1 May 2024 Jordan George James Fogg Howarth · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to document the ICU consultant’s rationale for examination and admission decisions View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jordan George James Fogg Howarth · 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
Jordan George James Fogg Howarth, a fit and healthy 25-year-old, was admitted to hospital on 3 April 2023 with an unexplained and deteriorating condition. He was not escalated for critical care review as required, and although a later review identified that he needed urgent ICU admission, this was delayed; he suffered a cardiac arrest on 6 April 2023 and could not be resuscitated. The principal concerns included inadequate coordination and continuity of care, failure to follow escalation policy, insufficient documentation of clinical decisions, and a lack of multidisciplinary discussion.
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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 document the ICU consultant’s rationale for examination and admission decisions
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point . All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Source location Jordan George James Fogg Howarth · 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 an amended ICU daily review chart with a dedicated microbiology input section and documented real-time multidisciplinary decisions.
Verbatim wording from the response “In response to this particular point the ICU team have updated and amended the daily review chart to include a specific section for microbiology input. All patients on ITU are” Source location Response from Tameside and Glossop Integrated Care
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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 Audit completion of the amended ICU daily review documentation through the ITU local audit programme.
Verbatim wording from the response “reviewed daily by the Microbiology Team, with a middle grade doctor in attendance to document and update the daily review chart. The attendance of the microbiologist on the ICU enables real time multidisciplinary discussions to take place and for any decisions to be recorded. The completion of the updated documentation will be audited to ensure that this is being completed. The audit has been planned with the Trust’s audit team and will form part of the local audit program for the ITU team.” Source location Response from Tameside and Glossop Integrated Care
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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 hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Verbatim wording from the response “Most of these issues are operational in nature and I note that you have rightly sent your report to the hospital in question (Tameside General Hospital). It will be important that they consider these issues and findings fully and write to you with the actions and improvements they will be taking to address your findings and prevent a recurrence of what happened to Mr Howarth.” Source location Response from Department of Health and Social Care
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Concerns raised 1
Lack of documentation of decisions to remove personal ligature risk assessments View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Ash BANNISTER · 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
Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.
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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 documentation of decisions to remove personal ligature risk assessments
Wider context from the report “I heard evidence to confirm that at some point between the April 2021 review and Ash’s death a decision to remove Ash’s personal Ligature Risk Assessment was made. United Children’s Services were unable to tell me the date on which the decision to remove Ash’s Ligature Risk Assessment was made because there is no documentation relating to the date on which that decision was made or the reasons why that decision was made . This lack of documentation is a grave concern.
Ash died on 7 August 2021 from 1a) Hanging (suspension placing a ligature around the neck) there was no personal Ligature Risk Assessment in place at the time of death.
” Source location Ash BANNISTER · Prevention of Future Deaths report
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15 Jan 2024 Nadia Wyatt · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to record readmission considerations, decision and rationale View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Nadia Wyatt · 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
Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.
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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 readmission considerations, decision and rationale
Wider context from the report “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer.
(2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale.
(3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history.
(4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan.
(5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was.
(6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists.
(7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission.
(8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well.
” Source location Nadia Wyatt · 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 Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.
Verbatim wording from the response “Response:
The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.” Source location Response from Essex Partnership NHS
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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 Remind Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.
Verbatim wording from the response “Response:
The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.” Source location Response from Essex Partnership NHS
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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 Arrange bespoke documentation training for all staff working in the urgent care pathway.
Verbatim wording from the response “Bespoke training on the importance of documentation is being arranged for all staff working in the urgent care pathway in April 2024.” Source location Response from Essex Partnership NHS
Open published response
Concerns raised 1
Failure to identify the prescribing doctor and record prescribing decision-making View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Royal Cornwall Hospitals NHS Trust
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Julie Louise Hancock · 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
Julie Louise Hancock underwent a right total knee replacement on 2 March 2022, was discharged on 5 March 2022, and died at home on 28 March 2022. Her post-mortem cause of death was pulmonary embolus due to deep vein thrombosis, with immobility following the knee replacement. The concerns included apparent prescription of low-risk thrombosis prophylaxis despite her being assessed as high risk, an unidentified doctor’s prescription of dalteparin that was stopped after one dose, and possible discrepancies between summary and full thrombosis-prevention guidance.
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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 the prescribing doctor and record prescribing decision-making
Wider context from the report “I enclose the bundle of evidence.
