Recurring concern

Failure to maintain effective safeguarding review and monitoring

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First reported 16 Sep 2013•Latest report 1 May 2026

Definition

What this concern includes

Includes failures of ongoing safeguarding review, monitoring, observation, escalation, or visibility of significant safeguarding information when these functions are part of safeguarding arrangements for a person receiving care or protection.

Not included

  • Excludes generic clinical, social-care, or service monitoring failures that are not explicitly tied to safeguarding.
  • Excludes isolated documentation deficiencies that do not affect safeguarding review, monitoring, or detection of risk.
  • Excludes failures in unrelated operational monitoring systems, such as equipment, security, or access-control monitoring.
  • Excludes failures limited to a single care intervention or treatment unless they directly impair safeguarding review or monitoring.
Reports
10

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
8

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.

Care Quality Commission2
Department for Education2
Ministry of Justice2
Berkshire Healthcare NHS Foundation Trust1
Birmingham City Council1
Bristol Prison1
Community Health Care1
Cookham Wood Prison1
Herefordshire and Worcestershire Health and Care NHS Trust1
Hewell Prison1
Hindley Prison1
HM Prison and Probation Service1
Home Office1
Lincolnshire County Council1
London Borough of Tower Hamlets1

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.

  1. Inner South London

    AI-generated summary

    Natasha Hill · 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

    Natasha Hill, who had been in care and was experiencing grooming, exploitation, self-harm, substance misuse and domestic violence, was pronounced dead at her abuser’s home in the early hours of 15 April 2018. The jury concluded that she was unlawfully killed by her abuser. The report raised concerns about safeguarding during the transition to adulthood, protection from exploitation and domestic abuse, and coordination of relevant policing and safeguarding policies.

    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 formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18

    Wider context from the report

    “• Anyone requiring/needing/suffering o Safeguarding o Domestic violence o Controlling/ coercive behaviour And incurring the consequential risks, as a teenager approaching 18 should be formally reviewed by an adult safeguarding team ad the independent reviewing officer. ”

    Source location

    Natasha Hill · 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

    Conduct an urgent review of adult safeguarding powers and duties, including consultation on updated safeguarding guidance and consideration of transition safeguards.

    Verbatim wording from the response

    “• The National Adult Safeguarding Board will be conducting an urgent review of adult safeguarding powers and duties. The first part of that work will be to consult on updating the safeguarding chapter of Care and support statutory guidance (CASSG). As part of this update, we will consider what guidance can be provided to strengthen safeguarding in the context of the transition of young people to adult services. In that process we will take the learning from this PFD report and consider the recommendation that when a teenager with care and support needs approaches 18 they should be reviewed formally by an adult safeguarding team and the independent reviewing officer.”

    Source location

    Response from Department for Education
    Page 2 · response
    Published 14 August 2026

    Open published response

  2. Berkshire

    AI-generated summary

    Lucy Anne Walles · 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

    Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.

    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 safeguarding audit systems to identify and address ongoing issues

    Wider context from the report

    “Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. ”

    Source location

    Lucy Anne Walles · 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

    Work with the Safeguarding Adults Review panel and respond to its recommendations.

    Verbatim wording from the response

    “The resourcing of mental health care remains a challenge. However, patient safety is at the heart of everything that we as a Trust do, and we feel that the initiatives we have implemented, and which are ongoing will optimise the deployment of available resources to ensure we support and safeguard our patients as best we can. We are aware that further learning may arise from the ongoing Safeguarding Adults Review (“SAR”), we are working closely with the panel and will respond to the recommendations.”

    Source location

    Response from Berkshire Healthcare NHS Foundation Trust
    Page 5 · response
    Published 23 June 2023

    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

    Appoint a Senior Safeguarding Lead to strengthen managerial oversight, audit cases and provide expert management of complex Section 42 enquiries.

