hospital on 15 September 2013 after sustaining a serious intracranial haemorrhage. The concerns identified were inconsistent recording of her falls risk, delays in providing the identified pressure mat and pendant, and the apparent absence of a clear process for reviewing her risk assessment after further falls.

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 clear and consistent identification of falling risk levels in records
Wider context from the report
“(1) There did not appear to be a clear identification of the level of risk of Mrs. Bulmer falling made within Dovecote Lodge records. In one section Mrs. Bulmer is described as very high risk, elsewhere she is described as high risk. ”
Source location
Edna Bulmer · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Obstacles inhibiting increases in assessed risk levels

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to follow NICE sepsis risk stratification guidance for lactate levels above 2

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to consult the referring general practitioner before downgrading suicide risk

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

Concerns raised1

Lack of clear and consistent identification of falling risk levels in records

Actions described in response 1

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 1