Recurring concern

Failure to recognise and act on deterioration in vulnerable adults’ living circumstances and support needs

First to latest report 30 Jan 2013 — 28 May 2021

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
4

What this concern includes

Includes failures in care, housing-support or community-support arrangements to recognise and act on material deterioration in a vulnerable adult’s living conditions, health, safety risks or ability to live independently, including cuckooing or escalating drug use, increased support needs, appropriate healthcare referral and reconsideration of the suitability of the living arrangement.

What is not included
  • Excludes isolated acute clinical-deterioration failures where no vulnerable-adult living-circumstances, support-needs or independent-living context is identified.
  • Excludes generic medical recognition, escalation or referral failures that are not connected to deterioration in a vulnerable adult’s living situation or support arrangement.
  • Excludes ordinary housing maintenance, environmental hazards or criminal exploitation concerns where no failure to recognise and respond to the person’s changing support or living-safety needs is asserted.
  • Excludes failures occurring after deterioration has been recognised and an appropriate response has been initiated, unless the reported unsafe condition is the failure to maintain a safe living arrangement or support response.

Reports and published responses 3 reports

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

  1. Brighton and Hove

    AI-generated summary

    KEVIN JOHN FITTON · 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

    Kevin Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.

    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 respond to deterioration in living conditions, physical health and drug use

    Wider context from the report

    “(7) There was a failure to react to the deterioration in Mr Fitton’s living conditions, his being cuckooed, the downward slide in his physical health and the increase in his drug use. ”

    Source location

    KEVIN JOHN FITTON · 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

    Continue attending the police-led multi-agency cuckooing meeting, promote directorate awareness and seek wider learning.

    Verbatim wording from the response

    “• We will continue to attend the police led multi agency cuckooing meeting and encourage increased awareness of this within our directorate and we will seek opportunities for wider learning from this meeting.”

    Source location

    2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
    Page 5 · response
    Published 27 May 2021

    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 internal casework risk-management protocols to strengthen organisational oversight.

    Verbatim wording from the response

    “• We will review our internal risk management protocols for casework to strengthen our organisational oversight.”

    Source location

    2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
    Page 5 · response
    Published 27 May 2021

    Open published response

  2. Norfolk

    AI-generated summary

    MICHAEL TERENCE HARMAN · 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

    Michael Terence Harman lived in sheltered housing and was found unresponsive at home on 28 July 2014 after being contacted daily by intercom but not seen. He was diagnosed with severe dehydration, acute kidney injury and a large pressure sore, and died despite treatment. Concerns included the lack of a follow-up check after he was found soiled, indicators that he may no longer have been suitable for independent living, and inadequate review and handover arrangements.

    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 identify when a tenant is no longer suitable for independent living despite indicators of deterioration and maximum support

    Wider context from the report

    “(2) There were several indicators that Mr Harman’s condition had possibly deteriorated to a point where he was no longer suitable for independent living, such as his flat being unusually untidy, his relapse in respect of drinking alcohol, his having soiled himself, his physical problems (he had recently been diagnosed with cellulitis). He was also receiving the maximum amount of support which could be offered. ”

    Source location

    MICHAEL TERENCE HARMAN · 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

    Draw up and roll out local guidance for reporting incidents, following up service users, making onward referrals, and undertaking scheduled and unscheduled reviews.

    Verbatim wording from the response

    “Draw up and roll out local guidance protocols for: (1) Reporting of accidents, incidents and near misses. (2) Follow up with a service user when an”

    Source location

    2014-0514-Response-by-Centra-Support1
    Page 3 · response
    Published 25 November 2014

    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

    Complete a schedule for auditing understanding and compliance with the new local guidance.

    Verbatim wording from the response

    “accident, incident or near miss has been reported (3) Making onward referrals (4) When to undertake scheduled and unscheduled reviews | | | Audit schedule developed to check understanding and compliance with new local guidance. | Team Manager | End of January | To be completed”

    Source location

    2014-0514-Response-by-Centra-Support1
    Page 4 · response
    Published 25 November 2014

    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

    Personal care delivery and assessment were the responsibility of regulated care providers and Norfolk County Council adult care services.

    Verbatim wording from the response

    “Provision of personal care in the community is regulated by the Care Quality Commission and is employed to support people to remain in their own homes for as long as possible. This provision depends on the person’s needs and preferences and can include several visits a day from care workers. With the exception of people who are able and willing to pay for and organise their own care, the majority of care at home is managed through local authority adult care services. This includes the assessment of individuals requiring care, against the Fair Access to Care Services eligibility criteria before the local authority commissions a ‘package of care’ for that person. The time frame from first contact with the local authority to receiving care is variable but not immediate.”

    Source location

    2014-0514-Response-by-Centra-Support1
    Page 2 · response
    Published 25 November 2014

    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 immediate crisis resulted from alcohol abuse and a recurring pattern, so an ongoing need for home-care referral was not immediately evident.

    Verbatim wording from the response

    “• The report does not appear to fully recognise that Mr Harman found himself in a very difficult situation on the 18th July as a direct result of alcohol abuse and that this had been a previous pattern of behaviour. As such, an ongoing need requiring a referral for care at home may not have been immediately evident.”

    Source location

    2014-0514-Response-by-Centra-Support1
    Page 3 · response
    Published 25 November 2014

    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

    Care at home required Mr Harman’s consent, and the available evidence indicated that he had previously declined such a service.

    Verbatim wording from the response

    “• Section 5 (3): Clarification: Centra’s support service is service user led and therefore the review process requires the tenant to engage with a review. In this situation, an immediate review ‘of’ Mr Harman and his situation would have resulted in a referral to Norfolk First Response for immediate support, along with a referral to Norfolk Adult Care Services to request an assessment for care at home. It is likely that a planned review ‘with’ Mr Harman would have resulted in the same recommendation. It is important to note that being assessed for and receiving care at home would require Mr Harman’s consent. Evidence given at the inquest indicated that Mr Harman had previously declined a care at home service. Again, evidence was given at the inquest indicating that the immediate need was in fact referred to Norfolk First Response by Centra staff.”

    Source location

    2014-0514-Response-by-Centra-Support1
    Page 3 · response
    Published 25 November 2014

    Open published response

  3. Manchester South

    AI-generated summary

    Gareth Mark Slater · 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

    Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

    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 reassess ability to live independently

    Wider context from the report

    “3. There was no further assessment since 2011 of Gareth’s ability to live independently (as opposed to in supported accommodation which had failed). ”

    Source location

    Gareth Mark Slater · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026