    Verbatim wording from the response

    “The other improvement in process in the management of safeguarding contacts through the Customer Contact Centre and the Safeguarding Team is that, since the creation of a dedicated senior Safeguarding Lead role for Reading in June this year, there are daily consultations between the Safeguarding Team and the Customer Contact Centre to ensure appropriate referral processes are followed and there is priority flagging of high-risk safeguarding referrals.”

    Source location

    Response from Reading Borough Council
    Page 2 · response
    Published 23 June 2023

    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

    Strengthen safeguarding case auditing and worker supervision to identify and address practice issues.

    Verbatim wording from the response

    “As noted earlier the West of Berkshire Safeguarding Adults Board provides the framework policies and procedures for all safeguarding in Reading and staff must adhere to those and operate to those, with due regard to the requirements for safeguarding set out in the Care Act (2014) and other legislation and guidance. Any issues identified with the procedures and policies are picked through the SAB as described in 5 (above) and any individual skills deficits with individual workers are addressed through managerial oversight and guidance as work is subject to auditing of cases and worker supervision which has been strengthened in Reading in the last 6 months. Themes from audits and the learning from them are shared with staff in “Learning Together” sessions which are led by the Principal Social Worker and Principal Occupational Therapist.”

    Source location

    Response from Reading Borough Council
    Page 5 · response
    Published 23 June 2023

    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

    Introduce a Quality Assurance Framework with a programme of internal and external audits of safeguarding referrals and related learning feedback.

    Verbatim wording from the response

    “In July 2023 Adult Social Care in Reading introduced a Quality Assurance Framework for the service which includes an audit programme which supports auditing of safeguarding referrals, not just at team level but also incorporating wider auditing by managers and some external commissioned audits undertaken by specialists. The individual learning from these audits is fed back to workers and their managers and any themes for learning which emerge, from the subject of workshops with appropriate staff. This Quality Assurance Framework systematises case audit in a more thorough form from previous auditing activity and allows for more rigorous consideration of any gaps in processes, policies or practice skills.”

    Source location

    Response from Reading Borough Council
    Page 6 · response
    Published 23 June 2023

    Open published response

  3. Lincolnshire

    AI-generated summary

    Colin Robert GUMM · 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

    Colin Robert GUMM, a vulnerable adult receiving a care package, was found collapsed by his carers and died at Lincoln County Hospital on 27 November 2021 despite treatment. The concerns include gaps in Adult Social Care monitoring and safeguarding, the identification of apparent underweight and clinical dehydration only shortly before his death, conflicting evidence about alcohol provision, and the reported premature closure of a safeguarding enquiry before toxicology results were received.

    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 safeguarding review and monitoring during periods of ongoing care

    Wider context from the report

    “2. It was not until April 2021, 3 years later and despite care packages being in place and funded by Lincolnshire county Council, that the deceased became known again to Adult Social Care where it was deemed necessary to provide ongoing support of the Wellbeing team and Adult Social Care until his passing in November 2021.This was as a result of a referral from the GP. What happened in those 3 years by way of observations upon the deceased by safeguarding and if none shouldn't there have been something in place? Nothing has been evidenced to date. Shouldn't measures have been in place to review/monitor? ”

    Source location

    Colin Robert GUMM · Prevention of Future Deaths report
    Page 1 · 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 authority was not responsible for monitoring or reviewing care when it had no commissioned care involvement or safeguarding referral.

    Verbatim wording from the response

    “This factual basis is incorrect. There were no packages of care provided or funded by Lincolnshire County Council (‘LCC’) between 2017 and April 2021. Furthermore, there was never any doubt about Mr Gumm's capacity to make his own decisions about his own care and support and in fact he made his own private arrangements. As LCC were not involved in the commissioning of any care for him, LCC would only become involved if a safeguarding concern was raised or if he had changed his mind about wanting support and was eligible for that support. Aside from the referral already referred to in the safeguarding statement, there were no safeguarding referrals which came to the attention of LCC in those 3 years. So, in summary there would not have been, nor should there have been, observations of him by safeguarding nor reviews of his care as this was not the responsibility of LCC.”

