Recurring concern

Failure to recognise impaired decision-making capacity in care decisions

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First reported 16 Dec 2013•Latest report 10 Mar 2026

Definition

What this concern includes

Includes failures to recognise, assess or account for impaired cognition or probable lack of decision-making capacity in decisions about a person’s care and welfare, including when capacity is wrongly inferred from acquiescence.

Not included

Excludes failures concerning other patient characteristics or risks unless they directly concern recognition or assessment of decision-making capacity.
Excludes failures in best-interest decision-making that omit carers’ or social services’ views when no capacity-recognition failure is identified.
Excludes generic documentation, communication or care-planning deficiencies that are not specifically tied to impaired decision-making capacity.

Reports: 37
Individual concerns: 39
Date range: 2013–2026
Stated actions: 101

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.

Department of Health and Social Care6

Greater Manchester Mental Health NHS Foundation Trust4

Care Quality Commission3

Manchester University NHS Foundation Trust3

London Borough of Redbridge2

Ministry of Justice2

NHS England2

Norfolk and Suffolk NHS Foundation Trust2

North East London NHS Foundation Trust2

Pennine Care NHS Foundation Trust2

Abbey Court Independent Hospital1

A & B Healthcare Limited1

Achieve Together Limited1

Advocacy Together Hub Rochdale1

Bolton Borough Council1

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.

10 Mar2026
Worcestershire
Concerns raised1
1. Failure to recognise when mental capacity assessment is required after food refusal begins
This report raised 7 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 5
1. Position
  Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.
  Stated by HM Prison and Probation ServiceRedirects responsibility
1. Position
  PPG, not MPFT, holds responsibility for physical healthcare, food refusal policy implementation, and initial capacity assessment.
  Stated by Midlands Partnership University NHS Foundation TrustRedirects responsibility
2. Position
  There was no clinical reason to believe the patient lacked capacity to refuse food, fluids or other offered care.
  Stated by Practice Plus GroupDisputes the concern
3. Position
  A formal capacity assessment would not necessarily have changed the care provided, according to the clinical reviewer.
  Stated by Practice Plus GroupDisputes the concern
4. Position
  The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.
  Stated by Practice Plus GroupExisting arrangements considered sufficient
AI-generated summary

Surendrakumar Patel · 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

Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.

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 recognise when mental capacity assessment is required after food refusal begins
Wider context from the report
“1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy: a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began b. Failure to consider hospital transfer for prisoners severely weakened by weight loss c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival d. Failure to consider and advocate for family contact 2. Prison staff lacked awareness of HMP Hewell food refusal policy, including: • Not informing Next of Kin of the prisoner’s decision to refuse food/fluids • Not asking the prisoner whether such information should be shared ”
Source location
Surendrakumar Patel · 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
Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.

Verbatim wording from the response
“Following evidence heard at the inquest you raised concerns directed to both HMPPS and Practice Plus Group (PPG). I understand PPG will respond to those issues relating to the delivery of healthcare at HMP Hewell, for which they are responsible. I am therefore responding to the issue relating to HMPPS.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 12 March 2026
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
PPG, not MPFT, holds responsibility for physical healthcare, food refusal policy implementation, and initial capacity assessment.

Verbatim wording from the response
“MPFT provides integrated mental health and psychosocial substance use services within HMP Hewell. Primary responsibility for physical healthcare, including nutritional monitoring, implementation of food refusal policies, and initial assessment of capacity in the context of food refusal, sits with the primary healthcare provider, Practice Plus Group (PPG).”

Source location
Response from Midlands Partnership NHS Foundation Trust
Page 1 · response
Published 12 March 2026
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
There was no clinical reason to believe the patient lacked capacity to refuse food, fluids or other offered care.

Verbatim wording from the response
“Practice Plus Group welcomes the opportunity to respond to the concerns raised by HM Assistant Coroner. The circumstances of this case were complex. Mr Patel arrived in prison in a malnourished state which the Inquest heard had been an ongoing chronic issue for him dating back at least one year. Further, and whilst Mr Patel was remanded at HMP Hewell, at no time was he found to lack capacity to refuse food and fluids and /or proposed medical assessments. This meant that, when assessments and food and fluid was offered and declined, the healthcare staff were required, pursuant to the Mental Capacity Act 2009, to respect the wishes of Mr Patel. This was reflected in the conclusion reached by the Jury that Surendra Patel died from natural causes contributed to by self-neglect by malnutrition.”

Source location
Response from Practice Plus Group
Page 1 · response
Published 12 March 2026
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
A formal capacity assessment would not necessarily have changed the care provided, according to the clinical reviewer.

Verbatim wording from the response
“It is of note that the clinical reviewer commented when giving evidence at the Inquest that she did consider the referral had been made as soon as was practically possible and, in any event, even if a formal Mental Capacity Act assessment had taken place, she was not convinced it would have made any difference to the care provided.”

Source location
Response from Practice Plus Group
Page 2 · response
Published 12 March 2026
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 food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.

