Recurring concern

Failure to convene coordinated professional case-planning discussions for safety concerns

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First reported 31 Oct 2014•Latest report 27 May 2026

Definition

What this concern includes

Includes failures to convene or conduct multi-professional, multi-disciplinary or multi-agency case-planning discussions needed to address a person's identified safety concerns or risks, including the anchor's senior professional planning meeting.

Not included

  • Excludes generic failures of communication, documentation, staffing or training unless they are directly part of convening and conducting the case-planning discussion.
  • Excludes post-incident learning meetings, governance working groups and routine meetings not intended to assess or manage an individual's safety concerns.
  • Excludes failures of a specific clinical, safeguarding or other pathway where the discussion is only an incidental component and the wider named pathway is the supported concern.
Reports
18

Distinct published reports

Individual concerns
19

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
29

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.

Department of Health and Social Care3
University Hospitals Sussex NHS Foundation Trust2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Denbighshire County Council1
Department for Education1
Devon County Council1
East Kent Hospitals University NHS Foundation Trust1
East London NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Police1
HM Prison and Probation Service1
Home Office1
Kent and Medway Mental Health NHS Trust1
Kent County Council1

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. West Yorkshire (West)

    AI-generated summary

    BARNABY LUKE AYLWARD · 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

    Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.

    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 regular multi-agency preventative review and reassessment of fire risks

    Wider context from the report

    “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency: a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time; b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed; c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist; d) may have been hampered by issues of confidentiality in communications between agencies. If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed. ”

    Source location

    BARNABY LUKE AYLWARD · 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

    Develop a vulnerability database to identify higher-risk tenants and update relevant information annually and at key tenancy or safeguarding points.

    Verbatim wording from the response

    “3.1 Information about our customers - We are developing further our database in relation to vulnerabilities including those related to fire risks. Annually we will update personal information from higher risk customers particularly those in supported housing and high rise flats. This database is aimed at ensuring we identify higher risk tenants and causes, it requests details on health and lifestyle issues. We request this data from tenants and where appropriate arrange joint safe and well visits with the fire service. The information is updated annually but also used at the start of new tenancies or where officers identify a safeguarding issue with a tenant.”

    Source location

    2018-0387-Responses
    Page 4 · response
    Published 13 May 2019

    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

    Resume regular tenancy audits focused on tenants with no recent contact or identified vulnerability, including property inspections where access is permitted.

    Verbatim wording from the response

    “4.2 Tenancy Audits - From April 2019 we are resuming regular visits to tenants, this programme of visits will focus on those where we have had no previous contact (eg via repairs or gas servicing) or have had concerns regarding vulnerability. These will include a property inspection where tenants will allow access. Any issues of concern will be acted upon via tenancy safeguarding procedures.”

    Source location

    2018-0387-Responses
    Page 5 · response
    Published 13 May 2019

    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

    Distribute a staff alert requiring hoarding-related risks and planned interventions to be recorded in care plans.

    Verbatim wording from the response

    “An alert will be distributed to all staff working in the Trust raising awareness that where there is a risk relating to hoarding and associated risks this should be included within the care plan and that interventions should be planned to manage the risk. These should be reviewed on a regular basis or as the risk changes. The alert will be distributed by the end of February 2019.”

    Source location

    2018-0387-Responses
    Page 9 · response
    Published 13 May 2019

    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

    Reinforce inclusion of family and carers in care planning and risk management through training, the information leaflet and staff alert.

    Verbatim wording from the response

    “Learning events have previously been provided by the safeguarding team which includes raising awareness to include carers and family in care planning and risk management, this will continue to be reinforced through our mandatory and core clinical training programmes. This will be reinforced through the publication of the above mentioned information leaflet and alert.”

    Source location

    2018-0387-Responses
    Page 9 · response
    Published 13 May 2019

    Open published response
  2. Milton Keynes

    AI-generated summary

    Kevin George Morgan · 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

    Kevin George Morgan, who had poorly controlled type 1 diabetes, was found deceased in his flat after family contacted police when they had not heard from him for several weeks. His body was heavily decomposed, and there were no suspicious circumstances. The principal concerns were the lack of effective follow-up by social services and housing, inadequate responses to safeguarding and safety concerns, and the absence of a post-death serious incident or safeguarding review.

    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 convene senior professionals to consider cases and prepare a plan

    Wider context from the report

    “(5) It was accepted by the Adult Social Care Access Team that a meeting of senior professionals should have been called to consider the case and prepare a plan. ”

    Source location

    Kevin George Morgan · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  3. Brighton and Hove

    AI-generated summary

    Marion Rose HOWES · 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

    Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable death.