At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of
Aspirin ████████ for 14 days
LMWH for 14 days and anti-embolism stockings
Rivaroxaban ████████ once daily for 14 days
As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making.
At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides:
Low risk – Aspirin ████████ daily for 14 days
High Risk – Rivaroxaban ████████ daily for 14 days or
Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.)
████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself.
█ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance.
████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position.
I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services.
” Source location Julie Louise Hancock · Prevention of Future Deaths report
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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 records identify the prescriber and document the rationale for suspending aspirin and prescribing dalteparin.
Verbatim wording from the response “After discussion with Pharmacy and a review of the ePMA (Electronic prescribing & Medicines Administration) records there is a clear audit trail of who prescribed the Dalteparin and when.” Source location Response from Royal Cornwall Hospitals NHS Trust
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27 Feb 2023 Sharon Elizabeth Langley · Prevention of Future Deaths report Essex
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Concerns raised 1
Incomplete recording of multidisciplinary decisions, observation rationale and risk-management plans View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sharon Elizabeth Langley · 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
Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk 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 Incomplete recording of multidisciplinary decisions, observation rationale and risk-management plans
Wider context from the report “(8) Quality of record keeping was not deemed to be appropriate by senior staff during evidence:
a. Significant examples of cut and paste including out-of-date risk information at all grades of ward staff, and
b. omissions in multi-disciplinary decision-making and risk of self-harm with no rationale for the level of observations set for the patient and a plan for how risks should be managed
” Source location Sharon Elizabeth Langley · 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 Roll out electronic observations across the Trust while maintaining review and assurance of observation records and multidisciplinary observation-level decisions.
Verbatim wording from the response “- In relation to completion of engagement and supportive observation records, local procedure is in place whereby the observation is completed by the assigned staff member in full. The Nurse in Charge at the end of the shift will sign the observations chart off. These are checked by the ward manager for assurance they’ve been completed accurately and in full before being uploaded to the electronic clinical records system. EPUT has piloted the use of electronic observations (e-obs) which is now being rolled out across the Trust. Observation levels are reviewed regularly by the MDT and documented within the care review documentation.” Source location Response from Essex Partnership University NHS Foundation 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 Undertake horizon scanning on multidisciplinary-team communication and patient-risk management, then review findings and take required actions.
Verbatim wording from the response “- The Trust is currently undertaking horizon scanning relating to MDT communication (including MDT meetings where individual patient risk is discussed and management plans agreed), which is one of EPUT’s nine medium to long term continuous improvement areas. The horizon scan tool is part of the NHS Patient Safety Incident Response Framework toolkit and supports health and social care teams to have a forward look at potential, or current, safety themes and issues. The horizon scanning tool uses the Systems Engineering Initiative for Patient Safety (SEIPS) framework to structure conversations about work as done and emerging patient and staff safety risks. The findings will be reviewed and actions taken as required.” Source location Response from Essex Partnership University NHS Foundation Trust
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25 Jan 2023 Andrew Mark Largin · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to record reasons for crisis-team pathway decisions View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Andrew Mark Largin · 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
Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.
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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 reasons for crisis-team pathway decisions
Wider context from the report “3. However, the SI report did not identify that the crisis team member who made the decision on 2 February simply to advise that Mr Largin should be dealt with by the neighbourhood team failed to record any reasons for her decision .
” Source location Andrew Mark Largin · Prevention of Future Deaths report
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22 Oct 2022 KEITH RUPERT DIMOND · Prevention of Future Deaths report North East Kent
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Concerns raised 1
Failure to record reasons for not following Consultant Haematologist anticoagulation advice View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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KEITH RUPERT DIMOND · 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
Keith Dimond died on 24 November 2021 at Queen Elizabeth Queen Mother Hospital following a catastrophic bleed from a ruptured iliac artery aneurysm, with anticoagulation contributing to the excessive bleeding. Concerns included communication failures about the known iliac artery aneurysm, lack of information about bleeding risks when anticoagulation was prescribed, delayed escalation when he deteriorated, and haematology advice on anticoagulation not being followed on two occasions.
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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 reasons for not following Consultant Haematologist anticoagulation advice
Wider context from the report “(3) Anti-coagulation on readmission was considered complex and the advice of a Consultant Haematologist was sought but not followed on two occasions:
(a) Beriplex and Vitamin K was administered. There was no rationale noted as to why advice to withhold Beriplex was not followed.
(b) There was no record as to why advice to give prophylactic clexane was not administered.
