Recurring concern

Failure to provide clear, accessible routes to care and funding for people with complex health and social needs

First to latest report 11 Jan 2016 — 5 Dec 2025

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
0

What this concern includes

Includes failures in health or social-care arrangements to provide clear, accessible and usable information about available services, responsible agencies, eligibility and funding routes for people with complex or overlapping needs, including effective signposting and support to navigate those routes.

What is not included
  • Excludes failures to provide a care package, placement or service after the person has been given a clear and usable route to access it.
  • Excludes generic funding shortages or refusals where the unsafe condition is not unclear or inaccessible care and funding routes.
  • Excludes generic communication or information-sharing deficiencies without a material care-service or funding-access context.
  • Excludes specialist referral or statutory pathways where a narrower named process provides the more specific supported boundary.

Reports and published responses 2 reports

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

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    John Graham ALSTON · 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 Alston, a 70-year-old man with dementia living in a specialist care home, was punched by another resident on 2 November 2022, suffered an unsurvivable brain bleed, and died in a hospice on 8 November 2022. The concerns relate to confusion over which commissioning body was responsible for the other resident, delays in finding a safer placement, and difficulties sharing discharge information; the report warns that similar delays could contribute to future deaths.

    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

    Delays in accessing increased funding, support, services or suitable placements

    Wider context from the report

    “1. ████████ had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. ████████ remained in hospital for some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred. It was quickly apparent that care home two could not meet ████████ needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for ████████. There were also difficulties in sharing information for discharge processes because it was unclear which area or from where ████████ had come. This inquest concluded that due to the complexity of ████████ presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements. I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident. I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue causes necessary care or changes when proactive determination of the issue before problems arise ought to be possible. ”

    Source location

    John Graham ALSTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Cornwall

    AI-generated summary

    Colin Keith Williams · 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 Williams was found dead at his home on 9 April 2013, where he had been lying on the kitchen floor in a state of decomposition. He was known to numerous agencies as a vulnerable adult with complex needs, alcohol misuse and a tendency to self-neglect, but his body was not found for some weeks. Evidence at the inquest described difficulties arising from the number of agencies involved, variable mental capacity and complex or unavailable funding arrangements, which hindered his access to support.

    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 services to provide clear, accessible routes to care and funding for people with complex health and social needs

    Wider context from the report

    “Mr Colin Williams was known to numerous agencies and personnel. At inquest evidence was given from Ocean Housing, Adult care, Health and Wellbeing, Taylors of Grampound, the Police, Royal Cornwall Hospital (together with minutes of Complex planning meetings arranged by Cornwall Council on 11.11.12, 13.03.12) the extent of his complex needs and tendency to self-neglect, particularly when under the influence of alcohol. Despite being known to have complex needs his body was not found for some weeks. Those at inquest gave evidence that due to the large number of potential agencies involved in his care, his age (below 65), and the fact he had variable mental capacity due to his chronic alcoholism (no mental health diagnosis) it made it difficult for Mr Williams to know which agency provided what service and whether they were free or not. This led to agency “blindness” preventing him from accessing help/funding particularly at a time of crisis (especially when he lacked capacity due to alcoholism). An example was given by Ocean Housing who had been involved with Mr Williams since 2011. Initially he was provided support through his tenancy which was funded by Cornwall Council supporting people budget. In 2011 the way funding was provided was changed and Mr Williams no longer qualified. An independent living service was set up in lieu which clients had to contribute towards. From this time forward Mr Williams did not engage as he had difficulty in understanding the structure. His funding was made more complicated by hospital admissions/care home placements which meant on occasions he was left without funds due to the necessary paperwork being completed – which he was unable to complete or understand on his own. Those at inquest considered that this was not an uncommon scenario; particular when a client had both health and social issues and this was made even more difficult if they were drug and/or alcohol dependant. ”

    Source location

    Colin Keith Williams · Prevention of Future Deaths report
    Page 1 · 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 maintain continuity of funding when required paperwork cannot be completed or understood independently

    Wider context from the report

    “Mr Colin Williams was known to numerous agencies and personnel. At inquest evidence was given from Ocean Housing, Adult care, Health and Wellbeing, Taylors of Grampound, the Police, Royal Cornwall Hospital (together with minutes of Complex planning meetings arranged by Cornwall Council on 11.11.12, 13.03.12) the extent of his complex needs and tendency to self-neglect, particularly when under the influence of alcohol. Despite being known to have complex needs his body was not found for some weeks. Those at inquest gave evidence that due to the large number of potential agencies involved in his care, his age (below 65), and the fact he had variable mental capacity due to his chronic alcoholism (no mental health diagnosis) it made it difficult for Mr Williams to know which agency provided what service and whether they were free or not. This led to agency “blindness” preventing him from accessing help/funding particularly at a time of crisis (especially when he lacked capacity due to alcoholism). An example was given by Ocean Housing who had been involved with Mr Williams since 2011. Initially he was provided support through his tenancy which was funded by Cornwall Council supporting people budget. In 2011 the way funding was provided was changed and Mr Williams no longer qualified. An independent living service was set up in lieu which clients had to contribute towards. From this time forward Mr Williams did not engage as he had difficulty in understanding the structure. His funding was made more complicated by hospital admissions/care home placements which meant on occasions he was left without funds due to the necessary paperwork being completed – which he was unable to complete or understand on his own. Those at inquest considered that this was not an uncommon scenario; particular when a client had both health and social issues and this was made even more difficult if they were drug and/or alcohol dependant. ”

    Source location

    Colin Keith Williams · 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