Recurring concern

Insufficient health visitor capacity to support vulnerable families and young children

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First reported 18 Nov 2020•Latest report 19 Mar 2025

Definition

What this concern includes

Includes deficiencies in health visitor staffing, permanence, geographic coverage, deployment or service capacity, including perinatal health visitor shortages and reductions in available health visitors, where these limit support to vulnerable families, new parents or young children or impair risk identification and interagency work.

Not included

Excludes generic healthcare staffing shortages not specifically affecting health visitor services.
Excludes deficiencies in perinatal mental-health treatment or specialist perinatal mental-health services where health visitor capacity is not the unsafe condition.
Excludes failures of individual health visitor competence, communication or documentation where insufficient staffing or coverage is not identified.
Excludes social-care, community-nursing or other family-support capacity deficiencies without a material health visitor service connection.

Reports: 3
Individual concerns: 3
Date range: 2020–2025
Stated actions: 1

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 Care2

Betsi Cadwaladr University LHB1

Crown Prosecution Service1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Greater Manchester Police1

Home Office1

Pennine Care NHS Foundation Trust1

Trafford 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.

19 Mar2025
North Wales (East and Central)
Concerns raised1
1. Insufficient permanent perinatal health visitor coverage across all three Health Board areas
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 Health Visiting Services and wider perinatal provision to identify access gaps and make recommendations.
  Stated by Betsi Cadwaladr University LHBStated planned
AI-generated summary

Leanne Marie Carroll · 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

Leanne Marie Carroll, aged 27, died on 29 June 2024 after excessive consumption of prescribed and non-prescribed medications. She had experienced anxiety and deteriorating OCD following the birth of her first child and had been referred to mental health support, but not to the Perinatal Mental Health Service. The report raises concerns about inadequate awareness and staffing of that service and the lack of written records of Single Point of Access discussions and decisions.

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
Insufficient permanent perinatal health visitor coverage across all three Health Board areas
Wider context from the report
“2. There are only 2 temporary perinatal health visitors across the 3 Health Board areas and not one in the Eastern area of the Health Board. By not having permanent perinatal health visitors across all three Health Board areas then those who need to access support will suffer ”
Source location
Leanne Marie Carroll · 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 Health Visiting Services and wider perinatal provision to identify access gaps and make recommendations.

Verbatim wording from the response
“With regard to Perinatal Health Visitors and the equity of access across North Wales, I can confirm that a review of Health Visiting Services at the Health Board that relate to wider perinatal services will be undertaken to determine whether gaps in service are evident. This will include consideration of access to specialist Perinatal Mental Health Services and the Mental Health Perinatal Service Manager will be involved within this process. An action plan will be developed to address any identified areas of need in order to ensure that there is equitable and appropriate access to perinatal services. Consideration will be given to the role and function of the Perinatal Health Visitor posts currently in place in the central and west areas on a temporary basis. This review will be undertaken with recommendations for the Health Board to consider by the end of July 2025.”

Source location
Response from BCUHB
Page 2 · response
Published 26 March 2025
Open published response
1 Dec2020
Manchester South
Concerns raised1
1. Insufficient Health Visitor capacity to support new parents and young children
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Violet Leona Jackman · 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

Violet Leona Jackman was a baby who was found unresponsive on 17 May 2020 in a bed at her home; the Moses basket in which she had been sleeping had tipped over. Concerns included safe-sleeping advice being given only to her mother despite shared care, a lack of detailed checking of sleeping arrangements, and reduced Health Visitor availability during the first wave of Covid-19.

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
Insufficient Health Visitor capacity to support new parents and young children
Wider context from the report
“3. The inquest was told that during the first wave of Covid 19, Health Visitors nationally were redeployed into other services. In the area served by this team that meant a 20% reduction decrease in available Health Visitors and stretched services to support new parents significantly. In Trafford, a decision had since been taken that the situation should not continue even in a second wave, given the stretch this put on Health Visitor services and their ability to support parents and young children. However, it was unclear if nationally a similar approach was being taken, or if Health Visitor services were being reduced to support other front line services. ”
Source location
Violet Leona Jackman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Nov2020
Manchester South
Concerns raised1
1. Insufficient health visitor capacity for safeguarding and interagency work
This report raised 21 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 3
1. Position
  The possible national issue was for central government, specifically the Department for Education, to address.
  Stated by Trafford Borough CouncilRedirects responsibility
1. Position
  Local authorities, not the Department, determine required health visitor numbers according to local needs.
  Stated by Department of Health and Social CareRedirects responsibility
2. Position
  Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
AI-generated summary

Alfie Gildea · 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

Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

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
Insufficient health visitor capacity for safeguarding and interagency work
Wider context from the report
“14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements. As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies. ”
Source location
Alfie Gildea · Prevention of Future Deaths report
Page 3 · 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
The possible national issue was for central government, specifically the Department for Education, to address.

Verbatim wording from the response
“As was confirmed and accepted at the inquest, the Council has made significant improvements to its policies and procedures since 2018. The full details of these changes and improvements were set out in detail in the Council’s evidence to the inquest such that you were able to confirm that you did not have any specific further concerns relating to the Council. In relation to the possible national issue identified in point 15 of your listed concerns, our understanding was that it was your intention to write to central government, specifically the Department for Education.”

Source location
2020-0242-Response-from-Childrens-Services-Trafford-Council-Redacted.pdf
Page 1 · response
Published 24 December 2020
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
Local authorities, not the Department, determine required health visitor numbers according to local needs.

Verbatim wording from the response
“Since 2015, local authorities have been responsible for the commissioning of services for children between the ages of 0-5 and it is for local authorities to determine the required numbers of health visitors based upon local needs. All commissioning should be based on a robust Joint Strategic Needs Assessment and supported by local workforce plans. In this financial year, local authorities will receive a £3.279 billion public health grant for their public health duties for all ages[5].”

Source location
2020-0242-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 24 December 2020
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 named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

Verbatim wording from the response
“I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

Source location
2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
Page 1 · response
Published 24 December 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient permanent perinatal health visitor coverage across all three Health Board areas

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

Concerns raised1

Insufficient Health Visitor capacity to support new parents and young children

Concerns raised1

Insufficient health visitor capacity for safeguarding and interagency work

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 1

Respondent positions 3