    Source location

    Response from Lincolnshire County Council
    Page 2 · response
    Published 3 May 2023

    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 authority had no opportunity to observe privately arranged care unless a safeguarding referral was made.

    Verbatim wording from the response

    “Adult social care was not involved in the provision of Mr Gumm’s care and therefore had no opportunity to be sighted on it unless a referral of a safeguarding nature was made. No such referral was made. Bluebird Care was the agency providing his privately arranged care.”

    Source location

    Response from Lincolnshire County Council
    Page 4 · response
    Published 3 May 2023

    Open published response

  4. Brighton and Hove

    AI-generated summary

    Mr. Thomas REILLY · 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

    Mr Thomas REILLY visited Beachy Head on 1 October 2019 intending to jump, but changed his mind after receiving support. A safeguarding alert was delayed and then sent to an individual mailbox rather than the appropriate generic mailbox; it was actioned after Mr Reilly had been found dead early on 3 October. The report identified a missed opportunity to prevent his suicide and stated that the safeguarding system was fundamentally flawed and needed urgent review.

    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 route safeguarding alerts to the appropriate generic mental health service mailbox

    Wider context from the report

    “When the police officer arrived back at Eastbourne police station he raised a safeguarding alert. This alert was sent to the Multi-Agency Safeguarding Hub (MASH). When received there it should have triggered fast onward transmission to the appropriate agency to support Mr Reilly. It was received at MASH at 15.33hrs on the 1st October but, although it had been sent as soon as possible after the incident, it was clear from the evidence that it stood no chance of being dealt with on the 1st. (2) The alerts are graded low, medium and high risk. The high risk alerts stand a chance of being dealt with timeously. This was graded medium which was a reasonable assessment. Everything else will be delayed. Indeed the alert for Mr Reilly was not dealt with until 12:40 hours on Friday, the 4th of October. That is after lunch on a Friday. (3) This alert was not dealt with again until Monday, the 7th of October when it was sent to the mailbox of a named mental health social worker ████████ rather than to the Sussex Partnership Foundation Trust generic mailbox where it would have been actioned on the 7th. As it was, it was received by ████████ on the morning of the 8th. She actioned it at once. Too late, Mr Reilly had been found dead early on the 3rd of October. ”

    Source location

    Mr. Thomas REILLY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester North

    AI-generated summary

    Ben Walmsley · 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

    Ben Walmsley died by suicide at his home on 4 February 2018, by hanging. Before his death, he searched school computers for suicide-related content, but the school had no mechanism to be alerted to blocked high-risk searches; the report raised concern about whether similar monitoring functionality was mandatory or available across schools and software providers.

    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 automated safeguarding alerts for high-risk pupil searches on school computers

    Wider context from the report

    “It was explained to the Court that the school filters are accessed via Smoothwall which provides age appropriate filtered content. Whilst Ben could not access these pages as they were blocked , there was no mechanism in place at the time for the school to be made aware that a pupil may have attempted to search for such pages. The Court heard evidence that at the time of Ben's death the only monitoring was in lessons and was solely reliant on the teacher trying to watch what students were doing. The school has 900 pupils and the Court heard in any one day there can be 12,000 attempts by pupils to access blocked content. Not all of these would be as concerning as the content Ben was trying to access, some may relate to social media pages which the school does not allow. Evidence was provided to the Court that since Ben’s death, Smoothwall have now upgraded functionality and staff now receive notifications when blocked high risk safeguarding categories are attempting to be accessed. These alerts are “real time” notifications and go to three identified members of staff. Since the installation staff have been notified of two other children attempting to access similar sites to Ben and have taken action to speak to them and also to speak to their parents to offer support. However it is not known if this functionality is mandatory for all schools or indeed whether other software providers who are used by schools have this option. If schools do not have this facility you may wish to consider disseminating this information, this is of course a matter for yourself. ”

    Source location

    Ben Walmsley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Surrey

    AI-generated summary

    Ronald Arthur Farrington · 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

    Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.

