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
Distinct published reports
Individual concerns
39
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
101
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.
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
NHS trust26
Ministerial department9
Healthcare site7
English unitary authority4
Integrated care board4
English county council3
English metropolitan district council3
Executive non-departmental public body3
Health and social care service regulator3
London borough council3
Private limited company3
Type not available3
Multi-service care provider2
Police force2
Coronial office1
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.
South Wales Central
Concerns raised1
Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid
This report raised 12 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide basic life support, mental capacity and bespoke prison-nursing training, with the bespoke programme underway from May 2024.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 25 March 2024.
Action
Provide mental capacity assessment training to medical staff and plan annual refresher updates.
Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 March 2024.
Cumbria
Concerns raised1
Failure to account for variable and fluctuating capacity in capacity assessments
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.
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.4
Action
Maintain a recurring Mental Capacity Act forum and reflective practice sessions addressing fluctuating capacity.
Stated by Cumberland CouncilStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Produce and circulate a seven-minute fluctuating-capacity briefing for managers to deliver in team meetings and staff supervision.
Stated by Cumberland CouncilStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
Action
Deliver rolling mandatory Mental Capacity Act training covering carers’ observations, executive capacity, fluctuating capacity and interpersonal influence.
Stated by Cumberland CouncilStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Deliver recurring legal briefings every six weeks addressing fluctuating capacity.
Stated by Cumberland CouncilStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
East London
Concerns raised1
Failure to undertake or consider a formal Mental Capacity Act assessment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide mental-capacity assessment training to all health and social care staff.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 September 2023.
Action
Complete mental-capacity assessments in complex cases.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 September 2023.
Essex
Concerns raised1
Lack of appreciation of autism diagnosis and suicide risk in decision-making capacity
This report raised 12 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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The acknowledged shortcomings were not causation or contributory factors in Molly’s death.
Stated by Essex County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Lack of assessment of patients’ capacity to refuse physical observations
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised1
Failure to apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions
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.
Mid Kent and Medway
Concerns raised1
Lack of formal mental capacity assessments for treatment decisions
This report raised 6 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 December 2021.
Action
Commission and complete an audit of consent and mental capacity practices.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Manchester North
Concerns raised1
Failure to conduct capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks
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.
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.9
Action
Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2022.
Action
Commission Mental Capacity Act training for all clinicians.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Deliver mental-capacity lunch-and-learn sessions in Oldham.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Design a Mental Capacity Act audit.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 October 2022.
Action
Implement PARIS across inpatient mental health wards, including a mental-capacity assessment documentation template.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Share inquest learning about longitudinal mental-capacity assessment with senior Oldham consultant psychiatrists.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Escalate the need for additional longitudinal mental-capacity education to the Safeguarding Team and Mental Health Law and Scrutiny Group.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2022.
Action
Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Yorkshire Eastern
Concerns raised1
Failure to undertake a formalised mental capacity assessment before section rescission decisions
This report raised 13 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review medical staff training provision on mental capacity assessments.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Action
Undertake a Trust-wide audit of mental capacity assessments and best-interest decisions, including possible detention-rescission decisions.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Action
Discuss amending the Responsible Clinician form to prompt documentation of mental capacity assessments when rescinding detention.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Manchester City
Concerns raised1
Failure to complete and properly record formal mental capacity assessments
This report raised 9 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Trigger formal Mental Capacity Assessments and Best Interest Meetings for inpatient concerns about capacity to consent to or refuse physical-health treatment, and disseminate the process.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Action
Deliver face-to-face Mental Capacity Act training to CMHT staff using case studies.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 October 2021.
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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.
