Recurring concern

Incomplete and unreliable information about carers and care arrangements

First to latest report 12 Dec 2013 — 5 Dec 2025

Reports that mention this concern
15
Times this concern has been raised
20
Stated actions linked to this concern
29

What this concern includes

Includes deficiencies in recording, verifying, communicating or escalating material information about carers, care arrangements and carers’ ability to provide safe care, where the failure directly concerns those arrangements.

What is not included
  • Excludes generic poor record keeping or information-sharing failures that are not materially about carers or care arrangements.
  • Excludes failures concerning clinical information, treatment, medication or discharge communication unless they specifically concern carers’ care responsibilities or the information they need to provide safe care.
  • Excludes failures to involve carers in decisions where no material information about care arrangements or safety needs is missing or unreliable.

Reports and published responses 15 reports

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

  1. West Sussex

    AI-generated summary

    Steffan Bonnot · 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

    Steffan Bonnot, a 17-year-old in the care of Brighton and Hove Local Authority, left a group during an outing on 1 January 2016 and was later found at a footcrossing after being struck by a train. The report states that he had anxiety about moving to a new foster placement and whether the prospective foster carers had been fully informed about his background. A principal concern was the lack of formal documentation showing exactly what information had been disclosed to the prospective foster carers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide prospective carers with all relevant background information about a child

    Wider context from the report

    “1. The author of the serious case review reported that the prospective foster carers who were to offer a placement to Steffan had advised that they had not been made fully aware of all the background to Steffan’s case. This was, however, at odds with what Steffan’s Social worker told us. However there was no formal documentation detailing exactly what had been disclosed. It was not therefore possible to be clear what information the prospective Foster Carer had been given. As we know the failing to provide Foster Carers with all the background information was one of Steffan’s major concerns and added to his level of anxiety about his move. 2. The above concern would apply equally to any individuals entrusted with the care of a child. All relevant information should be made available and it should be documented as to what has been provided so that the carers can make an informed decision before any placement is agreed. The young person could then be confident as to what the prospective carer’s knew. ”

    Source location

    Steffan Bonnot · Prevention of Future Deaths report
    Page 2 · concerns

    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 document information disclosed to prospective carers

    Wider context from the report

    “1. The author of the serious case review reported that the prospective foster carers who were to offer a placement to Steffan had advised that they had not been made fully aware of all the background to Steffan’s case. This was, however, at odds with what Steffan’s Social worker told us. However there was no formal documentation detailing exactly what had been disclosed. It was not therefore possible to be clear what information the prospective Foster Carer had been given. As we know the failing to provide Foster Carers with all the background information was one of Steffan’s major concerns and added to his level of anxiety about his move. 2. The above concern would apply equally to any individuals entrusted with the care of a child. All relevant information should be made available and it should be documented as to what has been provided so that the carers can make an informed decision before any placement is agreed. The young person could then be confident as to what the prospective carer’s knew. ”

    Source location

    Steffan Bonnot · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Mid Kent and Medway

    AI-generated summary

    Joanna Bowring · 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

    Joanna Bowring had depression, paranoid delusions and suicidal thoughts and was receiving community mental health support. She died by suicide on 1 June 2015 after being struck by a high-speed train on the rail track at Boxley, Kent, with evidence of significant planning. Concerns included the lack of a clear understanding of available services and a care plan after the initial assessment, carers not being routinely included in risk assessments, and carers not being advised about behaviours indicating increased suicide risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to advise carers about behaviours indicating increased risk of suicide

    Wider context from the report

    “(3) Carers were not advised about any behaviours that might indicate an increased risk of suicide ”

    Source location

    Joanna Bowring · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Relaunch the carers protocol across the service, including guidance on potential warning signs and behaviours.

    Verbatim wording from the response

    “• The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for. A copy of the Protocol is attached. A review and audit will be undertaken in June to ensure that it is being implemented appropriately.”

    Source location

    Joanna-Bowring-Response
    Page 2 · response
    Published 27 January 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit implementation of the carers protocol to ensure it is being followed appropriately.

    Verbatim wording from the response

    “• The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for. A copy of the Protocol is attached. A review and audit will be undertaken in June to ensure that it is being implemented appropriately.”

    Source location

    Joanna-Bowring-Response
    Page 2 · response
    Published 27 January 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There is no universal suicide-risk red-flag marker; relevant warning behaviours are patient-specific, although identifying useful guidance is recognised.

    Verbatim wording from the response

    “It is hoped that the steps outlined in number 2 above will help address point 3. As explained in evidence this is however a very difficult and case specific point. I have liaised with the Medical Director and with other clinical staff who have indicated the difficulty as there is no one "red flag" marker which indicates an increased risk of suicide generally, it is dependent on the patient; but there has been a recognition that this could be useful (in line with the changes indicated above).”

