Recurring concern

Unreliable coordinated review of vulnerable residents’ support needs

First to latest report 29 Jul 2022 — 24 Nov 2024

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
7

What this concern includes

Includes failures to convene, complete, record, reconvene or follow up coordinated professional reviews of vulnerable residents’ support, placement, supervision or safety needs, including multi-agency or multidisciplinary review when health, self-neglect, accommodation or need for enhanced support creates a material safety concern.

What is not included
  • Excludes routine meetings or case discussions where no vulnerable resident’s support, placement or safety needs are being reviewed.
  • Excludes failures in direct care, staffing, welfare checks or accommodation security when no deficient coordinated review or follow-up process is identified.
  • Excludes generic multidisciplinary communication or care-coordination failures without a specific vulnerable-resident support or safety-review context.
  • Excludes clinical, safeguarding or care assessments that are completed appropriately when the remaining issue is failure to implement the resulting care or protective action.

Reports and published responses 3 reports

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

  1. East Riding and Hull

    AI-generated summary

    Colin Wiles · 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 Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.

    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 hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect

    Wider context from the report

    “(1) No Vulnerable Adult Risk Management meeting was held despite multifactorial concerns with Mr Wiles’ comorbidities and self neglect leading to poor living conditions and increased risk to his safety ”

    Source location

    Colin Wiles · Prevention of Future Deaths report
    Page 3 · 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

    Review and renew the VARM procedure into a more contemporary, seamless and accessible Multi Agency Risk Management meeting procedure.

    Verbatim wording from the response

    “The current VARM procedure is available to all professionals and people in the east riding on the ERSAB website and guides them through the processes and paperwork involved (included as appendix 1). Training is provided to practitioners across the health and care system in the east riding on the use of VARM both through the ERSAB and the local authorities internal learning and skills team. To enable development in this area, the ERSAB and ASCH have collaborated with Hull City Council’s safeguarding adults board and Adult Services to review and renew the VARM procedure to contemporise the approach and develop a more seamless and accessible procedure in this geographical area.”

    Source location

    Response from East Riding of Yorkshire Council
    Page 1 · response
    Published 2 December 2024

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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

    Relaunch risk-management training after the new Multi Agency Risk Management procedure is finalised.

    Verbatim wording from the response

    “The VARM training is therefore currently under review and will be relaunched following the completion of this work to ensure and enable effective roll out of the new procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be considered by the service at our practice development board which is chaired by our Head of Service for Safeguarding and Quality Assurance.”

    Source location

    Response from East Riding of Yorkshire Council
    Page 1 · response
    Published 2 December 2024

    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

    Consider making Multi Agency Risk Management training mandatory for adult social care and health practitioners through the practice development board.

    Verbatim wording from the response

    “The VARM training is therefore currently under review and will be relaunched following the completion of this work to ensure and enable effective roll out of the new procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be considered by the service at our practice development board which is chaired by our Head of Service for Safeguarding and Quality Assurance.”

    Source location

    Response from East Riding of Yorkshire Council
    Page 1 · response
    Published 2 December 2024

    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

    Local and system concerns fall outside NHS England’s national policy and programme remit.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    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

    Local organisations should address the local and system concerns raised in the report.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    Open published response

  2. Dorset

    AI-generated summary

    Tarik Roger Drakes · 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

    Tarik Roger Drakes, who had a history of using heroin, was found collapsed and unresponsive at his supported accommodation on 12 November 2022. He was taken to hospital, where he was found to be in multi-organ failure, and died on 29 November 2022. Concerns were raised about staffing, welfare checks, monitoring, supervision, safeguarding, emergency access, and follow-up of his support needs at the accommodation.

    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 follow up professional meetings about vulnerable residents’ support needs

    Wider context from the report

    “1. During the inquest evidence was heard that: i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely. ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions. iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please. iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time. v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns. vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment. vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner. viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead. 2. I have concerns with regard to the following: i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement, and the processes and procedures in place around support to the residents. ”

    Source location

    Tarik Roger Drakes · Prevention of Future Deaths report
    Page 3 · 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

    Amend procedures to strengthen escalation when agencies do not attend professionals’ meetings.