” Source location KEITH RUPERT DIMOND · 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 Communicate to clinical teams the requirement to document decision-makers and rationales when withholding haematology-advised anticoagulant treatment.
Verbatim wording from the response “It is good practice for all clinical teams to seek advice from the haematologist regarding anti-coagulants if considered complex. Since this incident, we have communicated the importance of documenting who made the decision and the rationale behind withholding treatment that has been advised by the haematologist, for example in response to a rapidly changing clinical picture or additional information coming to light, to all clinical teams. This has been through via training and written communications from the clinical director. This element will also be included within the team learning review at the morbidity and mortality meetings for shared learning.” Source location Response from East Kent Hospitals University
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11 Apr 2022 Tracy Dawn WOOD · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to record administration of hazardous items and the rationale for overriding restrictions View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
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Tracy Dawn WOOD · 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
Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident 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 administration of hazardous items and the rationale for overriding restrictions
Wider context from the report “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward. There was no discussion with a Doctor or any other clinical staff when making this decision. There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made
” Source location Tracy Dawn WOOD · 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 Provide staff training on contemporaneous, high-standard record keeping through an external law firm.
Verbatim wording from the response “The issue of contemporaneous record keeping of a high standard is a priority for the Trust and we have commissioned an external law firm to provide training to staff on this subject. This will be underway within the next 6-8 weeks.” Source location Response from Hellesdon Hospital
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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 agency staff can access electronic patient records and understand expectations to record contemporaneous notes individually and comprehensively.
Verbatim wording from the response “There have been some ICT barriers to agency staff accessing the electronic patient record historically however this is being corrected to ensure that all staff have access and are aware of the expectation to record contemporaneous notes individually and comprehensively, see response to question 7.” Source location Response from Hellesdon Hospital
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8 Feb 2022 Benjamin Lee Stroud · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to document the rationale for non-referral to the MDT View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Benjamin Lee Stroud · 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
Benjamin Lee Stroud died at his home on 19 March 2021 after an overdose involving multiple drugs, including tramadol and alprazolam, with empty medication blister packets and insulin pens found around him. The report raised concerns that his case was not referred to the multidisciplinary team despite escalating psychosis, that the Care Coordinator made the referral decision without a recorded rationale, and that this practice posed a risk of future deaths.
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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 document the rationale for non-referral to the MDT
Wider context from the report “That in all cases must go before the MDT, the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death.
On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.
” Source location Benjamin Lee Stroud · Prevention of Future Deaths report
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3 Nov 2021 Saskia Jones and 2 others · Prevention of Future Deaths report London City
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Concerns raised 2
Failure to properly reason and record offender-manager licence-condition approvals View source Failure to record proper rationale for changes to OASys risk ratings View source
This report raised 22 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
College of Policing Ministry of Justice West Midlands Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
College of Policing
Continue working with partners and stakeholders to update offender-management guidance and products to reflect changes resulting from the report.
View source
West Midlands Police
Use Core Groups to examine case detail and recommend decisions to MAPPA panels for final approval.
View source
West Midlands Police
Arrange emergency MAPPA panels with documented decisions and rationales when urgent matters require timely responses.
View source
Ministry of Justice
Publish guidance on licence variation and authorisation, requiring decisions and rationales to be recorded on NDelius.
View source
Ministry of Justice
Develop and consolidate the Licence Conditions Policy Framework, including recording and partner-engagement requirements for licence decisions.
View source
Ministry of Justice
Provide reduced NSD caseloads and senior practitioner oversight through countersigning and regular supervision.
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Saskia Jones and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.
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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 properly reason and record offender-manager licence-condition approvals
Wider context from the report “This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded .
” Source location Saskia Jones and 2 others · 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 proper rationale for changes to OASys risk ratings
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale .
” Source location Saskia Jones and 2 others · 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 Continue working with partners and stakeholders to update offender-management guidance and products to reflect changes resulting from the report.
Verbatim wording from the response “The ‘offender management’ guidance and products have been developed over a number of years and we will continue to work with partners and stakeholders to ensure they are updated to” Source location 2021-0362-Response-from-College-of-Policing_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 Use Core Groups to examine case detail and recommend decisions to MAPPA panels for final approval.
