Recurring concern

Failure to make required contact with approved family and support contacts

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First reported 18 Dec 2017•Latest report 30 Jun 2023

Definition

What this concern includes

Includes failures to initiate, complete or appropriately follow up contact with family members, friends or other support contacts whom the person has approved or consented to involve, where the contact is required for welfare, community support, continuity of care or another safety-relevant purpose.

Not included

  • Excludes generic family communication or involvement failures where no required approved-contact or consent-based contact process is identified.
  • Excludes failures to contact professionals, agencies or emergency services unless the assertion also concerns an approved family or support contact.
  • Excludes failures occurring after contact has been reliably made, including inadequate action on information subsequently provided.
  • Excludes routine social contact and ordinary dissatisfaction where no safety-relevant or support-related contact requirement is identified.
  • Excludes the broader mental-health family-involvement and discharge-planning concerns when contact is not the specific unsafe condition.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2017–2023

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1
Department of Health and Social Care1
Herefordshire Council1
Office of the Chief Coroner1
Oxleas NHS Foundation Trust1
The Priory Hospital Ticehurst House1

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.

  1. Herefordshire

    AI-generated summary

    SAM MALCOLM TAYLOR · 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

    Sam Malcolm Taylor had mental health issues and previous suicide attempts, and was found alone in a tent next to the River Wye. The report raised concerns that a council communication process failure meant no contact was made with him or approved contacts before his death, that a housing vulnerability assessment was not progressed, and that systems for identifying process failures should be effective.

    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 make contact with the deceased or approved contacts

    Wider context from the report

    “(1) A prevention duty was owed to the deceased and due to Herefordshire Council communication process failure, contact was not made with him or those with whom he had approved contact prior to his death. ”

    Source location

    SAM MALCOLM TAYLOR · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Inner South London

    AI-generated summary

    Anne Morris · 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

    Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support 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 contact consented friends and relatives regarding community support

    Wider context from the report

    “(1) I am concerned that the staff at the Priory Hospital did not make contact with friends and relatives after Anne had consented to them being contacted. ”

    Source location

    Anne Morris · 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

    Review and relaunch the discharge policy, strengthening family involvement, care-plan circulation, service identification and written acceptance of follow-up responsibility.

    Verbatim wording from the response

    “Please note that we have reviewed and re-launched Priory Healthcare Policy H02: Admission, Transfer and Discharge and made reference to the involvement of family, friends and carers in the discharge planning process (paragraph 5.1e). A rolling programme of training webinars which detail policy and practice in relation to discharge planning will feature as part of these webinars. Please be assured that the point that you have made in respect of communicating with family and friends prior to discharge will be highlighted as part of these webinars.”

    Source location

    2017-0383-Response-by-Priory-Group
    Page 1 · response
    Published 12 February 2018

    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 a rolling webinar training programme highlighting discharge-planning policy, family communication, care-plan circulation and follow-up service responsibilities.

    Verbatim wording from the response

    “Please note that we have reviewed and re-launched Priory Healthcare Policy H02: Admission, Transfer and Discharge and made reference to the involvement of family, friends and carers in the discharge planning process (paragraph 5.1e). A rolling programme of training webinars which detail policy and practice in relation to discharge planning will feature as part of these webinars. Please be assured that the point that you have made in respect of communicating with family and friends prior to discharge will be highlighted as part of these webinars.”

    Source location

    2017-0383-Response-by-Priory-Group
    Page 1 · response
    Published 12 February 2018

    Open published response
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Data last updated 7 September 2026