25 Feb 2026 Emma Irene TURNER · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Safeguarding referral forms failing to capture key GP-relevant information View source
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.
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AI-generated summary
Emma Irene TURNER · 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
Emma Irene Turner died at home on 29 January 2023 after her airway became obstructed by vomit following her eating some cake. The report identified concerns about inadequate and untimely multi-agency processes, safeguarding referrals, face-to-face assessments and welfare checks, as well as poor information sharing between services. It also identified a risk that the safeguarding referral form used by GPs could omit key information and delay responses.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Safeguarding referral forms failing to capture key GP-relevant information
Wider context from the report “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests.
The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams . Thus the safeguarding team may be delayed in responding in a timely way .
” Source location Emma Irene TURNER · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a single safeguarding adults referral form across Derby City and Derbyshire County, available online to public and professional referrers.
Verbatim wording from the response “Across Derby and Derbyshire there is a joined-up, partnership approach to safeguarding adults, underpinned by a joint Safeguarding Adults Policy which operates across both the Derby Safeguarding Adults Board and the Derbyshire Safeguarding Adults Board areas. As part of this partnership approach, a single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. This form is available online for members of the public, all partner agencies and providers, including GP practices, to use when making safeguarding referrals.” Source location Response from Derby City Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Co-produce and implement a revised safeguarding adults referral form with partners, streamlining information requirements and reducing duplication and complexity.
Verbatim wording from the response “We recognise the concerns raised that some sections of the current template are less directly relevant to GPs and that this may increase the risk of key clinical or contextual information not being clearly set out and potentially delay the safeguarding team’s response. In recognition of this, Derby City Council and Derbyshire County Council have worked in partnership to collate feedback from partner agencies, including GPs, specifically on the structure, content and usability of the Safeguarding Adults Referral Form.” Source location Response from Derby City Council
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4 Feb 2026 Georgia Charlotte SCARFF · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure of staff to record important safeguarding detail in CPOMS View source
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.
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AI-generated summary
Georgia Charlotte SCARFF · 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
Georgia Charlotte SCARFF, aged 16, died immediately on 15 April 2024 after stepping into the path of a lorry on the A14 near Bury St Edmunds; the inquest concluded that she had been experiencing anxiety and acted impulsively in taking her own life. Concerns were raised that staff were not always proficient in using CPOMS, resulting in important safeguarding information not being recorded, and that the absence of a single standard safeguarding information management tool could create risks to life.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of staff to record important safeguarding detail in CPOMS
Wider context from the report “However, the Court also heard evidence that not all staff were familiar with or proficient in the use of CPOMS which, although not causative of Georgia’s death, led to important information not being recorded in Georgia’s CPOMS record .
I am concerned that in another case the failure to record important safeguarding detail may result in a risk to life.
” Source location Georgia Charlotte SCARFF · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of sufficient recording, flow and sharing of information across agencies and teams View source
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.
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. 7
Action
Implement direct handover of police-conveyed patients to Trust staff.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Revise and implement the Trust-wide Missing Persons policy, including risk assessment, detention, communication, escalation and post-departure procedures.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Disseminate Missing Persons policy guidance, flow charts and documentation to wards, emergency departments and clinical staff.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Review and update emergency-department triage, mental-health liaison, observation and communication documentation with partner clinicians.
Stated by UHSxStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025. View source
Action
Send daily reports of police-referred missing patients to Trust and emergency-department nursing leaders for risk review, feedback and learning.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Hold fortnightly multidisciplinary missing-patient meetings involving nursing, emergency, police, mental-health and security teams.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source
Action
Develop and recirculate quick-reference absconding guidance, flow charts and missing-person documentation for wards and emergency departments.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025. View source See 4 more actions
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Mark-Anthony SUMMERSETT · 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-Anthony Summerset attended Worthing Hospital Emergency Department on 5 February 2024 after expressing suicidal thoughts, but left before triage or assessment and was found deceased in his car in Arundel on 7 February 2024. The principal concern was insufficient recording, information flow and information sharing between the agencies involved, including failures to notify Police that he had left the Emergency Department, which may have limited efforts to locate, contact and urgently treat him.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of sufficient recording, flow and sharing of information across agencies and teams
Wider context from the report “Whilst I heard evidence that the UHS Foundation Trust has a Missing Person policy – Walkouts/absconding patients (approved 23 May 2024), in Mr Summerset’s case there was a lack of recorded and/or shared information across all the agencies and teams with whom he had contact, or to whom he was known , such that an accurate and fully reflective risk assessment was not achieved , exacerbated by delays in the triage process in the ED.