    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 required multidisciplinary and multi-agency care discussions

    Wider context from the report

    “(3) In Mrs. Howes’ case there was a complete lack of co-ordination and continuity of care for her. Nobody took charge of her. Nobody was responsible and responsible for liaising with all the relevant firms so that she was dealt with comprehensively and by the appropriate people. It is suggested that consideration be given to the patient being appointed a named Consultant (not one who is just about to go on holiday) from the day of first admission and this Consultant should understand his or her duties with regard to the managing of the patient and ensuring that they are referred on to the appropriate forms and that the multi-disciplinary and multi-agency discussions take place. ”

    Source location

    Marion Rose HOWES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. North Wales (East and Central)

    AI-generated summary

    Laura Beth Newlands · 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

    Laura Beth Newlands was known to Denbighshire Social Services because of concerns about self-harm related to difficult home circumstances. After her case was closed, a delay in arranging a professionals’ meeting meant that further support was not provided before she took her own life by overdose four days before the scheduled meeting. The report identified concerns about incomplete safety-plan input, delays in responding to risk, and the decision to close and not reopen the case.

    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 scheduling appropriate professional meetings

    Wider context from the report

    “2. A delay in scheduling an appropriate meeting of Professionals resulted in a missed opportunity to provide support and protection of a young person at risk and there was not therefore a prompt response to a crisis ”

    Source location

    Laura Beth Newlands · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Avon

    AI-generated summary

    Charlotte Emily BEVAN and Zaani Bevan Malbrouck · 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

    Charlotte Emily Bevan, who had schizophrenia and an undiagnosed psychotic relapse following childbirth, left hospital with her four-day-old daughter Zaani and went to the Avon Gorge cliff top; both died from injuries. The inquest identified failures including the absence of multidisciplinary care planning, insufficient psychiatric involvement, and failures to diagnose and manage Charlotte’s relapse.

    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 draw up appropriate multi-agency care plans

    Wider context from the report

    “It was not stated in evidence - that in all cases when a lady with a known mental health condition becomes pregnant that there is a multi-disciplinary team meeting to include all or some of the following professionals: GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate. It was not stated in evidence - that and an appropriate care plan involving all agencies and professionals is drawn up and then widely circulated to those professionals who are involved with the care and treatment of the patient. That group to include; GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate. ”

    Source location

    Charlotte Emily BEVAN and Zaani Bevan Malbrouck · 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

    Produce and prominently issue a reflective training vignette through the internal safety alert system, requiring confirmation of action and monitoring implementation through supervision and appraisal.

    Verbatim wording from the response

    “In addition, although we have not found the need to revise our existing policies, systems and procedures in light of Charlotte’s and Zaanyi’s deaths, we do plan to produce and issue in the New Year a vignette of Charlotte’s care that can be shared with all teams as a valuable reflective training exercise. This will place emphasis on the importance of multi-disciplinary working and care planning. This vignette will be issued with prominence via our internal safety alert system, that requires our positive confirmation that action has been taken. Implementation of change will be monitored via our supervision and appraisal processes.”

    Source location

    2015-0418-Response
    Page 1 · response
    Published 27 October 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

    No revision of existing policies, systems or procedures was considered necessary in light of the deaths.

    Verbatim wording from the response

    “In addition, although we have not found the need to revise our existing policies, systems and procedures in light of Charlotte’s and Zaanyi’s deaths, we do plan to produce and issue in the New Year a vignette of Charlotte’s care that can be shared with all teams as a valuable reflective training exercise. This will place emphasis on the importance of multi-disciplinary working and care planning. This vignette will be issued with prominence via our internal safety alert system, that requires our positive confirmation that action has been taken. Implementation of change will be monitored via our supervision and appraisal processes.”

    Source location

    2015-0418-Response
    Page 1 · response
    Published 27 October 2015

    Open published response
  6. Manchester South

    AI-generated summary

    Paul Mc Guigan · 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

    Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.

    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 of agencies to check and share available information before multi-agency meetings

    Wider context from the report

    “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing. ”

    Source location

    Paul Mc Guigan · 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

    Provide clinical staff attending multi-agency meetings with adequate time to review case information and contribute to discussions and action planning.

    Verbatim wording from the response

    “Clinical staff who are required to attend multi-agency meetings now have adequate time to access and assimilate pertinent information from case notes to be able to effectively contribute to the discussion and any subsequent action planning.”

    Source location

    2015-0185-Response-by-Pennine-Care-NHS-Trust
    Page 1 · response
    Published 12 May 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

    Issue guidance to MAPPA agencies on preparing for meetings and fully recording agreed actions, completed actions and communications.

    Verbatim wording from the response

    “A major lesson from the inquest is the need for more effective inter-agency working, particularly between the police and the probation service, in the context of the MAPP arrangements. Work to address the issues you have highlighted is being taken forward by the National MAPPA team, which will issue guidance to all MAPPA agencies shortly. This will cover the need to prepare for MAPPA meetings carefully, including obtaining full case details, and to record in full all actions agreed and taken and all communications in individual cases.”

