Recurring concern

Failure to reconcile conflicting information in safety assessments

Get email alerts

Request correction

First reported 17 Jan 2014•Latest report 26 Apr 2023

Definition

What this concern includes

Includes failures within safety assessments to identify, compare, investigate and resolve material inconsistencies between referral information, historical records, observations, collateral reports, recent concerns or other relevant evidence before reaching or approving an assessment conclusion.

Not included

Excludes generic clinical record, handover or communication deficiencies where no material conflict within a safety assessment is identified.
Excludes incomplete assessments where the issue is missing assessment content but not failure to reconcile conflicting information.
Excludes failures to act on a correctly reconciled assessment when the assessment process itself was reliable.
Excludes generic diagnostic disagreement or confirmation-bias concerns unless the report specifically identifies unreconciled conflicting information within a safety assessment.

Reports: 5
Individual concerns: 5
Date range: 2014–2023
Stated actions: 9

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Dac Beachcroft LLP1

Department of Health and Social Care1

Family1

Hampshire County Council1

HCRG Care Ltd1

Home Office1

Lincolnshire County Council1

London Borough of Tower Hamlets1

Medical Centre1

Mental Health Act assessors1

Ministry of Justice1

North London NHS Foundation Trust1

Recipient name withheld1

Royal Cornwall Hospitals NHS Trust1

Royal Free London NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

26 Apr2023
Lincolnshire
Concerns raised1
1. Failure to identify and assess conflicting evidence about alcohol provision
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.
Respondent positions 2
1. Position
  The toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.
  Stated by Lincolnshire County CouncilNo action considered necessary
1. Position
  Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.
  Stated by Lincolnshire County CouncilUnable to act
AI-generated summary

Colin Robert GUMM · 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

Colin Robert GUMM, a vulnerable adult receiving a care package, was found collapsed by his carers and died at Lincoln County Hospital on 27 November 2021 despite treatment. The concerns include gaps in Adult Social Care monitoring and safeguarding, the identification of apparent underweight and clinical dehydration only shortly before his death, conflicting evidence about alcohol provision, and the reported premature closure of a safeguarding enquiry before toxicology results were received.

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 identify and assess conflicting evidence about alcohol provision
Wider context from the report
“6.Conflicting evidence was provided by bluebird care that : Registered Manager (02/02/2023) - "the only drink we pour for him is water, we never poured alcohol for him" "26th November 2021 14:24 from carer's log - "water and whiskey provided on top of ongoing medication" EMAS report (12/04/2022) - "bottles of alcohol were found by his bed and enquired with the carers ,however they believed he doesn't drink a lot as he was unable to pour on his own". If that is right somebody was pouring for him. Shouldn't all this have been picked up by the safeguarding assessment? ”
Source location
Colin Robert GUMM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.

Verbatim wording from the response
“Mr Gumm had sadly died and therefore this ended the Local Authority's legal duty to take steps to safeguard Mr Gumm under s.42. However, the Safeguarding Team did progress with a s.42 enquiry (although it should have been recorded as a non s.42 enquiry at that time) to seek wider assurance in relation to the care providers involved and any potential wider risks. (LCC’s processes in relation to s.42 enquiries and more generally is explored below in the section on action by LCC). Proportionate enquiries/fact-findings was undertaken (in so far as the council were able to do so given the circumstances) and no concerns were identified in relation to the services provided to the deceased.”

Source location
Response from Lincolnshire County Council
Page 5 · response
Published 3 May 2023
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
Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.

Verbatim wording from the response
“We can only reiterate that LCC was not providing care to Mr Gumm at the time. LCC are not therefore in a position to determine whose evidence can or should be believed”

Source location
Response from Lincolnshire County Council
Page 5 · response
Published 3 May 2023
Open published response
24 Aug2017
Inner North London
Concerns raised1
1. Failure to reconcile and challenge contradictory suicide-risk information
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.
Actions described in response 1
1. Action
  Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
  Stated by Royal Free London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
  Stated by Royal Free London NHS Foundation TrustRedirects responsibility
AI-generated summary

Jonathan Anthony MEANEY · 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

Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.

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 reconcile and challenge contradictory suicide-risk information
Wider context from the report
“2. When the mental nurse assessed Mr Meaney before discharge on Wednesday, 15 March, he did not question Mr Meaney’s assertion that he had not intended to take an overdose two days before. This was despite the fact that Mr Meaney had told the assessing doctor that he had been trying to kill himself and he had written notes of intent. ”
Source location
Jonathan Anthony MEANEY · 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
Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.

Verbatim wording from the response
“It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.”

Source location
2017-0244-Response
Page 1 · response
Published 1 October 2017
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
CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.

Verbatim wording from the response
“We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.”