Verbatim wording from the response
“This does not mean that Practice Plus Group has not reflected on this case. The outcome of the Inquest follows a period whereupon the food and fluid refusal pathway has robustly been tested and, as a result, Practice Plus Group considers it to be robust and fit for purpose regardless of the”

Source location
Response from Practice Plus Group
Page 3 · response
Published 12 March 2026
Open published response
4 Aug2025
Surrey
Concerns raised2
1. Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions
2. Inadequate paramedic training for mental capacity assessments
This report raised 11 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 14
1. Action
  Continue collaborative work with SECAMB and system partners to support timely and safe joint decision making, including regular operational meetings.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
2. Action
  Launch an investigation into ambulance responses to mental health crisis calls via NHS 111 and 999, covering triage, training, capacity assessment, and conveyance decisions.
  Stated by Health Services Safety Investigations BodyStated planned
3. Action
  Implement improved electronic documentation requirements for capacity assessments, including refusals of care, clinical justification and oversight.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
1. Action
  Issue practice guidance for assessing capacity and escalating concerns involving suicidal patients.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
2. Action
  Provide a half-day suicidality and mental health training session within the 2026/27 annual clinical update programme.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated planned
3. Action
  Deliver revised scenario-based mental health learning for new operational staff and clinicians, covering pathways, collaboration, law, capacity and complex presentations.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progress
4. Action
  Review and redraft the mental capacity policy, adding guidance on unsafe decisions and escalation for remote clinical advice, then issue the revised policy by Q4 2025/26.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progress
5. Action
  Cascade the new mental capacity protocol across all clinical teams through the Trust’s governance routes.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated planned
6. Action
  Develop a framework for staff decision-making and documentation when suicidal patients decline conveyance, targeted for delivery by March 2026.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated planned
7. Action
  Review emergency mental health care pathways across Surrey, Sussex and Kent to establish a partnership framework for ambulance responses to suicidality.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
8. Action
  Work with partners to expand access to shared care records through the electronic Patient Care Record system.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progress
9. Action
  Consider changes to the paramedic Standards of Proficiency during the next scheduled review in 2027–2028.
  Stated by Health and Care Professions CouncilStated planned
10. Action
  Review the Standards of Education and Training governing preparation of learners for professional practice.
  Stated by Health and Care Professions CouncilStated in progress
11. Action
  Launch a public consultation on proposed changes to the Standards of Education and Training.
  Stated by Health and Care Professions CouncilStated planned
Respondent positions 6
1. Position
  The Healthcare Professionals Line is considered sufficient for safe, situation-specific multi-agency decisions instead of relying on previously prepared joint plans.
  Stated by Surrey and Borders Partnership NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  Clinical matters fall outside the commissioning organisation’s remit.
  Stated by NHS Southwest London Integrated Care BoardOutside remit
2. Position
  Clinical matters are the responsibility of the relevant Trusts.
  Stated by NHS Southwest London Integrated Care BoardRedirects responsibility
3. Position
  The Surrey Safeguarding Board will lead the Safeguarding Adults Review, with the organisation participating.
  Stated by NHS Southwest London Integrated Care BoardRedirects responsibility
4. Position
  Setting curricula and designing training courses are outside the respondent’s role.
  Stated by Health and Care Professions CouncilOutside remit
5. Position
  Other bodies are responsible for setting paramedic curricula and designing training courses.
  Stated by Health and Care Professions CouncilRedirects responsibility
AI-generated summary

Tracey Ostler · 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

Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.

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 undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report
“Training for Paramedics to undertake Capacity Assessments. Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service 3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her. 4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately. 5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed. 6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments. ”
Source location
Tracey Ostler · Prevention of Future Deaths report
Page 5 · 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
Inadequate paramedic training for mental capacity assessments
Wider context from the report
“Training for Paramedics to undertake Capacity Assessments. Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service 3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her. 4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately. 5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed. 6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments. ”
Source location
Tracey Ostler · Prevention of Future Deaths report
Page 5 · 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
Continue collaborative work with SECAMB and system partners to support timely and safe joint decision making, including regular operational meetings.

Verbatim wording from the response
“We are aware that South East Coast Ambulance Service (SECAMB) has recently approved a written protocol relating to mental capacity and suicidality which provides that the HCPL should be consulted when safety planning for patients in Surrey. The Trust has seen an overall increase in the number of calls from ambulance staff in recent months, from 52 calls in April 2025 to 105 in August 2025. A weekly operational meeting is held between the two trusts to discuss processes and resolve any issues that may arise.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 13 August 2025
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
Launch an investigation into ambulance responses to mental health crisis calls via NHS 111 and 999, covering triage, training, capacity assessment, and conveyance decisions.

Verbatim wording from the response
“Mental Health Crisis: Ambulance service response via NHS 111 and 999”

Source location
Response from Health Service Safety Investigations Body
Page 3 · response
Published 13 August 2025
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
Implement improved electronic documentation requirements for capacity assessments, including refusals of care, clinical justification and oversight.

Verbatim wording from the response
“In Surrey, SECAmb manages approximately 230 mental health incidents a week. Responding to mental health incidents is a core component of SECAmb’s operations. Developing an improved framework for staff decision making around managing suicidal patients declining conveyance has formed part of our 2024/2025 Quality Accounts. This work has seen improvements made to our patient records system, the development of new guidance for our staff, a commitment to additional training and improvements in patient care across the SECAmb region.”

Source location
Response from NHS South East Coast Ambulance Service
Page 1 · response
Published 13 August 2025
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
Issue practice guidance for assessing capacity and escalating concerns involving suicidal patients.