    Verbatim wording from the response

    “Through reflecting on Mr Drakes support we feel that there would be benefits in focusing on how we can enhance our work with partners and escalate where agencies do not attend professionals’ meetings. We have already discussed this with Adult Social Care (ASC) and will be making an amendment to our procedures on this. ASC have also offered further support and guidance to agencies on how to escalate issues and develop further understanding of the process on this. We are also rolling out safeguarding training for managers which will reinforce this action.”

    Source location

    Response from BCHA
    Page 4 · response
    Published 22 March 2023

    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

    Provide safeguarding escalation training to service managers and above.

    Verbatim wording from the response

    “Through reflecting on Mr Drakes support we feel that there would be benefits in focusing on how we can enhance our work with partners and escalate where agencies do not attend professionals’ meetings. We have already discussed this with Adult Social Care (ASC) and will be making an amendment to our procedures on this. ASC have also offered further support and guidance to agencies on how to escalate issues and develop further understanding of the process on this. We are also rolling out safeguarding training for managers which will reinforce this action.”

    Source location

    Response from BCHA
    Page 4 · response
    Published 22 March 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

    The service provides housing-related support and does not undertake care planning because it is not a CQC-regulated service.

    Verbatim wording from the response

    “As you are aware from the inquest, the service at Dorset Lodge provides housing with some support. The support that we provide is directly commissioned by Bournemouth, Christchurch and Poole Council (BCP) which consists of temporary housing for people experiencing homelessness. The service is not an exclusive accommodation to support drugs and alcohol addictions, although some customers are experiencing these issues. Customers can find themselves homeless because of many issues and quite often require a range of different supports from various statutory and non-statutory agencies.”

    Source location

    Response from BCHA
    Page 1 · response
    Published 22 March 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

    The professionals meeting was not immediately rearranged because the tenancy risk had been mitigated, with subsequent individual discussions addressing housing and support needs.

    Verbatim wording from the response

    “BCHA did organise a professionals meeting on 9th September for Mr Drakes, the purpose of the meeting was to discuss Mr Drakes maintaining his tenancy. A regular feature of this meeting would have also included his support needs and the relevance of 24/7 placement. BCP Housing, Social Worker and We Are With You (Substance Support) were not able to attend. The meeting for Mr Drakes was not rearranged immediately as the risk around his tenancy had been mitigated and was no longer an issue. Although the meeting did not go ahead there were subsequent conversations on Mr Drakes housing & needs between the professional's group on an individual basis.”

    Source location

    Response from BCHA
    Page 8 · response
    Published 22 March 2023

    Open published response

  3. West London

    AI-generated summary

    Asher William Robert Sinclair · 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

    Asher William Robert Sinclair was a ventilator-dependent child who died in hospital on 8 October 2019 after life support was withdrawn, following a displaced tracheal tube and a prolonged loss of oxygen. The report identified concerns about inadequate staffing, training, planning, oversight, review and escalation within his complex care package, including that he was left in the care of a sole nurse who did not follow the emergency procedure.

    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 escalate and follow up concerns raised about the care package

    Wider context from the report

    “The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all, leaving the situation in the house dangerous with an ultimately calamitous outcome. ”

    Source location

    Asher William Robert Sinclair · 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

    Hold quarterly case-manager meetings with commissioned providers’ clinical leads and the child’s lead professional to identify concerns and monitor whether clinical needs are safely met.

    Verbatim wording from the response

    “The children’s continuing care case managers now meet at quarterly intervals with the clinical leads for the provider commissioned to provide a children’s care package, within this meeting, the appropriate lead professional for the child is also involved, to identify any clinical concerns and monitor the provision of the package of care, as well as identifying and ensuring that the child’s clinical needs are being safely and appropriately met.”

    Source location

    Response from NHS NorthWest London
    Page 2 · response
    Published 4 October 2022

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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

    Develop a parental agreement and provide families with escalation routes and information about raising concerns during assessment and planning.

    Verbatim wording from the response

    “A parental agreement has been developed which sets out expectations and responsibilities in regard to parental responsibility. Where parents feel that they are unable to maintain parental responsibility for the care of their child, parents can escalate their concerns initially via their names case manager, continuing healthcare senior manager or via NHS North West London’s complaints team. During the initial continuing care assessment and planning stage, all families are now informed of this process for raising concerns, in addition to further information provided both in a paper based information leaflet, as well as within NHS North West London’s website.”

    Source location

    Response from NHS NorthWest London
    Page 2 · response
    Published 4 October 2022

    Open published response

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

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Data last updated 7 September 2026