    Source location

    Joanna-Bowring-Response
    Page 3 · response
    Published 27 January 2016

    Open published response

  3. Norfolk

    AI-generated summary

    JOHN HENRY WILSHER · 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

    Mr Wilsher, a resident of Springdale Care Home, deteriorated after falls and was found to have extradural and subdural haemorrhages. He died on 21 December 2013 after discharge from hospital to the care home, which quickly became unable to cope with his mobility. Concerns included inaccurate discharge information, inadequate communication about his care needs and prior referral, and delays or gaps in care assessments.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate concerns about care home adequacy

    Wider context from the report

    “(2) Concerns were raised by the GP and a referral made to NCC Community Services on 25 November 2013 as to the suitability of the Care Home in providing care to Mr Wilsher due to his deteriorating condition. He was admitted to NNUH on 27 November 2013 for assessment and plans were made for discharge to the Care Home. Neither NNUH nor the Care Home were aware concerns had already been raised (prior to a further deterioration in his condition) as to the adequacy of the Care Home to cope with his needs. On Mr Wilsher’s discharge to the Care Home it quickly became apparent they could not cope with his needs. ”

    Source location

    JOHN HENRY WILSHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed feedback to safeguarding referrers as an integral part of the safeguarding process.

    Verbatim wording from the response

    “I confirm that the importance of giving appropriate feedback to the person who raised the safeguarding concern (the “referrer”) has been acknowledged and it is agreed that this should be an integral part of the safeguarding process. The Multi-Agency Safeguarding Hub (“MASH”) and the safeguarding manager within Norfolk Council have been working with colleagues to ensure this action is embedded in the safeguarding process. This will ensure a more outcome focussed safeguarding process. This will also enable the referrer to be clear when the council has assessed an issue not to fall within the safeguarding arena.”

    Source location

    2014-0360-Response-by-Norfolk-County-Council
    Page 1 · response
    Published 5 August 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue working with the hospital to support safe discharges for older people returning to residential homes.

    Verbatim wording from the response

    “Norfolk County Council Community Services continues to work closely with the Norfolk & Norwich Community Hospital to ensure safe discharges are made. There are social care practitioners linked to those Wards which care for older people who, if requested, are available to support any health staff who are directly in contact with residential home managers and staff.”

    Source location

    2014-0360-Response-by-Norfolk-County-Council
    Page 1 · response
    Published 5 August 2014

    Open published response

  4. Inner North London

    AI-generated summary

    Harold George de Mello · 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

    Harold George de Mello, who had multiple co-morbidities, limited mobility and incontinence, died in hospital on 13 April 2014 after collapsing at home and being treated for bronchopneumonia. The principal concerns were that social-care assessments did not adequately investigate or record the reported incontinence, hygiene problems, care arrangements and differing information, and lacked sufficiently comprehensive guidance and senior review.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inaccurate and incomplete recording of carers and care arrangements

    Wider context from the report

    “(4) that no reference was made to any of the people to whom the service user referred as being carers, that information was wrongly recorded (a person wrongly described as a niece who was not a relative) and that there is a significant difference in the fact that the visit assessment suggests that the deceased had adequate social care whilst also noting that a ‘carer’ was not fit and able to undertake domestic tasks. That no investigation was properly made into the actual care available to Mr de Mello and no contact made with either the claimed carer or the relative with power of attorney to confirm the reality of his situation and the extent of his dependence or needs ”

    Source location

    Harold George de Mello · Prevention of Future Deaths report
    Page 2 · concerns

    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 verify care arrangements and support needs

    Wider context from the report

    “(4) that no reference was made to any of the people to whom the service user referred as being carers, that information was wrongly recorded (a person wrongly described as a niece who was not a relative) and that there is a significant difference in the fact that the visit assessment suggests that the deceased had adequate social care whilst also noting that a ‘carer’ was not fit and able to undertake domestic tasks. That no investigation was properly made into the actual care available to Mr de Mello and no contact made with either the claimed carer or the relative with power of attorney to confirm the reality of his situation and the extent of his dependence or needs ”

    Source location

    Harold George de Mello · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce a mandatory electronic-record section documenting informal carers’ views and involvement in assessments.

    Verbatim wording from the response

    “Introduction of a new mandatory Carers’ Views section in the electronic record (Framework) which records informal carer involvement thereby ensuring all supportive networks are considered as part of the assessment process. This will reduce risk of carers not being involved in the assessment process in the future. | Adult Social Care Dept. | Completed”

    Source location

    2014-0449-Response-by-Tower-Hamlets-Local-Authority
    Page 4 · response
    Published 7 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce an eco-mapping tool to identify support networks, gaps, risks and factors affecting informed decision-making.

    Verbatim wording from the response

    “Introduction of an eco-mapping tool which facilitates identification of a person’s support network thereby ensuring quality, informed decision making and risks are appropriately identified and managed. The tool will support practitioners to consider: Who and what agencies are involved? What is helping? What is hindering? Where are the gaps in support?”

    Source location

    2014-0449-Response-by-Tower-Hamlets-Local-Authority
    Page 5 · response
    Published 7 July 2014

    Open published response

  5. South Yorkshire (Eastern)

    AI-generated summary

    ROSEMARY BRONWYN FERGUSON · 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

    ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of discharge.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clarity in communicating post-discharge supervision expectations to informal carers

    Wider context from the report

    “(2) The clinician discharged Ms Ferguson based on clinical issues and NICE guidelines. She was discharged to the care of her friend ████████ The only conversation between the clinicians and ████████ was a telephone call in which it was arranged for Ms Ferguson to be driven straight to his home on leaving hospital. This duly took place, but ████████ did not understand that the clinician expected him to remain in her company for at least the next 24 hours in order to watch for any significant changes in her condition and accordingly, he did not remain with her constantly. There was clearly a difference of perception about his role, possibly as a result of lack of clarity in the conversation between himself and the clinician. I am concerned that a repetition of this in other cases may lead to danger. ”

    Source location

    ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026