Verbatim wording from the response “10. As the Coroner is aware, West Midlands Police has had a CT MAPPA arrangement in place for some years. It has included regular discussions around proposed licence conditions and any variations through the MAPPA process. Licence conditions are now firmly a matter for HMPPS but if MAPPA’s input is required, as CTPHQ describe at paragraph 7 above, there is a clear process for this to take place in a structured way. Since the attacks at Fishmongers’ Hall, developments have also taken place to improve the structure and quality of decision-making, including the introduction of Core Groups which consider the operational detail of a particular case, and enable detailed discussion by key professionals involved in that case. These Core Groups make recommendations to the MAPPA panel for debate and final sign off.” Source location 2021-0362-Response-from-West-Midlands-Police_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 Arrange emergency MAPPA panels with documented decisions and rationales when urgent matters require timely responses.
Verbatim wording from the response “12. A dedicated Minute Taker (Probation Service National Security Division) will be recruited to provide consistency and continuity in note-taking, and final minutes are reviewed by the MAPPA Chair prior to dissemination, to ensure accuracy. Additionally, where events are urgent and require a more timely response, emergency MAPPA panels can be arranged at short notice with documented records made of decisions and rationale. These improvements, fully supported by a senior CTWM Manager, have enabled the MAPPA panel to operate in a more efficient and structured way and ensured that notes taken can more accurately reflect the more focussed discussion taking place.” Source location 2021-0362-Response-from-West-Midlands-Police_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 Publish guidance on licence variation and authorisation, requiring decisions and rationales to be recorded on NDelius.
Verbatim wording from the response “• We have published guidance on Licence Variation and Authorisation. A draft version of the Licence Conditions Policy Framework is currently being considered by stakeholders and will update and consolidate all changes into policy following the Royal Assent for the Police, Crime, Sentencing and Courts Bill, expected in February 2022. This Framework will set out expectations of probation and prison staff in relation to both changes in licence conditions and the specific authorisation which must be obtained before an offender is permitted to undertake an activity which would otherwise be prohibited by the licence. One of the key policy changes will be the introduction of a requirement that practitioners ensure that any discussions and decisions around whether or not to vary a licence condition or authorise activity outside of a condition are recorded in case notes on NDelius.” Source location 2021-0362-Response-from-MoJ_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 and consolidate the Licence Conditions Policy Framework, including recording and partner-engagement requirements for licence decisions.
Verbatim wording from the response “• We have published guidance on Licence Variation and Authorisation. A draft version of the Licence Conditions Policy Framework is currently being considered by stakeholders and will update and consolidate all changes into policy following the Royal Assent for the Police, Crime, Sentencing and Courts Bill, expected in February 2022. This Framework will set out expectations of probation and prison staff in relation to both changes in licence conditions and the specific authorisation which must be obtained before an offender is permitted to undertake an activity which would otherwise be prohibited by the licence. One of the key policy changes will be the introduction of a requirement that practitioners ensure that any discussions and decisions around whether or not to vary a licence condition or authorise activity outside of a condition are recorded in case notes on NDelius.” Source location 2021-0362-Response-from-MoJ_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 Provide reduced NSD caseloads and senior practitioner oversight through countersigning and regular supervision.
Verbatim wording from the response “• The reduced caseloads in NSD enable Senior Probation Practitioners (SPPs) to provide greater management oversight of cases. SPPs countersign all OASys assessments and provide regular supervision for Probation Practitioners (PPs) creating opportunities to review cases and ensure PPs are taking a balanced view.” Source location 2021-0362-Response-from-MoJ_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 Licence conditions are a matter for HMPPS, with police supporting MAPPA discussions when its input is required.
Verbatim wording from the response “7. Licence conditions are a matter for HMPPS but if it is determined a discussion at MAPPA would be helpful then Local CT policing will support this through new specialist CT MAPPA arrangements. The Probation Service National Security Division have specialist administrators to support the new operating model for specialist CT MAPPA and to ensure effective minute taking and sharing which are set out in more detail at paragraph 12 below.” Source location 2021-0362-Response-from-West-Midlands-Police_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 MAPPA does not make final decisions to apply, remove or authorise licence conditions; those decisions are recorded on case management systems.
Verbatim wording from the response “• The final decision for applying/removing/authorising a licence condition is not made by MAPPA: these decisions will be recorded on case management systems, including where stakeholders have been involved including MAPPA and the Police. The new model introduced by the NSD will enable greater oversight of cases and decision-making by Senior Managers. Management oversight will be monitored through performance and quality assurance measures.” Source location 2021-0362-Response-from-MoJ_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.