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.
Manchester South
Concerns raised1
Failure to adequately assess patients’ mental capacity for care decisions
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
Action
Maintain and expand the Trust’s Mental Capacity Act improvement programme, led by a dedicated Senior Mental Health Nurse.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Establish a multi-agency Mental Capacity Act group with the local authority to review and benchmark policies, procedures, strategy and training.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Action
Review the revised Mental Capacity Act Code of Practice and develop aligned audit processes, audit cycles and training linked to Liberty Protection Safeguards.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Action
Deliver a continuing Trust-wide Mental Capacity Act learning and awareness programme using masterclasses, e-learning, briefings, podcasts, animations and related resources.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Action
Launch the Trust’s Mental Capacity Act awareness campaign and assess staff knowledge and confidence through surveys and scheduled monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Monitor the Mental Capacity Act improvement project through safeguarding, quality and governance committees and revised multi-agency audit arrangements.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Develop and roll out electronic patient-record prompts and alerts to support capacity assessment, vulnerability recognition and safe discharge planning.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Include Betty’s Story and its learning in recurrent multi-professional induction and training, and develop a live-play version for organisational dissemination.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
Stated by Tameside Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Update Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
Stated by Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Action
Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
Stated by Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Action
Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
Stated by Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Norfolk
Concerns raised1
Failure to adequately assess under the Mental Capacity Act
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
Stated by Norfolk and Suffolk NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
For physical health decisions requiring capacity assessment, the physical health expert is the decision maker.
Stated by Norfolk and Suffolk NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Brighton and Hove
Concerns raised1
Lack of 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Explore joint commissioning with health to establish specialist access for capacity assessments involving acquired brain injury.
Stated by Brighton and Hove City CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 May 2021.
Action
Develop standalone training on mental capacity assessments and executive functioning.
Stated by Brighton and Hove City CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 May 2021.
Mid Kent and Medway
Concerns raised2
Failure to reassess fluctuating mental capacity
Failure to establish capacity before decisions about care and treatment
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to recognise lack of decision-making capacity
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.7
Action
Strengthen and ratify the Mental Capacity Act policy to clarify assessment responsibilities, decision makers and Independent Mental Capacity Advocate referrals.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Review and revise Mental Capacity Act training provision to clarify roles and responsibilities for relevant clinical staff.
Stated by Bolton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Provide bespoke Mental Capacity Act training to designated staff cohorts.
Stated by Bolton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Make Mental Capacity Act forms available for completion by all staff designations on the Electronic Patient Record.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
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 9 June 2020.
Action
Share inquest learning with senior management and leadership teams and put an action plan in place to keep staff current with Best Interest, Capacity and CPA training.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
GMMHFT will provide a further response concerning mental capacity assessment and advocacy arrangements.
Stated by Bolton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester City
Concerns raised1
Failure of clinicians treating physical illness to undertake required capacity assessments
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.
Manchester North
Concerns raised1
Failure to correctly apply Mental Capacity Act capacity requirements to decisions about investigations
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester City
Concerns raised1
Failure to account for impaired cognition and probable lack of mental capacity in care and welfare decisions
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review mental capacity awareness training to clarify complex decision-making.
Stated by Manchester City CouncilStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.
South London
Concerns raised1
Failure to formally review mental capacity to consent to treatment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2019.
Action
Continue auditing MDT template use, capacity assessments, and responses to family concerns.
Stated by Oxleas NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2019.
Action
Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Action
Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Action
Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 19 January 2019.
Action
Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Wiltshire and Swindon
Concerns raised1
Failure to undertake a mental capacity assessment for a serious and complex decision
This report raised 8 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.
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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.