Verbatim wording from the response
“As an interim measure whilst the policy review is completed, new practice guidance ratified in August 2025 at SECAmb’s Professional Practice Group has been issued to all staff (appendix 1). This explicitly guides ambulance clinicians on how to approach mental capacity act assessments for suicidal patients, including the appropriate escalation pathways. The guidance has been designed to align with national expectations, best practice and the legal framework set out in the Mental Capacity Act (2005). The guidance is available to all our clinicians via the Trust’s intranet and clinical guidance application which can be accessed via clinicians’ mobile devices.”

Source location
Response from NHS South East Coast Ambulance Service
Page 4 · response
Published 13 August 2025
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 a half-day suicidality and mental health training session within the 2026/27 annual clinical update programme.

Verbatim wording from the response
“We have reviewed all our learning packages related to mental health, including internal education for newly qualified paramedics. Following this review, we will be providing a half day training session on mental health as part of our annual clinical”

Source location
Response from NHS South East Coast Ambulance Service
Page 2 · response
Published 13 August 2025
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 revised scenario-based mental health learning for new operational staff and clinicians, covering pathways, collaboration, law, capacity and complex presentations.

Verbatim wording from the response
“We have started delivering revised and improved scenario-based learning packages as part of our ‘Clinical Conversion Course’, which is for all new operational staff joining the trust, as well as our Key Skills programme for clinicians working in the Emergency Operations Centre and 111 service. The revised and improved learning packages were developed by a multi-disciplinary team of experienced mental health professionals and specifically focus on:”

Source location
Response from NHS South East Coast Ambulance Service
Page 3 · response
Published 13 August 2025
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 and redraft the mental capacity policy, adding guidance on unsafe decisions and escalation for remote clinical advice, then issue the revised policy by Q4 2025/26.

Verbatim wording from the response
“We are currently reviewing and redrafting our policy on mental capacity to ensure an effective and consistent approach across Surrey, Sussex and Kent. This review is scheduled to be completed with a revised policy issued by Q4 of 2025/26. The current policy doesn’t directly provide guidance on unsafe decision making that could result in significant harm or death, however this will be included in the revised”

Source location
Response from NHS South East Coast Ambulance Service
Page 3 · response
Published 13 August 2025
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
Cascade the new mental capacity protocol across all clinical teams through the Trust’s governance routes.

Verbatim wording from the response
“SECAmb’s 2024/25 Quality Account reports on progress of patient safety and effectiveness of patient care. The Quality Account also outlines the Trust’s priorities for improvement for 2025/26. One of these priorities is to develop a framework for staff decision making and documentation in managing suicidal patients who decline conveyance and is expected to be delivered by March 2026. In the meantime, the new MCA protocol outlined in Section 2 above will be cascaded across all clinical teams via the Trust’s usual governance routes.”

Source location
Response from NHS South East Coast Ambulance Service
Page 4 · response
Published 13 August 2025
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
Develop a framework for staff decision-making and documentation when suicidal patients decline conveyance, targeted for delivery by March 2026.

Verbatim wording from the response
“SECAmb’s 2024/25 Quality Account reports on progress of patient safety and effectiveness of patient care. The Quality Account also outlines the Trust’s priorities for improvement for 2025/26. One of these priorities is to develop a framework for staff decision making and documentation in managing suicidal patients who decline conveyance and is expected to be delivered by March 2026. In the meantime, the new MCA protocol outlined in Section 2 above will be cascaded across all clinical teams via the Trust’s usual governance routes.”

Source location
Response from NHS South East Coast Ambulance Service
Page 4 · response
Published 13 August 2025
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 emergency mental health care pathways across Surrey, Sussex and Kent to establish a partnership framework for ambulance responses to suicidality.

Verbatim wording from the response
“• To work with partners in Surrey, Kent and Sussex to further inform and develop shared decision-making pathway”

Source location
Response from NHS South East Coast Ambulance Service
Page 4 · response
Published 13 August 2025
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
Work with partners to expand access to shared care records through the electronic Patient Care Record system.

Verbatim wording from the response
“In addition to the pathway outlined above, the Trust is working closely with key partners to expand access to existing and new shared care records system platforms via our electronic Patient Care Record (ePCR) system. The expected functionality includes GP records, hospital data, community and mental health notes, with the potential for including care coordination notes, vaccination history and long-term condition (LTC) management. This will support frontline clinicians to make more informed decisions, including complex mental capacity assessments, and improve patient outcomes. Currently, only clinicians based in the Emergency Operations Centre (EOC) and Clinical Hubs have access to the Summary Care Records (SCR) and two other regional local Shared Care Records (SCRs): Kent and Medway Care Record (KMCR), Thames Valley and Surrey Care Record (TVS).”

Source location
Response from NHS South East Coast Ambulance Service
Page 5 · response
Published 13 August 2025
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 changes to the paramedic Standards of Proficiency during the next scheduled review in 2027–2028.

Verbatim wording from the response
“The current versions of our SOPs became effective for our registrants and for new cohorts on education and training programmes from September 2023. We will further”

Source location
Response from Health & Care Professions Council
Page 2 · response
Published 13 August 2025
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 the Standards of Education and Training governing preparation of learners for professional practice.

Verbatim wording from the response
“We are currently reviewing our Standards of Education and Training (SETs), which set out how education providers must prepare learners for professional practice. These outcome-focused standards ensure education providers are appropriately organised to deliver high-quality education and training. We plan to launch a public consultation on proposed changes this autumn.”

Source location
Response from Health & Care Professions Council
Page 3 · response
Published 13 August 2025
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
Launch a public consultation on proposed changes to the Standards of Education and Training.

