Recurring concern

Unreliable handling of safety-related complaints

First to latest report 23 May 2013 — 2 May 2025

Reports that mention this concern
13
Times this concern has been raised
16
Stated actions linked to this concern
33

What this concern includes

Includes deficiencies in complaint-handling processes where complaints or concerns about safety are not reliably accepted, read, recorded, triaged, investigated, progressed, kept under review or responded to, including failures to take statements, investigate next-of-kin concerns, handle service complaints or communicate outcomes.

What is not included
  • Excludes generic incident investigations, disciplinary investigations or post-death investigations unless the asserted deficiency concerns handling a complaint or safety concern raised through a complaint process.
  • Excludes ordinary dissatisfaction or complaints with no identified safety-related handling deficiency.
  • Excludes generic communication, documentation, staffing or training deficiencies unless they directly impair the complaint-handling process.
  • Excludes failure to act on a safety hazard or care concern where no complaint-handling failure is identified.

Reports and published responses 13 reports

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

  1. Shropshire, Telford and Wrekin

    AI-generated summary

    Derrick Edward ROSE-FOWLER · 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

    Derrick Edward ROSE-FOWLER was found hanging by his neck from his prison cell window on 5 June 2015 and was pronounced dead after being transferred to hospital. The concerns included the first attending prison officer not being first-aid trained, the handling of alleged bullying, and the failure to raise concerns about the deceased at a MASH meeting despite several relevant factors.

    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

    Ineffective implementation of the Tackling Bullying Behaviour policy in response to bullying complaints

    Wider context from the report

    “(1) There was evidence that bullying was ‘rife’. Whilst the majority of the evidence at the inquest indicated that the deceased was not himself being bullied there was some evidence that he was. The prison has a Tackling Bullying Behaviour (TBB) policy but there is concern as to how effective it was implemented on the complaints raised by the deceased himself that he was, in terms, being bullied. ”

    Source location

    Derrick Edward ROSE-FOWLER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Andrew James AITKEN · 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 Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.

    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 investigate and respond to complaints

    Wider context from the report

    “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes. I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint. ”

    Source location

    Andrew James AITKEN · 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 second and third concerns are being investigated and addressed separately by East London NHS Foundation Trust.

    Verbatim wording from the response

    “Your second and third concerns are being investigated and addressed separately by the East London NHS Foundation Trust.”

    Source location

    2014-0561-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 15 December 2014

    Open published response

  3. North Wales (East and Central)

    AI-generated summary

    Clive William · 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

    Clive William, a resident at Cae Glas Psychiatric Rehabilitation Care Home, died in bed on 21 October 2013. Concerns were raised about poor standards of care, missed medication and appointments, and a complaints process that could prevent concerns reaching senior management, potentially leaving residents at risk of harm.

    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 of the complaints procedure to escalate concerns to senior management

    Wider context from the report

    “(1) Evidence was given by the family of Mr Clinton that they had complained to the manager of the Care Home on several occasions about the standard of care which was being provided to Mr Clinton, namely that they would often find him drenched in urine and faeces, that his soiled bedding and clothing would be left in his room, that there were occasions when he would not receive his prescribed medication and that he would sometimes medical appointments which had been arranged for him. (2) Evidence was also given by a representative of European Care who own the care home, confirming that although a complaints procedure exists within the organisation, the concerns of the family in this instance had not reached a senior level as should happen so that action could be taken. (3) My concerns relate to the apparent failings of a complaints procedure in which staff can effectively withhold concerns from senior management and the lack of information within the care home that could advise persons with concerns as to how they may direct their complaints to a more senior level of management within the organisation. In the absence of a truly robust system of complaint, it is possible that concerns may not be addressed in a timely fashion or at all and could ultimately place residents at risk of harm. ”

    Source location

    Clive William · Prevention of Future Deaths report
    Page 1 · 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