Mr Summerset was not notified to Police as a missing person and nor were Police informed he had left the ED, despite them simultaneously raising a safeguarding risk via a Vulnerable Adult Single Combined Assessment of Risk Form.
In sum, there was therefore a lack of information sufficiency, flow and sharing across the agencies whilst he was present in, and at and after the point he left, the ED, which might have enabled greater efforts to locate, contact and more urgently treat him.
” Source location Mark-Anthony SUMMERSETT · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement direct handover of police-conveyed patients to Trust staff.
Verbatim wording from the response “Following the investigation report into Mr Summerset’s attendance and suicide in February 2024, I would firstly confirm that the two key actions in the action plan (support for triage at times of high demand and handover from police to Trust staff) have been addressed.” Source location Response from University Hospitals Sussex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and implement the Trust-wide Missing Persons policy, including risk assessment, detention, communication, escalation and post-departure procedures.
Verbatim wording from the response “The Trust has fully reviewed and revised the Missing Persons policy, with more information around the required processes in relation to patients who are at risk of absconding, and actions to be taken when patients do leave. This was done collaboratively across primarily the medical divisions and ED teams, but also with the other Divisions. There is detailed information around the legal principles and powers available to staff to detain and prevent patients from leaving (Mental Health Act and Mental Capacity Act) alongside more detailed information about the police response to missing persons, and criteria of those patients of critical concern who they will respond to. There are clear guidelines, flow charts and documentation to be used for the assessment of vulnerable patients, a process if concern are intending to leave and once have left.” Source location Response from University Hospitals Sussex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate Missing Persons policy guidance, flow charts and documentation to wards, emergency departments and clinical staff.
Verbatim wording from the response “The policy essential documentation and guidelines therein, were circulated to all wards and EDs before May 25th when phase 2 of RCRP was introduced across Sussex, and the main documents and flow charts to be used sent as separate, ready to hand information. These were further recirculated in Q2 (following slight update/ minor amendments to the policy early September, which included the system escalation responses) to ensure there was a renewed focus for clinical teams.” Source location Response from University Hospitals Sussex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update emergency-department triage, mental-health liaison, observation and communication documentation with partner clinicians.
Verbatim wording from the response “The Divisions of Medicine have continued to work collaboratively with SPFT colleagues over the year reviewing ED documentation (reviewing assessments of both triage and Mental Health Liaison Team (MHLT), enhanced observation processes, and the communications between the EDs and the” Source location Response from University Hospitals Sussex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send daily reports of police-referred missing patients to Trust and emergency-department nursing leaders for risk review, feedback and learning.
Verbatim wording from the response “Since May 2024, UHSx have worked further with Sussex Police to review missing patients who have been referred to police for follow up post absconding. Daily reports are sent to the hospital nurse directors, medicine divisional directors of nursing, and ED matron/heads of nursing, in order to review the patients, to confirm if request for police follow up was appropriate in terms of risk of patient or not, and also to share any feedback and learning.” Source location Response from University Hospitals Sussex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold fortnightly multidisciplinary missing-patient meetings involving nursing, emergency, police, mental-health and security teams.
Verbatim wording from the response “The Trust has commenced on the Royal Sussex County Hospital and Princess Royal Hospital sites a fortnightly meeting to discuss cases with senior nurse leads/ED, police, SPFT and security teams present. This is helping to inform learning and improve processes and communication between all system partners. Similar meetings will be set up for Worthing Hospital and St Richard’s Hospital sites to facilitate the same shared learning and improvements in processes. It is hoped these can commence in March 2025.” Source location Response from University Hospitals Sussex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and recirculate quick-reference absconding guidance, flow charts and missing-person documentation for wards and emergency departments.
Verbatim wording from the response “Post coroner’s inquest, the Divisional Director of Nursing for Medicine, Worthing, has further followed up with lead in SPFT for Worthing site, and having reviewed the guidelines produced for MHLT colleagues, has developed some similar bullet point guidelines for wards and EDs for quick easy reference, and is recirculating these across the Trust with the key flowcharts and missing person documentation from the policy. This will provide further quick reference laminated guidance at point of care to help staff at the time when faced by an absconding patient, to ensure correct processes are followed to promote the patient’s safeguarding to reduce potential harm after leaving the department. This can be provided as evidence should HM Coroner request this.” Source location Response from University Hospitals Sussex
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4 Nov 2024 Janet Brown Townend · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 2
Failure to record how review responses were obtained View source Failure to record family input in Safeguarding Adult Reviews View source
This report raised 6 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.
