Recurring concern

Failure to conduct required welfare checks on people in distress

Get email alerts

Request correction

First reported 11 Nov 2014•Latest report 4 Feb 2026

Definition

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.

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: 23
Individual concerns: 24
Date range: 2014–2026
Stated actions: 39

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.

Department of Health and Social Care3

Ministry of Justice3

NHS England2

Welsh Ambulance Services NHS Trust2

Adullam Homes Housing Association Limited1

Birmingham and Solihull Mental Health NHS Foundation Trust1

Birmingham Community Healthcare NHS Foundation Trust1

British Transport Police1

Broadmoor Hospital1

Bury Borough Council1

Cardiff & Vale University LHB1

Care Quality Commission1

Coventry City Council1

David Ake & Co1

Department for Education1

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.

24 Jul2015
Exeter and Greater Devon
Concerns raised1
1. Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme
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 2
1. Action
  Review patients on drug treatment programmes jointly with prison staff, agree observation arrangements, and share caseload information.
  Stated by Dorset Healthcare University NHS Foundation TrustStated completed
2. Action
  Introduce a robust system for monitoring patients arriving at HMP Exeter who require night welfare checks.
  Stated by Dorset Healthcare University NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  The action plan addressed identified care issues, with ongoing compliance audit and executive review providing sufficient assurance.
  Stated by Dorset Healthcare University NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  NOMS at HMP Exeter is responsible for training and auditing operation of the ACCT document system.
  Stated by Dorset Healthcare University NHS Foundation TrustRedirects responsibility
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
26 Dec2014
Manchester North
Concerns raised1
1. Delays in follow-up and welfare checks after self-discharge following a life-threatening drugs overdose
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
11 Nov2014
Coventry
Concerns raised1
1. Failure to check the well-being of people occupying toilets for prolonged periods
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

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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

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

Concerns raised1

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

Actions described in response 2

Respondent positions 2