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. Dorset

    AI-generated summary

    Anthony John Larcher · 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

    On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.

    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 observations and welfare checks for prisoners found under the influence of psychoactive substances

    Wider context from the report

    “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS). ”

    Source location

    Anthony John Larcher · Prevention of Future Deaths report
    Page 5 · 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

    Gather information from regional prison safety groups about local initiatives for observations and welfare checks.

    Verbatim wording from the response

    “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.”

    Source location

    2021-0356-Response-from-HMPPS_Published
    Page 1 · response
    Published 22 October 2021

    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

    Discuss nationally rolling out local drug-related safety initiatives with the NHSE/I national team.

    Verbatim wording from the response

    “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.”

    Source location

    2021-0356-Response-from-HMPPS_Published
    Page 1 · response
    Published 22 October 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

    HMPPS is responsible for deciding whether local welfare, substance intervention and life-support processes should be rolled out nationally.

    Verbatim wording from the response

    “1. Consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP), and the Custodial Officer Intermediate Life Support initiatives (COILS).”

    Source location

    2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 1 · response
    Published 22 October 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

    Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.

    Verbatim wording from the response

    “We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these.”

    Source location

    2021-0356-Response-from-NHS-Digital_Published
    Page 1 · response
    Published 22 October 2021

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    Richard Gordon Franks · 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

    Richard Gordon Franks was remanded in custody at HMP Leeds and was found dead in his cell on 12 April 2019, after appearing distressed and indicating that he was likely to commit suicide if sentenced to imprisonment. The concerns included that this information was not communicated to prison staff, that he mistakenly believed he had received a five-year sentence, and that no checks were made on him for approximately 10 hours.

    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 conduct timely welfare checks on a prisoner at risk of suicide

    Wider context from the report

    “(1) Mr Franks had a known history of self-harming and suicide attempts. His emotional state when seen at court on 11 April 2019 was triggered at least in part to his reaction to a development in the prosecution brought against him which he had not foreseen. His statement that he was likely to commit suicide was not communicated to either the security staff at the court or the prison staff. In consequence, the prison staff had no information concerning the events which took place at court. (2) Mr Franks somehow perceived that he had been sentenced to five years imprisonment, which was not the case. This false impression caused him to be in distress prior to being locked in his cell around 19:00 hours. (3) Had information concerning his emotions at court been relayed to the prison staff, this may have triggered a decision to open an ACCT – the process by which a prisoner is subject to increased monitoring and support. In the event no checks were made on him for some 10 hours. (4) At a previous hearing on 25.02.17 Mr Franks had made a comparable threat to kill himself as a result of what he perceived to be an adverse development in the case brought against him. At that time his signed consent authorising information to be passed to the prison was obtained and communicated to the prison. (5) The benefit of relaying helpful information to the prison intended to protect Mr Franks, does not seem to involve a breach of professional privilege. It would have been sufficient to request that the prison staff assess Mr Franks for themselves on his return in view of (unspecified) developments at court that day. ”

    Source location

    Richard Gordon Franks · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Manchester North

    AI-generated summary

    Liam Kenyon · 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

    Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.

    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 conduct a two-person physical welfare check after no response

    Wider context from the report

    “5. The Court heard that on the 18th July a staff member went to Liams room on three occasions (from 10am) and knocked on the door receiving no response. The Court heard that where no response was received a physical welfare check involving 2 members of staff entering the room using the master key should have occurred. ”

    Source location

    Liam Kenyon · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Lincolnshire

    AI-generated summary

    Toby Peter Edward Nieland · 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

    Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

    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 assertive outreach and organised welfare checks after community discharge

    Wider context from the report

    “6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    Care coordination and assertive outreach concerns relate to services commissioned by the CCG and provided by Lincolnshire Partnership NHS Trust.

    Verbatim wording from the response

    “This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust. If Care coordination is in place it is imperative that the substance misuse services work in partnership with the mental health team to provide a comprehensive individually tailored care package.”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 3 · response
    Published 26 October 2020

    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

    A police welfare check was not considered necessary based on the information available at the time.

    Verbatim wording from the response

    “The Trust was informed by the out of area inpatient unit that Mr Nieland had been discharged into the community. In accordance with Trust policy and national guidance, the Trust’s Crisis Resolution and Home Treatment Team offered timely follow-up appointments with Mr Nieland to assess his risk and care arrangements. Based upon the information available at the time, a clinical decision to request a police welfare check was not considered necessary. The Trust appreciate the importance of the views of family and carers has in formulating appropriate care arrangements for patients. With the benefit of hindsight, it is accepted that the knowledge and concerns of Mr Nieland’s family would have better informed assessment of risk. The Trust is continuing to support staff and to emphasise the importance of working and supporting patients to include family and carers in their care.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 5 · response
    Published 26 October 2020

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    John Anthony Delahaye · 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

    John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.

