Recurring concern

Unreliable safety assessment during vulnerable-person home visits

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First reported 26 Sep 2013•Latest report 3 Oct 2018

Definition

What this concern includes

Includes failures in vulnerable-person home visits to assess relevant home conditions, care arrangements, safeguarding concerns and safety risks, including inadequate coverage of the home environment, failure to complete or follow up an appropriate risk assessment after a visit, and failure to make necessary home-based enquiries or escalate concerns.

Not included

  • Excludes generic home-visit policy deficiencies where no failure in carrying out or applying a safety assessment during an actual visit is identified.
  • Excludes failures to arrange or attend a home visit when the unsafe condition is solely access or attendance, not inadequate safety assessment during the visit.
  • Excludes routine clinical examination or treatment during a home visit where the concern is not assessment of the person’s living environment, care arrangements or related safety risks.
  • Excludes general safeguarding, care coordination or environmental-hazard concerns without a direct vulnerable-person home-visit assessment connection.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2013–2018

First to latest report issue date

Stated actions
0

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.

Archdiocese of Westminster1
Diocese of Northampton1
East Coast Community Healthcare C.I.C.1
Patrick Stead Hospital1
Safehands Ltd1
South Tyneside Borough Council1
South Tyneside Safeguarding Adults Board1

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. Suffolk

    AI-generated summary

    Brian Alban Frost · 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

    Brian Alban Frost, a 92-year-old retired Roman Catholic priest who lived alone, died after an unwitnessed fall at home on 30 June 2018, sustaining severe head injuries. The report raised concerns about loose kitchen floor tiles presenting a trip hazard and about the inadequacy of welfare checks and health-and-safety risk assessments for retired clergy living in diocesan properties.

    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 undertake health and safety or risk assessments during welfare visits

    Wider context from the report

    “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. 9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home. ”

    Source location

    Brian Alban Frost · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Blackpool and the Fylde

    AI-generated summary

    Dennis Geoffrey Oldland · 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

    Dennis Geoffrey Oldland was found at home with a significant burn injury after being left partially clothed in an armchair near a fire following a care visit lasting approximately seven and a half minutes. He later suffered a stroke and died on 14 December 2016; the medical cause of death included stroke, advanced frailty and burn injury. The principal concern was that care workers might leave vulnerable service users prematurely, without sufficient interaction to identify risks or welfare 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 ensure care workers remain for the expected duration of visits

    Wider context from the report

    “(1) a. A care worker – who was an impressive witness and clearly trying to assist the court - gave evidence at the inquest and when asked if there were circumstances in which her view could justify a visit to a service user lasting less than the allotted time period responded on the basis that such visits can be justified if the care worker’s tasks have been completed, has assessed how the service user is, and if the service user appears content for the carer to depart. b. I have a concern that limiting the amount of interaction creates a risk that a potential risk or a concern about the service user’s welfare may go unnoticed. c. In contrast, were carers to ensure they overserve vulnerable service users and remain at the location for the expected duration of the visit, then a potentially concerning issue is more likely to come to the carer’s attention and they can respond appropriately. d. In summary I have a concern that carers may leave a service user’s home prematurely, confident that the service user appears well, but in reality unaware of an issue that would have, with more time and interaction, become apparent. ”

    Source location

    Dennis Geoffrey Oldland · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Gateshead and South Tyneside

    AI-generated summary

    Joan Farran · 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

    Joan Farran, who had multiple co-morbidities and was cared for by her adult son, died at home from bronchopneumonia due to chronic obstructive pulmonary disease and Alzheimer’s disease. The report states that her death from a potentially treatable pneumonia was contributed to by neglect in obtaining medical support and treatment. Concerns included inadequate coordination and information-sharing between agencies, limited assessment of the home environment, withdrawal of community visits without replacement services, and the cancellation of a GP home visit without further follow-up.

    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 examine the full home environment during care visits

    Wider context from the report

    “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death. 8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present. 9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing. 10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however. 11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December. 12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency. 13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism. 14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided. 15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them. 16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after. 17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services. 18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies. ”

    Source location

    Joan Farran · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026