    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 produce an adequate s42 report

    Wider context from the report

    “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made. ”

    Source location

    Ronald Arthur Farrington · 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

    Implement a revised quality assurance auditing programme for adult safeguarding work.

    Verbatim wording from the response

    “We have also put in place a revised quality assurance auditing programme of our adult safeguarding work so that we can more readily identify when our adult safeguarding work is falling short of expectations and take action to address this.”

    Source location

    2017-0494-Response
    Page 2 · response
    Published 22 December 2017

    Open published response

  7. Birmingham and Solihull

    AI-generated summary

    Eliza Simpson · 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

    Eliza Simpson left Roseneath Care Home unobserved on 2 April 2015 and was found recently deceased at a local allotment on 6 April 2015. The inquest recorded the medical cause of death as ischaemic heart disease due to coronary artery disease and concluded that the death was accidental. Concerns included the lack of a system to reassess and renew expired deprivation of liberty safeguarding orders and the absence of CCTV, which hampered the police investigation.

    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 and renew deprivation of liberty safeguarding orders when required

    Wider context from the report

    “(1) The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate, seeking further order. In this case the home would have had no legal authority to hold Mrs. Simpson if she had been detected attempting to leave the premises on the 2nd April 2015. The very act of assessing Mrs. Simpson and renewing an application would have served to enforce to the Care Home and its staff the risk of her absconding and may have resulted in closer observation. Although the Roseneath Care Home has now closed if such a system is not standard in Care Homes this issue may arise elsewhere. ”

    Source location

    Eliza Simpson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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 highlight significant events in ongoing safeguarding records

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · 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 ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.

    Verbatim wording from the response

    “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

    Source location

    2014-0555-Response-by-Ministry-of-Justice
    Page 5 · response
    Published 28 December 2014

    Open published response

  9. Manchester West

    AI-generated summary

    Jake Reginald Hardy · 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

    Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.

    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 an effective system to routinely monitor and tackle night-time verbal bullying

    Wider context from the report

    “4. Verbal bullying by means of detainees “shouting out” at night is a common problem in HM YOI Hindley and can increase the risk of self-harm and suicide by those targeted, especially overnight. The fabric, lay-out and design of the cells in HM YOI Hindley does not remedy this problem. Further, it is difficult for the night orderly officer on duty on a wing, who is there alone, to tackle the problem effectively. There is no effective system in place to ensure that the problem is routinely monitored and tackled effectively, whether by means of additional staff or otherwise. This concern may be of relevance to other Young Offender Institutes also. ”

    Source location

    Jake Reginald Hardy · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  10. Worcestershire

    AI-generated summary

    Reggie Johns · 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

    Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.

    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 ensure officers remain engaged throughout the review

    Wider context from the report

    “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status. (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare. This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review. Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed. (3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view. Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel. Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents. ”

    Source location

    Reggie Johns · 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

    Review Prison Service Instruction 64/2011 to identify and address areas of non-compliance at HMP Hewell.

    Verbatim wording from the response

    “I can also confirm that following the inquest into Mr Johns’ death ████████ and ████████ Prison Governor, HMP Hewell have reviewed Prison Service Instruction 64/2011 (updated) – in order to identify any areas of non-compliance and to address these.”

    Source location

    2013-0202-Response-by-Worcestershire-Health-Care-NHS
    Page 2 · response
    Published 16 September 2013

    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 Operational Orders requiring ACCT reviews to be multidisciplinary and obtain views from all appropriate departments.

    Verbatim wording from the response

    “Since Mr Johns' death, the enclosed Operational Orders have been issued entitled ‘Chairing ACCT Reviews’ and ‘ACCT Reviews’ which provide guidance for selecting appropriate ACCT case managers, and confirm that it is the case manager's responsibility to ensure that each review is multi-disciplinary with views from all appropriate departments being taken into consideration.”

    Source location

    2013-0202-Response-by-NOMS
    Page 2 · response
    Published 16 September 2013

    Open published response
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Data last updated 7 September 2026