    Source location

    2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
    Page 4 · response
    Published 12 May 2015

    Open published response
  7. Manchester West

    AI-generated summary

    Aleysha Martine Karla McLoughlin · 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

    Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.

    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 hold urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm

    Wider context from the report

    “(3) That it should be considered that systems such as those now being developed in Bolton should be further developed so as to ensure that multi agency discussions involving all relevant agencies are held urgently for those at risk of self harm and particularly for those who do not engage. Evidence was given that meetings concerning Aleysha Martine Karla McLoughlin did not include the Child and Adolescent Mental Health Services although evidence was given that their input would have been valuable. ”

    Source location

    Aleysha Martine Karla McLoughlin · 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

    Support the Public Service Transformation Network and Early Intervention Foundation in co-designing better outcomes for vulnerable people.

    Verbatim wording from the response

    “Lastly, DCLG is focussed on supporting local services to provide early, integrated support for people who need the most help. Central to this is a need to ensure effective sharing of information between agencies and developing effective multi-agency approaches. The department supports the Public Service Transformation Network and the Early Intervention Foundation to help councils and their local partners in the co-design and co-production of better outcomes for vulnerable people. DCLG also supports local authorities on the delivery of the expanded troubled families programme. This aims to directly help up to 400,000 families over the next five years, transforming lives by improving the way local services operate, crucially joining up and co-ordinating the support they offer these families.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 4 · response
    Published 8 April 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

    Support local authorities in delivering the expanded troubled families programme to improve coordinated services for vulnerable families.

    Verbatim wording from the response

    “Lastly, DCLG is focussed on supporting local services to provide early, integrated support for people who need the most help. Central to this is a need to ensure effective sharing of information between agencies and developing effective multi-agency approaches. The department supports the Public Service Transformation Network and the Early Intervention Foundation to help councils and their local partners in the co-design and co-production of better outcomes for vulnerable people. DCLG also supports local authorities on the delivery of the expanded troubled families programme. This aims to directly help up to 400,000 families over the next five years, transforming lives by improving the way local services operate, crucially joining up and co-ordinating the support they offer these families.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 4 · response
    Published 8 April 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

    Local Safeguarding Children Boards are responsible for safeguarding children and ensuring local agencies’ effectiveness.

    Verbatim wording from the response

    “Provision exists under Section 14 of the Children Act 2004 for Local Safeguarding Children Boards (LSCBs) to have responsibility for safeguarding and promoting the welfare of children and ensuring the effectiveness of local agencies in this respect.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 3 · response
    Published 8 April 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 Association of Independent LSCB Chairs was asked to consider the concerns raised about local safeguarding arrangements.

    Verbatim wording from the response

    “DfE has forwarded a copy of your letter to ████████ of the Association of Independent LSCB Chairs asking him to consider the points you raise. DfE has also introduced a number of reforms of social work practice to protect vulnerable people.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 3 · response
    Published 8 April 2015

    Open published response
  8. Brighton and Hove

    AI-generated summary

    Maureen Annette ELLETT · 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

    The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

    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 formulate a detailed and complete senior clinical plan

    Wider context from the report

    “(2) Discussion by the Junior Doctor with the Senior Doctor as to the plan for Mrs. Ellett was brief to the point of transient. No proper detailed plan was formulated. Clues to the patient's condition were missed, probably because the discussion was so brief and the paperwork required for transfer to the short-stay ward, also known as the Clinical Decisions Unit, was signed by the A&E Consultant but neither dated nor timed by him. The plan was incomplete and the counter-signatory of the Senior Nurse with date and time was completely missing. Therefore the transfer should not have taken place. ”

    Source location

    Maureen Annette ELLETT · Prevention of Future Deaths report
    Page 1 · 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

    Remind consultants and shift leaders to require a detailed management plan and shift-leader confirmation before transferring patients.

    Verbatim wording from the response

    “2. We believe the A&E consultant’s failure to date and time his signature on the transfer documentation, while not best practice, is not relevant to the clinical care of Mrs Ellett. However, we agree that she should not have been transferred until an appropriately detailed plan for her management had been agreed and summarized in a series of bullet points in the documentation, and the clinical shift leader had confirmed his agreement by signing the proforma. All the consultants and the relevant shift leaders have been reminded of the importance of this aspect of their duties.”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 31 October 2014

    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 consultant’s undated signature on transfer documentation was not relevant to the patient’s clinical care.

    Verbatim wording from the response

    “2. We believe the A&E consultant’s failure to date and time his signature on the transfer documentation, while not best practice, is not relevant to the clinical care of Mrs Ellett. However, we agree that she should not have been transferred until an appropriately detailed plan for her management had been agreed and summarized in a series of bullet points in the documentation, and the clinical shift leader had confirmed his agreement by signing the proforma. All the consultants and the relevant shift leaders have been reminded of the importance of this aspect of their duties.”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 31 October 2014

    Open published response
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Data last updated 7 September 2026