Verbatim wording from the response
“We are currently reviewing our Standards of Education and Training (SETs), which set out how education providers must prepare learners for professional practice. These outcome-focused standards ensure education providers are appropriately organised to deliver high-quality education and training. We plan to launch a public consultation on proposed changes this autumn.”

Source location
Response from Health & Care Professions Council
Page 3 · response
Published 13 August 2025
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 Healthcare Professionals Line is considered sufficient for safe, situation-specific multi-agency decisions instead of relying on previously prepared joint plans.

Verbatim wording from the response
“The use of the Healthcare Professionals Line (HCPL) is crucial in ensuring appropriate and safe multi agency decision making. A joint plan, prepared at an earlier juncture, cannot be relied upon to enable the ambulance service, or other professionals, to make decisions in emergency or crisis situations.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 13 August 2025
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
Clinical matters fall outside the commissioning organisation’s remit.

Verbatim wording from the response
“As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.”

Source location
Response from NHS South West London Integrated Care Board
Page 1 · response
Published 13 August 2025
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
Clinical matters are the responsibility of the relevant Trusts.

Verbatim wording from the response
“As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.”

Source location
Response from NHS South West London Integrated Care Board
Page 1 · response
Published 13 August 2025
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 Surrey Safeguarding Board will lead the Safeguarding Adults Review, with the organisation participating.

Verbatim wording from the response
“I can assure you that we are committed to ensuring the learning and improvements are embedded moving forward. As Ms Ostler was a Surrey resident, rather than a South West London resident, we have engaged with Surrey Heartland ICB and have been made aware that a Safeguarding Adult Review (SAR) will be led by the Surrey Safeguarding Board, which we will fully engage with.”

Source location
Response from NHS South West London Integrated Care Board
Page 1 · response
Published 13 August 2025
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
Setting curricula and designing training courses are outside the respondent’s role.

Verbatim wording from the response
“It is not our role to set curricula or design training courses. That is the role of other bodies.”

Source location
Response from Health & Care Professions Council
Page 2 · response
Published 13 August 2025
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
Other bodies are responsible for setting paramedic curricula and designing training courses.

Verbatim wording from the response
“It is not our role to set curricula or design training courses. That is the role of other bodies.”

Source location
Response from Health & Care Professions Council
Page 2 · response
Published 13 August 2025
Open published response
3 Apr2025
County Durham and Darlington
Concerns raised1
1. Failure of mental capacity assessment guidance to recognise Executive Dysfunction
This report raised 1 other concern. 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

Loraine Michelle CHEESMAN · 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

Loraine Michelle CHEESMAN died in Darlington on 13 May 2023 as a consequence of a fire at the property. Her Hoarding Disorder and Executive Dysfunction made a more than minimal contribution to the fire, and concerns were raised about the lack of specific guidance on incorporating Executive Dysfunction into mental-capacity assessments and determining when external intervention should be triggered.

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 mental capacity assessment guidance to recognise Executive Dysfunction
Wider context from the report
“Department of Health and Social Care (2023), Care and Support Statutory Guidance, Section 14.17 states in relation to Self Neglect and Hoarding Disorder: “‘This covers a wide range of behaviour neglecting to care of one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.” During the course of the evidence I heard from social workers and safeguarding professionals than in relation to assessing whether “the point” had been reached in relation to an adult suffering from Hoarding Disorder and Executive Dysfunction there was no specific guidance and that such guidance would in future be welcome. Currently they are constrained by existing guidance for assessing mental capacity, which does not directly recognise Executive Dysfunction, or for assessing whether the adult’s behaviour constitutes a potentially chargeable criminal or regulatory offence, for example in relation to public nuisance, health hazard, or anti social behaviour, rather than the root cause of the behaviour - a mental disorder or disorders. So, the matter of concern consists of this request - for guidance to be provided as to how to incorporate consideration of Executive Dysfunction into the assessment of mental capacity and how to assess when the point when external intervention can be triggered has been reached. ”
Source location
Loraine Michelle CHEESMAN · Prevention of Future Deaths report
Page 1 · concerns
Open source report
8 Nov2024
Manchester West
Concerns raised1
1. Failure to assess capacity to decide to leave hospital
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.
Actions described in response 2
1. Action
  Implement the NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
2. Action
  Continue work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.
  Stated by Northern Care Alliance NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Anne 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

Anne Taylor sustained a head injury after banging her head on a bedside cabinet and falling from a bed during a holiday. After initially leaving hospital before assessment because of waiting times, she returned the next day and was diagnosed with a traumatic brain injury involving bilateral acute subdural bleeding and midline shift; she deteriorated and died on 31 July 2024. Concerns included the lack of consideration of investigations during the waiting period, the absence of evidence that her capacity to leave was assessed, and uncertainty about a new procedure for patients leaving before clinical assessment.

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 assess capacity to decide to leave hospital
Wider context from the report
“3. No evidence was provided that the deceased’s capacity to decide to leave the hospital was assessed given the history of suspected head injury. ”
Source location
Anne Taylor · 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
Implement the NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.