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Janet Brown Townend · 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
Janet Brown Townend developed an infected foot wound that progressed to sepsis after an injury, and she died in hospital on 15 October 2023 despite antibiotics, surgery and other treatment. Concerns were raised about the care she received and about the subsequent Safeguarding Adult Review, which was described as lacking professional curiosity, family input, appropriate scrutiny and proper documentation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record how review responses were obtained
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained . The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record family input in Safeguarding Adult Reviews
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminated lessons learned from the identified enquiry practice issues across the safeguarding team.
Verbatim wording from the response “The record of the enquiry also lacked analysis of the information that was received from both services approached for information and it was not fully triangulated with other information gathered from both Janet Brown Townend herself and members of her family within the record of the section 42 enquiry. It is difficult to say whether the outcome of the enquiry would have been different had these issues been addressed, however, it is acknowledged that the recorded evidence for decision making and subsequent actions in this case could have been improved. The practice issues identified in this enquiry have been addressed with the individual practitioner and lessons learned disseminated within the team.” Source location Response from East Riding of Yorkshire Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implemented new forms guiding practitioners to undertake and record safeguarding concerns and Section 42 enquiries, including person and family voices and outcome-sharing records.
Verbatim wording from the response “In November 2023 (after this enquiry took place), as part of the implementation of a new service and practice model for safeguarding adults, the service launched a new set of forms to record safeguarding adult concerns and section 42 enquiries. These forms lead the practitioner through a much more succinct process for undertaking and recording their intervention with the voice of the person and their family/representative at the heart of the enquiry record.” Source location Response from East Riding of Yorkshire Council
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3 Aug 2021 Emma Day · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to record the duration and conditions of protective orders View source
This report raised 10 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.
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AI-generated summary
Emma Day · 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
Emma Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record the duration and conditions of protective orders
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order , nor did there appear to be any safety netting if the situation escalated.
” Source location Emma Day · Prevention of Future Deaths report
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9 Jul 2021 Alan Howard Foster Griffin · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to identify and correct copied allegation errors View source
This report raised 16 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.
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. 4
Action
Conduct an independent external Lessons Learned Review of safeguarding and conduct handling, including information management, risk assessment, casework and inter-church sharing.
Stated by Diocese of London and Lambeth PalaceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2021. View source
Action
Design and implement improved systems for capturing, triaging, recording, assessing and appropriately sharing safeguarding and conduct information.
Stated by Diocese of London and Lambeth PalaceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021. View source
Action
Develop casework tracking and structured review systems to record progress against milestones and monitor actions throughout each case.
Stated by Diocese of London and Lambeth PalaceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021. View source
Action
Deliver safeguarding-specific GDPR training and strengthen recording, auditing and lawful, proportionate information-sharing practice.
Stated by Diocese of London and Lambeth PalaceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021. View source See 1 more action
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Alan Howard Foster Griffin · 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
Alan Howard Foster Griffin died by suicide at home on 8 November 2020 while under investigation by his former and current dioceses. The principal concerns were systemic and individual failings in the handling of unverified allegations, including inadequate verification, inaccurate and incomplete information-sharing, unclear responsibility, and failure to seek recommended legal advice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify and correct copied allegation errors
Wider context from the report “6. As I have indicated, the archdeacon told me that he placed great weight on the information given by the head of operations that Father Griffin had told the head of operations that he had used rent boys. However, regarding the record of “concerns of possible child exploitation”, the safeguarding manager told me that she had made a mistake, and that this phrase had been mistakenly copied and pasted from another entry.
She did not believe that there was any evidence of sexual activity with a minor, nor any reason to investigate that, but her typographical error was never noted and corrected, either by her or by anyone else.
” Source location Alan Howard Foster Griffin · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an independent external Lessons Learned Review of safeguarding and conduct handling, including information management, risk assessment, casework and inter-church sharing.
Verbatim wording from the response “We aim to agree the Terms of Reference by early September with the intention of the Lessons Learned Review ("the Review") beginning in September 2021. The purpose and objectives of the Review are currently as follows:” Source location 2021-0243-Response-from-Church-of-England_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and implement improved systems for capturing, triaging, recording, assessing and appropriately sharing safeguarding and conduct information.
Verbatim wording from the response “• Our new Head of Safeguarding has already started working with the team to design and implement new systems of information capture, triage, recording, assessment and appropriate sharing of safeguarding and conduct matters. These issues will form part of our overarching improvement plan.” Source location 2021-0243-Response-from-Church-of-England_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop casework tracking and structured review systems to record progress against milestones and monitor actions throughout each case.
