Recurring concern

Failure to conduct required welfare checks on people in distress

First to latest report 11 Nov 2014 — 4 Feb 2026

Reports that mention this concern
23
Times this concern has been raised
24
Stated actions linked to this concern
39

What this concern includes

Includes failures to initiate, complete, repeat or physically verify a required welfare check for a person who is distressed, in potential medical distress, or otherwise presents a welfare concern.

What is not included
  • Excludes failures concerning routine monitoring where no distress or welfare concern is identified.
  • Excludes failures to check records, prescriptions, guidance or other administrative information unless the report directly concerns completion of a welfare check.
  • Excludes generic staffing, training, policy or lone-working deficiencies that are not directly tied to a failure to conduct a welfare check.

Reports and published responses 23 reports

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

  1. Exeter and Greater Devon

    AI-generated summary

    Carl David Roy SMITH · 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

    Carl David Roy SMITH was found unconscious and without signs of life in his cell at HMP Exeter on 22 November 2012, after being held on remand and receiving medication for seizures and detoxification. His death was concluded to be drug-related, involving methadone toxicity and illicitly obtained methadone. The report identified insufficient custodial and welfare checks and deficient information sharing about those checks for a prisoner on an ACCT and Methadone Stabilisation Programme.

    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

    Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme

    Wider context from the report

    “The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient. ”

    Source location

    Carl David Roy SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review patients on drug treatment programmes jointly with prison staff, agree observation arrangements, and share caseload information.

    Verbatim wording from the response

    “5.5. Concern 1 - To review the systems for Information Sharing reference those on drug treatments stabilisation programmes for Substance Misuse IDTS with Prison Officers so that all Prison Officers are aware of Prisoners concerned.”

    Source location

    2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
    Page 3 · response
    Published 24 July 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

    Introduce a robust system for monitoring patients arriving at HMP Exeter who require night welfare checks.

    Verbatim wording from the response

    “6.1. In addition to the Coroners Ruling noted in this report the Trust has introduced a robust system for the monitoring of patients arriving at HMP Exeter and requiring Night Welfare Checks (see appendix 5). This guidance was developed jointly with Public Health England (NTA), HMP Exeter National Offender Management Service and will be approved by NHS England at the Devon Prison Partnership Board in October 2015.”

    Source location

    2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
    Page 4 · response
    Published 24 July 2015

    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 action plan addressed identified care issues, with ongoing compliance audit and executive review providing sufficient assurance.

    Verbatim wording from the response

    “5.1. The Trust recognises that there were failings in relation to Mr Smith’s care, and agrees with both the PPO and HM Coroners view that these issues are of concern. In order to ensure that these issues do not reoccur within the Trust services, an action plan was put into place at the time of receipt of the PPO report into Mr Smith’s death, as the Trust was not the provider at the time of Mr Smith’s death. This action plan assured the Trust that actions taken by the provider at the time of Mr Smith’s death addressed the issues outlined.”

    Source location

    2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
    Page 3 · response
    Published 24 July 2015

    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

    NOMS at HMP Exeter is responsible for training and auditing operation of the ACCT document system.

    Verbatim wording from the response

    “5.7. Concern 3- To review training and audit the operation of the ACCT document system so that it is made as robust as possible.”

    Source location

    2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
    Page 4 · response
    Published 24 July 2015

    Open published response

  2. Manchester North

    AI-generated summary

    Anthony Maurice Huggan · 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

    Anthony Maurice Huggan, who had a longstanding drug problem, was admitted to hospital after an accidental opiate overdose but self-discharged against medical advice on 3 June 2014. He was found deceased at home the following day after taking excessive amounts of prescribed and illicit substances; post-mortem examination and toxicology identified combined drugs toxicity involving Pregabalin, Morphine and Methadone. Concerns included the lack of an out-of-hours community drugs service and the timeliness of follow-up or welfare checks after a life-threatening overdose and self-discharge.

    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

    Delays in follow-up and welfare checks after self-discharge following a life-threatening drugs overdose

    Wider context from the report

    “2. Where a patient takes self-discharge following a life threatening drugs overdose, concerns arise around the timeliness of follow up/welfare checks, given the limitations of the service commissioned by the Local Authority. ”

    Source location

    Anthony Maurice Huggan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Coventry

    AI-generated summary

    Amar MAJID · 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

    Amar Majid was found dead in a disabled toilet at the Public Library, Coventry, with a syringe in his hand and material believed to be heroin. The principal concern was that no one checked on his well-being for over five hours despite evidence that the toilets were cleaned hourly; the report also noted possible confusion about procedures for checking a toilet occupied for a considerable period.

    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 check the well-being of people occupying toilets for prolonged periods

    Wider context from the report

    “I heard evidence from ████████ (Business Improvement Manager) of Coventry City Council (CCC) that the disabled toilets in the library are used by individuals abusing drugs. Mr Majid was present in the toilet from 10.00am and heard to be making noises. I was concerned that no-one checked on his well-being for over 5 hours, despite what I understand to be hourly cleaning of the toilet. Earlier intervention may have prevented his death. ”

    Source location

    Amar MAJID · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026