Verbatim wording from the response
“In addition to the above, as of 25th November 2024, Salford Royal Hospital has become an early adopter of the NHSE Acuity Tool, an initial assessment model which aims to standardize the measurement of acuity in Emergency Departments and Urgent Treatment Centres. Patients who attend the ED at Salford Royal now receive an initial, primary assessment to identify patients with an acuity 1, 2 or 5 which will allow them to either be directed immediately to a receiving location or be directed to an alternative provider such as primary care. Acuity 1 patients are those with immediate life/limb threatening illness/injury, acuity 2 are those with imminent life/limb threatening illness/injury and acuity 5 denotes no threat to life or limb, no ED specific resource necessary. Patients who do not meet an acuity 1, 2 or 5 will then go on to receive a secondary assessment.”

Source location
Response from Northern Care Alliance
Page 2 · response
Published 11 November 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
Continue work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.

Verbatim wording from the response
“The target time for secondary assessment is 15 minutes, Salford Care Organisation are on track to achieve this. Progress of the early adopter programme is being shared with NHSE at regular intervals. Patients receiving a secondary assessment can be identified for early clinical intervention and front loading of essential investigations such as, CT scan. Work is ongoing to meet the NHSE secondary assessment target to provide the significant benefits it offers of reducing the risk of patients with serious conditions sitting in the waiting room for a long time undiagnosed. In addition, the new acuity tool, has a specific question regarding mental capacity assessment relating to a patient’s decision to leave the department.”

Source location
Response from Northern Care Alliance
Page 2 · response
Published 11 November 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
Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.

Verbatim wording from the response
“I note that your Report has also been sent to Salford Royal Hospital Foundation Trust, who are the appropriate organisation to respond to the concerns raised. NHS England has asked to be sighted on the Trust’s response to the Coroner and will review this once received.”

Source location
Response from NHS England
Page 1 · response
Published 11 November 2024
Open published response
4 Nov2024
East Riding and Hull
Concerns raised1
1. Failure to consider reassessment of capacity
This report raised 7 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
  Undertake an unannounced assessment covering visit duration, nutrition and hydration, health monitoring, escalation, record keeping, governance, safeguarding and decision-making.
  Stated by Care Quality CommissionStated planned
Respondent positions 1
1. Position
  Neither inspection identified concerns about recognising or escalating safeguarding issues, and staff showed good understanding of safeguarding processes.
  Stated by Care Quality CommissionDisputes the concern
AI-generated summary

Janet Brown Townend · 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

Janet Brown Townend, who had diabetes and other comorbidities, developed an infected foot wound that progressed to sepsis despite hospital treatment, and she died on 15 October 2023. Concerns arose about the care provided by carers, including brief visits, failure to escalate poor nutrition, sickness and early warning signs, inaccurate records, and failure to follow up or escalate refusals of care and medical intervention.

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 reassessment of capacity
Wider context from the report
“During the course of the evidence a number of concerns arose as to the level of care Ms Townend received from the carers employed by A&B Healthcare. These include: a) Carers at times spent no more than 15 minutes, on one occasion 8 minutes, with Ms Townend. Bearing in times the tasks, document keeping and care to administer and considering Early Warning Signs have there was no attention to detail; Their duties when there included to prepare meals, conduct personal care if required and talk to the service user. 8 to 15 minutes is not an adequate time to conduct these tasks; ; b) Carers did not escalate any concerns when Ms Townend was not eating. As Ms Townend had comorbidities and was at risk of infection nutrition was very important; c) Carers did not escalate any concerns when Ms Townend was unwell with sickness. There were a number of times Ms Townend presented with having been sick and this was not considered as a concern; d) Carers did not accurately record concerns regarding Early Warning Signs (EWS) or escalate when they were present. The EWS were always recorded as no concerns. This was not correct as there were occasions where Ms Townend was displaying signs that were Early Warning Signs which should have been escalated; e) Carers did not follow up with Ms Townend when she had indicated she was seeking GP support as she was feeling unwell. This was recorded in the Observation Log that Ms Townend said she would contact her GP however the proceeding carers did not enquire whether this had been done; f) Although Ms Townend was deemed to have capacity carers did not escalate any concerns when Ms Townend was making unwise decisions to refuse personal care, decline food and decline medical intervention. This meant that she was sitting at times in her own faeces and becoming weak and it was not considered whether she needed to be reassessed regarding her capacity. ”
Source location
Janet Brown Townend · 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
Undertake an unannounced assessment covering visit duration, nutrition and hydration, health monitoring, escalation, record keeping, governance, safeguarding and decision-making.

Verbatim wording from the response
“Both inspections of Bridlington found no concerns regarding the deployment of staff and the published reports include positive feedback from people about the support they received. In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing the duration of staff visits. We intend to undertake an unannounced assessment of the service which will include staff having adequate time to meet people’s needs. CQC only neglects the carrying out of personal care, however, adequate”

Source location
Response from CQC
Page 2 · response
Published 5 November 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
Neither inspection identified concerns about recognising or escalating safeguarding issues, and staff showed good understanding of safeguarding processes.

Verbatim wording from the response
“Neither inspection of Bridlington identified concerns regarding staffs ability to recognise and escalate safeguarding concerns. The inspection of Bridlington in January 2020 found staff had a good understanding of safeguarding processes (Appendix 1). In response to the concerns raised by the coroner concerning the death of Janet Brown, the CQC has received an action plan from the provider addressing staff understanding of the mental capacity act. We intend to undertake an unannounced assessment of the service which will include safeguarding and decision making. We have also requested immediate assurances from the provider regarding their safeguarding processes.”