Verbatim wording from the response “3. The development of a casework management tracking system for all referrals into the safeguarding team to record timely progress against key milestones and ensure a structured review process (including risk and mental health) during the lifetime of a case.” Source location 2021-0243-Response-from-Church-of-England_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver safeguarding-specific GDPR training and strengthen recording, auditing and lawful, proportionate information-sharing practice.
Verbatim wording from the response “4. Delivering additional GDPR training specific to safeguarding to ensure staff in the Diocesan Safeguarding Team are competent and confident to ensure information that is shared is recorded and audited, and that the principles of information sharing are applied lawfully and proportionately. In due course this will be delivered to senior staff involved in handling personal and safeguarding related data to support their practice and decision making.” Source location 2021-0243-Response-from-Church-of-England_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is not possible to quality-assure all internal documents, although improved working practices and closer supervision will be established.
Verbatim wording from the response “6. The introduction of an error recording “concerns of possible child exploitation.” | We agree this was mistake and is a matter of regret. This description was entered into the spreadsheet referred to above as part of the Two Cities report, which was an internal document. It was not shared with the RC church as part of the referral. | It is not possible to quality assure all internal documents; however, we will ensure good working practices and closer supervision are established. | We will ensure the appropriate resourcing of the safeguarding team to enable this to take place.” Source location 2021-0243-Response-from-Church-of-England_Published
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19 Jun 2019 Aram Ali Mustafa · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to log safeguarding matters with the safeguarding hub regardless of a person's location in the system View source
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.
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AI-generated summary
Aram Ali Mustafa · 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
Aram Ali Mustafa, an asylum seeker living in initial accommodation, was found hanging by a scarf in his room on 4 February 2019 and was declared deceased at 23.10. The report identified concerns that earlier suicide and safeguarding information was not sufficiently detailed or logged across the organisations involved.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to log safeguarding matters with the safeguarding hub regardless of a person's location in the system
Wider context from the report “2. The events on 29/10/18 when he made a threat to kill himself were not logged with the safeguarding hub as he was about to be deported. There needs to be a system to ensure all safeguarding matters are logged regardless of where the person is in the system
” Source location Aram Ali Mustafa · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify UKVI safeguarding leads and the Safeguarding Hub immediately through the central contact centre, and relay resulting advice to operational teams.
Verbatim wording from the response “As above, G4S were not aware of Mr Mustafa’s prior suicide threat and are not responsible for managing the Safeguarding Hub. Given that this rests with UKVI, it is not something upon which it can respond further. G4S does however have systems in place to ensure that matters of safeguarding concerns uncovered during the course of delivering its services are notified to UKVI. UKVI has its own Safeguarding Hub as well as 2 x safeguarding leads in each of the G4S contract regions. Any issues in relation to safeguarding are immediately raised with these respective leads as well as the Safeguarding Hub by our central contact centre which collates all information and feeds back advice and information to the relevant operational teams.” Source location 2019-0508-Response-from-G4S-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Compile incident reports containing relevant information and forward them to UKVI, including safeguarding recipients where applicable.
Verbatim wording from the response “We also have a robust incident management process and operational teams, including UHS, compile incident reports which include all relevant information about the incident in question. All incident reports are forwarded to UKVI by our central contact centre. Should these incidents relate to safeguarding concerns then the Safeguarding Hub and leads are included in the communication.” Source location 2019-0508-Response-from-G4S-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a shared safeguarding spreadsheet for teams to record actions, updates, onward referrals and Safeguarding Hub referrals.
Verbatim wording from the response “In addition, a spreadsheet has been introduced that records all the safeguarding action and will be jointly in use by all the Teams in accordance with the order of process, i.e. Intake will make the initial input as per referral and followed by RIAV (Routing Initial Accommodation Validation) and Routing updating their subsequent action – this will include onward referrals to the Service Providers, and the Safeguarding Hub.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot and introduce a vulnerability-scoring purpose matrix to guide escalation and Safeguarding Hub referrals, subject to senior-management sign-off.
Verbatim wording from the response “Additionally, a NAAU purpose matrix will be piloted, with a point base scoring system which will guide staff in terms of vulnerabilities that require escalation to the Hub. This is awaiting to be signed off by Senior Management. The Matrix which is due to be introduced will help to decide on the level of vulnerability and hence if a Safeguarding Referral is required.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
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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 Managing the Safeguarding Hub rests with UKVI, so no further response can be provided on that matter.