    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 conduct a welfare check on cell unlock

    Wider context from the report

    “4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified. ”

    Source location

    John Anthony Delahaye · 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 the Residential Activities, Basics and Cleanliness compliance process to support welfare checks during prisoner unlocks.

    Verbatim wording from the response

    “Your second concern is that whilst you were told at the inquest that senior staff had been advised that unlocking prisoners should include a welfare check, it was not clear how this had been communicated to the staff who were actually unlocking prisoners, or how compliance would be monitored.”

    Source location

    2018-0388-Responses
    Page 4 · response
    Published 13 May 2019

    Open published response

  6. South Wales Central

    AI-generated summary

    Mr Richard Thomas Peter Barrett · 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

    On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.

    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 request police assistance for welfare checks when ambulance resources are constrained

    Wider context from the report

    “(4) The police could have been asked to perform a welfare check. Evidence showed that the Ambulance Trust is pessimistic in assuming that the police are also under-resourced and would not be able to assist in such a task. Here the police were not even asked if they could help. Had he been found earlier, whether by police or ambulance, there is a chance that the deceased may have been able to be given first aid and had a better chance of survival. ”

    Source location

    Mr Richard Thomas Peter Barrett · 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

    Raise overdose welfare checks with police and seek a formal memorandum-of-understanding extension.

    Verbatim wording from the response

    “We have a memorandum of understanding with the Police which does specify circumstances in which the Trust should contact the Police. Welfare checks are not included within that document. The Trust does meet with the Police as part of the joint emergency services network. The Trust will raise this issue with the Police at these joint meetings and seek an increase to the specific circumstances to include overdose cases. We will write to you further once that meeting has taken place and update in relation to the matter.”

    Source location

    2018-0249-Response-by-University-Health-Board
    Page 5 · response
    Published 24 September 2018

    Open published response

  7. Inner North London

    AI-generated summary

    Dudley Vincent Brown · 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

    Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.

    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 arrange welfare checks pending mental health assessment

    Wider context from the report

    “(2) Mr Brown’s care package was withdrawn on 27 December 2017. No arrangements were put into place for Mr Brown’s welfare to be checked in the period pending a mental health assessment. ”

    Source location

    Dudley Vincent Brown · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Exeter and Great Devon District

    AI-generated summary

    Mark Craig BANKS · 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

    Mark Craig Banks, a homeless man with long-term alcohol and mental health problems, died from exposure in an unmade tent near the Tarka Trail in bad weather in the early hours of 23 February 2015; alcohol was a factor. Concerns included failures to contact or correctly grade an ambulance call and insufficient efforts to search for and check on Mr Banks’ wellbeing.

    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 efforts to search and check upon a person's wellbeing when asked to attend the scene

    Wider context from the report

    “(3) RE: ████████ at Page 176 of the Independent Police Complaints Commission report – insufficient efforts to search and check upon Mr Banks’ wellbeing when asked to attend the scene. ”

    Source location

    Mark Craig BANKS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Inner North London

    AI-generated summary

    Chadrack Mbala MULO · 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

    Chadrack Mbala Mulo, aged four, died of dehydration and acute protein-energy malnutrition after his mother died unexpectedly at home and he was left alone for approximately a fortnight. He was found about 48 hours after his death. The substantive concerns were that the school had contact details only for his mother, did not immediately visit the home when he failed to attend, and did not immediately contact the police when staff could not gain access.

    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 conducting a home welfare visit after unexplained non-attendance

    Wider context from the report

    “2. If a child unexpectedly fails to attend and no relevant adult can be contacted via phone, staff at the school do not now wait three to five days as they did then, but instead immediately send a member of staff to the family home. They now make a distinction between an attendance issue that may warrant a penalty (not the case for Chadrack because he was under the age of five years) and a potential welfare issue. ”

    Source location

    Chadrack Mbala MULO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Berkshire

    AI-generated summary

    Christopher Harold Brand · 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

    Christopher Harold Brand, a 53-year-old patient at Broadmoor Hospital, became unresponsive after returning from treatment at Frimley Park Hospital and could not be revived despite resuscitation attempts. Concerns included failures to follow observation procedures, failure to check that he was alive when his room was unlocked, and a delay in starting CPR.

    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 that patients are alive and well when room doors are unlocked

    Wider context from the report

    “(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”

    Source location

    Christopher Harold Brand · 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

    Implement standard operating procedures requiring the nurse in charge to attend each post-confinement door opening and confirm each patient’s presence and wellbeing.

    Verbatim wording from the response

    “There has been no evidence of this practice being more widespread, but we introduced standard operating procedures for all nurses in charge of wards, which detail, clearly, expectations and responsibilities. One of these is that they will be present when each door is opened following the conclusion of night time confinement and the nurse in charge must see and speak to each patient. A verbal response must be received (or a deliberate conscious movement, such as a hand wave). This is to ensure the patient’s presence and check their general wellbeing.”

    Source location

    2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
    Page 2 · response
    Published 21 April 2016

    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