Source location
Response from CQC
Page 4 · response
Published 5 November 2024
Open published response
30 Oct2024
Birmingham and Solihull
Concerns raised1
1. Failure to account for current and fluctuating capacity when closing incident logs
This report raised 2 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 4
1. Action
  Require officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.
  Stated by West Midlands PoliceStated planned
2. Action
  Continue Re-THRIVE quality assurance and communications requiring rationalised decision-making in THRIVE records, with particular focus on dispatch.
  Stated by West Midlands PoliceStated in progress
3. Action
  Refresh force-wide communications instructing staff to use only the latest medical capacity assessment in decision making.
  Stated by West Midlands PoliceStated planned
1. Action
  Reinforce through training that staff must re-THRIVE and record a full rationale when recommending non-police attendance.
  Stated by West Midlands PoliceStated planned
AI-generated summary

Sebastian Benjamin OLIVER · 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

Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.

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 account for current and fluctuating capacity when closing incident logs
Wider context from the report
“3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call). 4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check". 5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed. 6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres. It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue. 7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity. ”
Source location
Sebastian Benjamin OLIVER · 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
Require officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.

Verbatim wording from the response
“(iii) Collaboration with partners: Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded utilising WMP systems and fed back to WMP supervisors and shared with the reporting partner agency. Whilst WMP can professionally challenge partners it is more appropriate to follow the process in the best interest of the public and inaccuracies be fed back within working groups such as Joint Strategic Operation Groups (JSOG) to aid future learning.”

Source location
Response from West Midlands Police
Page 5 · response
Published 1 November 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
Continue Re-THRIVE quality assurance and communications requiring rationalised decision-making in THRIVE records, with particular focus on dispatch.

Verbatim wording from the response
“In the event of a question about resourcing a log could be escalated to supervision to allocate resource and dispatch. This happened in Mr Oliver’s case following the second call from WMAS requesting a “safe and well”. A decision was then made by a supervisor not to attend. After the supervisory review it was transferred out of dispatch into the ‘FCRTF’ which is a queue for cases to be reviewed and closed. WMAS were advised WMP would not attend. The decision to close a log would be an individual decision also applying the ‘THRIVE’/RE-THRIVE risk assessment principles and a consideration of any change in circumstances which may affect a risk profile. Where a grading is changed or reviewed, in this case the supervisor, should completed a ‘Re-THRIVE’. They should detail their rational for a change in the THRIVE assessment on the log and, preferably, also in a new THRIVE form.”

Source location
Response from West Midlands Police
Page 2 · response
Published 1 November 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
Refresh force-wide communications instructing staff to use only the latest medical capacity assessment in decision making.

Verbatim wording from the response
“(vi) To refresh communications across WMP: via corporate communications, relating to medical assessment capacity on logs to use only the latest assessment in decision making.”

Source location
Response from West Midlands Police
Page 5 · response
Published 1 November 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
Reinforce through training that staff must re-THRIVE and record a full rationale when recommending non-police attendance.

Verbatim wording from the response
“(viii) Training to reinforce to staff to re-THRIVE: and a complete a full rationale if recommending non-Police attendance.”

Source location
Response from West Midlands Police
Page 5 · response
Published 1 November 2024
Open published response
23 Jul2024
County Durham and Darlington
Concerns raised1
1. Failure to carry out capacity assessments and subsequent best interests decision making
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
  Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
  Stated by County Durham and Darlington NHS Foundation TrustStated completed
AI-generated summary

Janet Rice · 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

Janet Rice, aged 65, died in hospital from pulmonary and cerebral embolism after surgery for a hip fracture sustained in an accidental fall. Anti-coagulant medication was inconsistently administered, including during a period when she was experiencing acute delirium; concerns included the absence of a capacity assessment, best-interests decision, escalation, or consideration of alternative treatment. The report also raised concerns about delays and limitations in the Trust’s patient safety investigation and the limited scope of related training.

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 carry out capacity assessments and subsequent best interests decision making
Wider context from the report
“(2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE. ”
Source location
Janet Rice · 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 update the patient safety investigation report and action plan to cover the patient’s acute and community care.

Verbatim wording from the response
“The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti-coagulant and does not consider or address the omission to administer anti-coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti-coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti-coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE.”

Source location
Response from Durham and Darlington NHS
Page 2 · response
Published 1 August 2024
Open published response
26 Mar2024
East London
Concerns raised1
1. Lack of formal capacity assessment for nursing-home residents
This report raised 2 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 3
1. Action
  Use qualified BIA and S12 doctor assessments with IMCA involvement where DoLS procedures identify a lack of capacity.
  Stated by The Local AuthorityStated completed
2. Action
  Formally document capacity assessments in future similar cases.
  Stated by The Evergreen Surgery, WansteadStated planned
3. Action
  Deliver an educational session for the clinical team on capacity assessments, including complex assessments.
  Stated by The Evergreen Surgery, WansteadStated planned
Respondent positions 2
1. Position
  A formal capacity assessment was completed, and an IMCA acted as his voice in best-interests decisions about accommodation, care and treatment.
  Stated by The Local AuthorityDisputes the concern
1. Position
  Existing clinical and nursing-staff capacity assessments indicated capacity and no need for a further formal assessment.
  Stated by The Evergreen Surgery, WansteadExisting arrangements considered sufficient
AI-generated summary

Mark Wolfe Kinzley · 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

Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.

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
Lack of formal capacity assessment for nursing-home residents
Wider context from the report
“2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests. ”
Source location
Mark Wolfe Kinzley · 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
Use qualified BIA and S12 doctor assessments with IMCA involvement where DoLS procedures identify a lack of capacity.

