Recurring concern

Failure to use direct contact to assess vulnerable people’s safety risks and understanding

First to latest report 1 Apr 2015 — 16 May 2023

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
4

What this concern includes

Includes failures to make or use direct contact with a vulnerable person when that contact is needed to understand material safety risks, assess changing circumstances or confirm that the person understands available help or protective options.

What is not included
  • Excludes routine communication, welfare contact or outreach where no safety-risk assessment or confirmation of protective understanding is involved.
  • Excludes failures to obtain collateral information from family, carers or professionals when direct contact with the vulnerable person is not the asserted control.
  • Excludes failures of subsequent referral, treatment, escalation or safeguarding action where the required direct safety-focused contact was completed.
  • Excludes generic communication, staffing or documentation deficiencies that do not directly cause failure to make or use the required safety-focused contact.

Reports and published responses 2 reports

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

  1. Manchester South

    AI-generated summary

    Carl Garry Thompson · 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 Garry Thompson died from a drug overdose while on leave from Arden Ward, Stepping Hill Hospital, and was likely to have died on the night of 9 March 2022. Concerns included inadequate risk assessments and planning for his leave, insufficient response and escalation after family concerns about increased risk, and failure to provide a face-to-face Community Mental Health Team assessment or allocate a care coordinator before leave.

    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 use direct contact to understand identified risk factors

    Wider context from the report

    “2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother who outlined her concerns. 3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse. 4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl. 5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical support. ”

    Source location

    Carl Garry Thompson · 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 awareness of contacting patients on leave when concerns arise through supervision and an inpatient learning forum.

    Verbatim wording from the response

    “This was identified as an action within the Investigation detailed ‘Where there are concerns expressed whilst a patient is on leave – consider making attempts to contact the patient to assess the situation.’”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 3 · response
    Published 17 May 2023

    Open published response

  2. Norfolk

    AI-generated summary

    CHRISTOPHER WATSON · 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 Watson, who had become isolated after losing his job, was found dead in his home on 7 January 2015 after having been dead for some weeks. The concerns focused on Norfolk County Council Adult Social Care closing his file after sending a letter that Mr Watson might not receive, open or understand, and on the lack of direct contact to ensure he understood that help was available and to assess whether his capacity needed assessment. The inquest recorded that he died from exsanguination after cutting his own arm, with his intention not known.

    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 make direct contact with vulnerable people to ensure they understand available help

    Wider context from the report

    “(2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. “painfully thin, unwashed and dishevelled”. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed. ”

    Source location

    CHRISTOPHER WATSON · 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

    Stop sending letters that close concerns without confirmed contact and require face-to-face contact when telephone contact fails.

    Verbatim wording from the response

    “I can confirm that action has been taken to ensure that practice across all Adult Social Services teams has been changed. An instruction has been issued to staff to ensure that the practice of sending a letter to individuals about whom concerns have been raised is ceased with immediate effect. In cases where the Department is unable to contact an individual by telephone, staff have been instructed to ensure that face-to-face contact is made with the person.”

    Source location

    2015-0133-Response-by-Norfolk-County-Council
    Page 1 · response
    Published 1 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

    Implement contact-monitoring and risk-escalation requirements, including recording contact attempts, assessing risk, arranging visits, and escalating delayed contact to senior staff.

    Verbatim wording from the response

    “I can confirm that staff have been reminded to record all the steps they have taken to make contact with the person about whom concerns have been raised. At each attempt, the level of risk must be assessed and recorded. If the risk to the person is thought to be significant, staff have been instructed that an immediate home visit will be arranged. Even where the risk to the person is thought to be low, if the time taken to make contact extends to two days, the case must be escalated to a senior member of staff; either a Practice Consultant or Team Manager. The manager will”

    Source location

    2015-0133-Response-by-Norfolk-County-Council
    Page 1 · response
    Published 1 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

    Formalise the contact-monitoring and risk-escalation requirements as a new Operational Instruction.

    Verbatim wording from the response

    “be required to make a timely and appropriate decision regarding the next course of action. For example, this may mean a welfare check or emergency visit. This advice has been re-issued to staff in the form of a best practice factsheet. It is also being formalised as a new Operational Instruction which will be completed shortly.”

    Source location

    2015-0133-Response-by-Norfolk-County-Council
    Page 2 · response
    Published 1 April 2015

    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