Source location
2017-0244-Response
Page 1 · response
Published 1 October 2017
Open published response
25 Oct2016
Inner South London
Concerns raised1
1. Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
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.
Actions described in response 6
1. Action
  Publish AMHP guidance requiring direct scrutiny of police custody records and logs.
  Stated by Hampshire County Council and Portsmouth City CouncilStated planned
2. Action
  Publish AMHP guidance requiring direct scrutiny of detained persons’ medical forms.
  Stated by Hampshire County Council and Portsmouth City CouncilStated planned
3. Action
  Publish AMHP guidance requiring direct discussion with police custody officers during each custody-centre assessment.
  Stated by Hampshire County Council and Portsmouth City CouncilStated planned
1. Action
  Require AMHPs to obtain written medical reports when assessments do not result in detention recommendations.
  Stated by Hampshire County Council and Portsmouth City CouncilStated completed
2. Action
  Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.
  Stated by Hampshire County Council and Portsmouth City CouncilStated planned
3. Action
  Review professional development opportunities for AMHPs conducting police-custody assessments.
  Stated by Hampshire County Council and Portsmouth City CouncilStated planned
AI-generated summary

Richard Walsh · 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

Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and 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 consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report
“There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person, or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened. ”
Source location
Richard Walsh · 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
Publish AMHP guidance requiring direct scrutiny of police custody records and logs.

Verbatim wording from the response
“The Coroner has highlighted the fact that the MHA assessors did not directly examine the custody record or log.”

Source location
2016-0377-Response-by-Hampshire-County-Council_Redacted
Page 2 · response
Published 26 February 2017
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
Publish AMHP guidance requiring direct scrutiny of detained persons’ medical forms.

Verbatim wording from the response
“The Coroner has highlighted the fact that the MHA assessors did not directly examine the ‘Detained Persons Medical Forms’.”

Source location
2016-0377-Response-by-Hampshire-County-Council_Redacted
Page 2 · response
Published 26 February 2017
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
Publish AMHP guidance requiring direct discussion with police custody officers during each custody-centre assessment.

Verbatim wording from the response
“The Coroner has highlighted that the Custody Officers and the MHA assessors never spoke.”

Source location
2016-0377-Response-by-Hampshire-County-Council_Redacted
Page 2 · response
Published 26 February 2017
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
Require AMHPs to obtain written medical reports when assessments do not result in detention recommendations.

Verbatim wording from the response
“HCC/ PCC will be working with local NHS Provider Trusts and Hampshire Constabulary to review information sharing with the Police following joint assessment in Police Custody.”

Source location
2016-0377-Response-by-Hampshire-County-Council_Redacted
Page 3 · response
Published 26 February 2017
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
Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.

Verbatim wording from the response
“The standard of mental health act assessments is brought into question by the Coroner in light of the findings from this inquest. Certainly the conduct of each of the practitioners involved in this case is referred to separately.”

Source location
2016-0377-Response-by-Hampshire-County-Council_Redacted
Page 3 · response
Published 26 February 2017
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
Review professional development opportunities for AMHPs conducting police-custody assessments.

Verbatim wording from the response
“5.0 Training and Professional Development for AMHP staff when dealing with assessments in Police Custody”

Source location
2016-0377-Response-by-Hampshire-County-Council_Redacted
Page 4 · response
Published 26 February 2017
Open published response
7 Jul2014
Inner North London
Concerns raised1
1. Failure to reconcile assessments with referral and historical information
This report raised 8 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 2
1. Action
  Disseminate the internal management review, action plan and lessons learned to managers and relevant frontline staff for discussion and implementation.
  Stated by London Borough of Tower HamletsStated planned
2. Action
  Deliver targeted Critical/Cumulative Analysis training to staff.
  Stated by London Borough of Tower HamletsStated planned
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
Failure to reconcile assessments with referral and historical information
Wider context from the report
“(3) that, given that a conclusion was made that there would be no social care provided, the assessment was made (and signed off by a senior colleague) without any reference to the rather different reports from the referrer and in the deceased’s historical record. There is an incongruence between the claimed observations of the First Response Officer and the information that led to the assessment that was not explored ”
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
Disseminate the internal management review, action plan and lessons learned to managers and relevant frontline staff for discussion and implementation.

Verbatim wording from the response
“Immediate Practice Improvements | Disseminate internal management review and action plan to management team:”

Source location
2014-0449-Response-by-Tower-Hamlets-Local-Authority
Page 3 · 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
Deliver targeted Critical/Cumulative Analysis training to staff.

Verbatim wording from the response
“A programme of targeted Critical/Cumulative Analysis training with staff members has been scheduled for December 2014.”

Source location
2014-0449-Response-by-Tower-Hamlets-Local-Authority
Page 5 · response
Published 7 July 2014
Open published response
17 Jan2014
Cornwall
Concerns raised1
1. Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing
This report raised 3 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.
AI-generated summary

JULIA SHEEREN DELL · 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

Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

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 reconcile reassurance about mood stabilisation with recent concerns about wellbeing
Wider context from the report
“I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”
Source location
JULIA SHEEREN DELL · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to identify and assess conflicting evidence about alcohol provision

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to reconcile and challenge contradictory suicide-risk information

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.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion

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.6

Concerns raised1

Failure to reconcile assessments with referral and historical information

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.2

Concerns raised1

Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing

Respondent positions 2

Actions described in response 1

Respondent positions 1

Actions described in response 6

Actions described in response 2