Verbatim wording from the response
“Mr Kinzley was formally assessed by both duly qualified and authorised BIA and S12 doctor (05/07/2023) following an application by the Care Home for a DoLS authorisation given the level of restrictions placed upon him with his care and treatment in the accommodation. Both agreed he lacked capacity regarding matters relating to his accommodation, care and treatment at the care home. A recommendation was made for the maximum permissible duration of an authorisation of 12 months.”

Source location
Response from NELFT and Redbridge Council
Page 2 · response
Published 3 April 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
Formally document capacity assessments in future similar cases.

Verbatim wording from the response
“We have also agreed that in any similar cases in future, we would formally document the capacity assessment. At our next practice Governance meeting (23 July 2024), we are providing an educational session to the whole clinical team on capacity assessments, with a particular focus on more complex capacity assessments.”

Source location
Response from Evergreen Surgery
Page 3 · response
Published 3 April 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
Deliver an educational session for the clinical team on capacity assessments, including complex assessments.

Verbatim wording from the response
“We have also agreed that in any similar cases in future, we would formally document the capacity assessment. At our next practice Governance meeting (23 July 2024), we are providing an educational session to the whole clinical team on capacity assessments, with a particular focus on more complex capacity assessments.”

Source location
Response from Evergreen Surgery
Page 3 · response
Published 3 April 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
A formal capacity assessment was completed, and an IMCA acted as his voice in best-interests decisions about accommodation, care and treatment.

Verbatim wording from the response
“Mr Kinzley was formally assessed by both duly qualified and authorised BIA and S12 doctor (05/07/2023) following an application by the Care Home for a DoLS authorisation given the level of restrictions placed upon him with his care and treatment in the accommodation. Both agreed he lacked capacity regarding matters relating to his accommodation, care and treatment at the care home. A recommendation was made for the maximum permissible duration of an authorisation of 12 months.”

Source location
Response from NELFT and Redbridge Council
Page 2 · response
Published 3 April 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
Existing clinical and nursing-staff capacity assessments indicated capacity and no need for a further formal assessment.

Verbatim wording from the response
“Our clinical staff conducted multiple assessments of Mr Kinzley's capacity during his interactions with our Surgery. Capacity assessments are question and time specific. At the time of Mr Kinzley’s assessments by our clinicians, he was deemed to have capacity. There are various decisions that Mr Kinzley made regarding his physical and mental health detailed in the medical record. We detail these below:”

Source location
Response from Evergreen Surgery
Page 2 · response
Published 3 April 2024
Open published response
25 Mar2024
Norfolk
Concerns raised1
1. Lack of understanding of mental capacity assessment
This report raised 7 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 4
1. Action
  Complete induction, competency assessment and supervised competency development for CRHTT assessing staff.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
2. Action
  Deliver bespoke mental capacity training to CRHTT staff.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
3. Action
  Discuss mental capacity case studies during the forthcoming CRHTT training day.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
1. Action
  Implement monthly mental capacity audits locally and Trust-wide, reporting findings through quality and safety governance.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
AI-generated summary

Christopher Edward SIDLE · 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

Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.

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
Lack of understanding of mental capacity assessment
Wider context from the report
“3. There remains a lack of understanding with regard to assessing a person’s mental capacity to make decisions and to fully and properly record the rationale for making decisions. ”
Source location
Christopher Edward SIDLE · 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
Complete induction, competency assessment and supervised competency development for CRHTT assessing staff.

Verbatim wording from the response
“Nevertheless, in response to this incident and as presented at inquest, the Trust has developed a core competency framework for CRHTT assessors which reflects fidelities outlined within the Core CRISIS Fidelity Scale. This was developed by 31.08.23 in response to an action arising from the Safety Incident Review (SIR) that was undertaken by the NSFT Patient Safety Team. Our action was to ensure that new assessing staff complete an induction and all assessors within the team complete core competency.”

Source location
Response from Norfolk and Suffolk NHS Foundation Trust
Page 1 · response
Published 3 April 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
Deliver bespoke mental capacity training to CRHTT staff.

Verbatim wording from the response
“Bespoke training was designed in response to the difficulties identified in Mr Sidle’s care. This was delivered by the Mental Capacity Act Lead (MCA) to the CRHTT involved in his care. This was an interactive session delivered through “Teams” on 01.05.24 & 02.05.24. Staff awareness will be further supported through discussion of case studies as part of table discussion, at the forthcoming CRHTT training day on 21 August 2024.”

Source location
Response from Norfolk and Suffolk NHS Foundation Trust
Page 2 · response
Published 3 April 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
Discuss mental capacity case studies during the forthcoming CRHTT training day.

Verbatim wording from the response
“Bespoke training was designed in response to the difficulties identified in Mr Sidle’s care. This was delivered by the Mental Capacity Act Lead (MCA) to the CRHTT involved in his care. This was an interactive session delivered through “Teams” on 01.05.24 & 02.05.24. Staff awareness will be further supported through discussion of case studies as part of table discussion, at the forthcoming CRHTT training day on 21 August 2024.”

Source location
Response from Norfolk and Suffolk NHS Foundation Trust
Page 2 · response
Published 3 April 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
Implement monthly mental capacity audits locally and Trust-wide, reporting findings through quality and safety governance.