Verbatim wording from the response “As above, G4S were not aware of Mr Mustafa’s prior suicide threat and are not responsible for managing the Safeguarding Hub. Given that this rests with UKVI, it is not something upon which it can respond further. G4S does however have systems in place to ensure that matters of safeguarding concerns uncovered during the course of delivering its services are notified to UKVI. UKVI has its own Safeguarding Hub as well as 2 x safeguarding leads in each of the G4S contract regions. Any issues in relation to safeguarding are immediately raised with these respective leads as well as the Safeguarding Hub by our central contact centre which collates all information and feeds back advice and information to the relevant operational teams.” Source location 2019-0508-Response-from-G4S-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Safeguarding Hub is funded only for asylum-claimant service users and cannot act on referrals made after removal.
Verbatim wording from the response “Referrals can come into the Safeguarding Hub from any source however they deal with service users who have an asylum claim; they are only funded for this. G4S and others would have had access to the Hub provided they are regarding asylum applicants. The Hub could not have done anything if a referral was made post removal. However, if a referral had been made prior to removal and included details of suicide risk, the Hub would have accepted the referral.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
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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 Safeguarding Hub is operated by UKVI and is outside the respondent's control.
Verbatim wording from the response “The threats made by Mr Mustafa on 29 October 2018 were shortly prior to his removal from the country when he was not resident with us. UHS had no knowledge of this threat. We note this was not recorded with the Safeguarding Hub. The Safeguarding Hub is operated by UKVI and as such is outside of UHS' control. We understand UKVI is reviewing this system following the tragic death of Mr Mustafa.” Source location 2019-0508-Response-from-Urban-Housing-Redacted
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4 Oct 2017 Sofia Ann Legg · Prevention of Future Deaths report Somerset
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Concerns raised 1
Insufficient detail in care plans to record safeguarding requirements View source
This report raised 5 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.
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AI-generated summary
Sofia Ann Legg · 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
Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI Report.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient detail in care plans to record safeguarding requirements
Wider context from the report “4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school, where she would be during the following days to a psychiatrist. Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia.
” Source location Sofia Ann Legg · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure CAMHS care plans are explicit and communicate information clearly, with implementation monitored through clinical supervision.
Verbatim wording from the response “4.1 It has been recognised that the recollections of Mrs Legg and Sofia’s care co-ordinator are not in agreement with regards to the level of detailed safety advice given. Mrs Legg herself has told us that we, as a service, may not fully understand how challenging this situation was for her as a parent. She was being asked to absorb new information about her daughter’s mental state and her risk of ending her life, which was new and shocking for her. I extend again my own and the Trust’s sincere apologies to Mrs Legg for this. The Trust appreciates and fully understands this feedback given by Sofia’s mother and realises that services need to work much harder to help families understand the impulsive and fluctuating nature of suicide risk in young people. CAMHS practitioners have been made aware of the importance of ensuring care plans are explicit and information is written clearly.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue staff risk training and team meetings to reinforce clear crisis plans explaining supervision requirements to young people and parents.
Verbatim wording from the response “4.3 It has been fully recognised that family members need to be involved at the earliest stage when young people are expressing suicidal ideation and given time to absorb information and to process advice. The CAMH service is continuing to work with staff through risk training and via local team business meetings to emphasise the importance of crisis plans which give advice to both the young” Source location 2017-0293-Response-by-Somerset-NHS-Trust
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16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
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Concerns raised 3
Insufficient recording of safeguarding information by Appropriate Adults View source Failure to record safeguarding intelligence on nominal profiles View source Lack of a process for recording safeguarding concerns View source
This report raised 25 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.
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AI-generated summary
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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 recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” Source location Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Open source report × 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 record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” Source location Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Open source report × 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 a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Source location Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Open source report
28 Dec 2014 Alex Kelly · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Inconsistent recording of significant events across safeguarding records View source
This report raised 27 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.
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AI-generated summary
Alex Kelly · 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
Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent recording of significant events across safeguarding records
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Source location Alex Kelly · Prevention of Future Deaths report
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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 Deliver ongoing ACCT refresher training to staff and train Supervising Officers as ACCT case managers.
Verbatim wording from the response “All staff at HMYOI Cookham Wood who are in direct contact with young people receive the Introduction to Safer Custody training as part of prison officer entry level training or during their induction. This is an introductory course that gives a general introduction to safer custody, including suicide prevention, self-harm management and violence, and the different roles and processes related to it.” Source location 2014-0555-Response-by-Ministry-of-Justice
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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 more rigorous ACCT quality-assurance process with individual feedback to case managers.
Verbatim wording from the response “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.” Source location 2014-0555-Response-by-Ministry-of-Justice
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.
Verbatim wording from the response “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.” Source location 2014-0555-Response-by-Ministry-of-Justice
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Includes failures to record, update or preserve material safeguarding information in designated safeguarding forms, admission records or comparable care and custody records where the omission can impair recognition, assessment, communication or management of safeguarding risk.