Verbatim wording from the response
“To provide assurance that CRHTT apply their MCA knowledge consistently and appropriately, an audit programme has been developed. A monthly audit will go live in Norfolk CRHTT on 20.05.24. We will use our audit findings and other means (for example feedback from patient safety investigations), to identify ongoing training needs. We will provide bespoke training where this is identified as needed. This bespoke training offer is in addition to the Trust’s existing requirement for all clinical assessors to receive mandatory e learning training in mental capacity every three years.”

Source location
Response from Norfolk and Suffolk NHS Foundation Trust
Page 2 · response
Published 3 April 2024
Open published response
22 Mar2024
East London
Concerns raised1
1. Failure to formally assess mental capacity
This report raised 4 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 5
1. Action
  Use established joint-working forums for practitioners to discuss service-user mental-capacity concerns.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Review the Direct Payment Policy and develop practice guidance and a practitioner checklist covering capacity, best interests, double-handed care, hospital discharge, quality concerns and safeguarding thresholds.
  Stated by London Borough of NewhamStated planned
3. Action
  Share case themes with the borough’s Mental Capacity Act Oversight Group.
  Stated by London Borough of NewhamStated in progress
1. Action
  Review and improve Mental Capacity Act training and refresher provision for all adult social care professional groups.
  Stated by London Borough of NewhamStated planned
2. Action
  Develop specific Mental Capacity Act training for occupational therapy staff through peer learning and a separately planned formal training session.
  Stated by London Borough of NewhamStated planned
Respondent positions 1
1. Position
  LBN, not the Trust, is responsible for assessing capacity concerning social care and support needs.
  Stated by East London NHS Foundation TrustRedirects responsibility
AI-generated summary

Regina Olufunmilola Ademiluyi · 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

Regina Olufunmilola Ademiluyi was an 83-year-old woman who was bed-bound following surgery for a broken hip and died in March 2024 after declining cognition and physical health, malnutrition, a grade 4 sacral pressure ulcer and an aspiration incident. The report raised concerns that state-funded domiciliary care was not provided, and that the NHS Trust and local authority did not adequately assess or respond to safeguarding, mental-capacity and carer-support concerns.

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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 formally assess mental capacity
Wider context from the report
“1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways; a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further. b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report. c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place. d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand. ”
Source location
Regina Olufunmilola Ademiluyi · 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
Use established joint-working forums for practitioners to discuss service-user mental-capacity concerns.

Verbatim wording from the response
“12. I asked the Trust’s Mental Capacity Act Lead to explore issues surrounding Ms Ademiluyi’s capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the ‘MCA’) the Trust is only the decision-maker in relation to decisions pertaining to her health care. The social care provider (LBN) is responsible for assessing capacity in relation to care and support needs.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 25 March 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
Review the Direct Payment Policy and develop practice guidance and a practitioner checklist covering capacity, best interests, double-handed care, hospital discharge, quality concerns and safeguarding thresholds.

Verbatim wording from the response
“In addition to this, the new DP set up process provides additional ‘hand holding’ support for the first 6 weeks to ensure that DP recipients and their representative(s) fully understand how to utilise their DP. | Direct Payments Team | End of May 2024 2.2 Undertake a review of the Council’s Direct Payment Policy, and develop associated practice guidance (including a practitioner checklist). This will encompass:”

Source location
Response from London Borough of Newham
Page 2 · response
Published 25 March 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
Share case themes with the borough’s Mental Capacity Act Oversight Group.

Verbatim wording from the response
“Action: | By who: | By when: 3.1 Improve consistency of MCA practice and decision making in the context of best interest decisions which override family where appropriate (including the use of Independent Mental Capacity Advocacy). This will encompass:”

Source location
Response from London Borough of Newham
Page 3 · response
Published 25 March 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
Review and improve Mental Capacity Act training and refresher provision for all adult social care professional groups.

Verbatim wording from the response
“Action: | By who: | By when: 3.1 Improve consistency of MCA practice and decision making in the context of best interest decisions which override family where appropriate (including the use of Independent Mental Capacity Advocacy). This will encompass:”

Source location
Response from London Borough of Newham
Page 3 · response
Published 25 March 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
Develop specific Mental Capacity Act training for occupational therapy staff through peer learning and a separately planned formal training session.

Verbatim wording from the response
“• Developing specific training interventions for Occupational Therapy staff regarding the application of the Mental Capacity Act in practice – this has been planned as a topic for the borough’s cross-organisational OT Peer Learning session in May 2024. A separate formal training date is being planned. | Principal Occupational Therapist”

Source location
Response from London Borough of Newham
Page 4 · response
Published 25 March 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
LBN, not the Trust, is responsible for assessing capacity concerning social care and support needs.

Verbatim wording from the response
“12. I asked the Trust’s Mental Capacity Act Lead to explore issues surrounding Ms Ademiluyi’s capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the ‘MCA’) the Trust is only the decision-maker in relation to decisions pertaining to her health care. The social care provider (LBN) is responsible for assessing capacity in relation to care and support needs.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 25 March 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to recognise when mental capacity assessment is required after food refusal begins

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised2

Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions

Inadequate paramedic training for mental capacity assessments

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.14

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6

Concerns raised1

Failure of mental capacity assessment guidance to recognise Executive Dysfunction

Concerns raised1

Failure to assess capacity to decide to leave hospital

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

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

Respondent positions 5

Actions described in response 14

Respondent positions 6

Actions described in response 2

Respondent positions 1