Recurring concern

Inadequate assessment of care needs before accepting patients into care

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First reported 3 Feb 2014•Latest report 18 Jun 2025

Definition

What this concern includes

Includes deficiencies in pre-admission or pre-transfer assessment of patient care needs, risks, suitability, or the receiving placement’s ability to provide safe care.

Not included

Excludes assessments occurring after admission or transfer unless they are part of the process for deciding whether to accept the patient.
Excludes generic failures to obtain or communicate information that are not explicitly tied to assessing care needs before acceptance.
Excludes discharge, pre-leave, pre-operative, emergency, and other assessments serving a different operational decision.

Reports: 15
Individual concerns: 17
Date range: 2014–2025
Stated actions: 26

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.

Care Quality Commission2

1st Care 4U Ltd1

Amplius Living1

Avenue House Nursing and Care Home1

Betsi Cadwaladr University LHB1

Black Country Healthcare NHS Foundation Trust1

Bolton Borough Council1

Bury Borough Council1

Cardiff Prison1

Cardiff & Vale University LHB1

Department of Health and Social Care1

Devon Partnership NHS Trust1

Durham County Council1

Greater Manchester Mental Health NHS Foundation Trust1

Highfield Care Home, Wrexham1

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.

4 May2017
Black Country
Concerns raised1
1. Failure to ensure admission decisions reflect senior clinical assessment of patient suitability
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

Mr Reginald Frank Lewis · 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 Reginald Frank Lewis was admitted to hospital after a fall, later fell again while on Ward C19 and sustained a head injury causing an intracerebral bleed; he died on 17 January 2017. Concerns included inadequate communication of his confusion, falls risk and blindness during transfer, his being left unsupervised after family visitors left, and pressure to accept him into a ward already managing several patients requiring continuous observation.

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 admission decisions reflect senior clinical assessment of patient suitability
Wider context from the report
“4. Despite initial reservations, junior nursing staff did eventually accept Mr Lewis into Ward C19 on the basis he had mild confusion and claimed they felt “under some pressure” from senior nursing staff to accept him. This was in contrast to the opinion of the senior Charge Nurse on ward C19 who gave evidence that he still would not have accepted the patient in the circumstances. ”
Source location
Mr Reginald Frank Lewis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 May2016
Northamptonshire
Concerns raised1
1. Failure to undertake a specific falls risk assessment before or upon care-home placement
This report raised 2 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

Mrs Freda Cordy · 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

Mrs Freda Cordy, a 93-year-old woman with dementia and a history of falls, was admitted to a care home after a fall but received checks only every two hours despite an identified need for constant supervision. She suffered two further falls from her bed, sustaining head injuries and a subdural haematoma, and died in hospital on 1 November 2015. The principal concerns were the lack of constant supervision, the absence of a specific falls risk assessment, and limited consideration of preventative equipment.

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 undertake a specific falls risk assessment before or upon care-home placement
Wider context from the report
“2) Despite the previous history of falls and admission to hospital on 5th August 2015 being precisely due to a fall, no specific falls risk assessment was undertaken either before or upon Mrs Cordy’s placement in the care home. ”
Source location
Mrs Freda Cordy · Prevention of Future Deaths report
Page 1 · concerns
Open source report
23 Nov2015
Mid Kent and Medway
Concerns raised1
1. Lack of relevant information for residential and nursing placement assessments
This report raised 2 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

Alan Ludlow · 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

Alan Ludlow died in hospital after suffering a subdural haematoma following a blow to his face from another resident at his care home, and subsequently developing pneumonia. The principal concern was that relevant information about the incident was not passed to the care home where the other resident was later placed, and that residential placements and changing needs must be appropriately assessed and reviewed.

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 relevant information for residential and nursing placement assessments
Wider context from the report
“One of the matters which became apparent during the course of the evidence related to the issue of ensuring that when someone is assessed for a particular placement within residential and nursing environments that those undertaking the assessments and the home in which a person is placed, have all relevant information to ensure that the placement is the most appropriate for that person. ”
Source location
Alan Ludlow · Prevention of Future Deaths report
Page 4 · concerns
Open source report
23 May2014
Milton Keynes
Concerns raised1
1. Lack of adequate assessment of individual needs
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 1
1. Action
  Ensure social care team managers discuss respite-bed use, clear assessment, and support planning with their teams.
  Stated by Community WellbeingStated planned
Respondent positions 2
1. Position
  The temporary placement was appropriate and did not result from inadequate assessment or support planning.
  Stated by Community WellbeingDisputes the concern
1. Position
  Continued falls were not caused by the type of care and support provided at the care centre.
  Stated by Community WellbeingDisputes the concern
AI-generated summary

Ross Robson · 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

Ross Robson Boyd died following a number of falls from his wheelchair while resident at the Willows Care Home in Milton Keynes. The principal concern was that he was admitted without an adequate assessment of his needs and placed in a setting that was inappropriate for those needs.

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 adequate assessment of individual needs
Wider context from the report
“Ross Boyd was admitted to the Willows without an adequate assessment as to his needs being carried out with the result that he was placed at the Willows that was totally inappropriate for his needs. ”
Source location
Ross Robson · Prevention of Future Deaths report
Page 1 · 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
Ensure social care team managers discuss respite-bed use, clear assessment, and support planning with their teams.

Verbatim wording from the response
“In summary Mr Boyd’s placement at the Willows was made in an emergency as he was not managing at home and he, his family, and professionals involved believed a period of respite was in the best interests. Although it became apparent the Willows had difficulties meeting all of his needs I do not find that this was because of inadequate assessment prior to the placement. The Willows is a well-regarded care home and Adult Social Care use our contracted respite beds in the Centre for emergency care when required. I will ensure that managers of the social care teams discuss the use of respite beds with their teams and the need for clear assessment and support planning.”

Source location
2014-0313-Response-by-Milton-Keynes-Council
Page 2 · response
Published 23 May 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 temporary placement was appropriate and did not result from inadequate assessment or support planning.

Verbatim wording from the response
“An assessment of Mr Boyd’s needs was conducted on 4 October 2013 by ████████ and a care package at home was provided; additionally there was involvement and assessment from Community Occupational Therapy, Physiotherapy and the Rapid Assessment Team (RAIT) which is part of intermediate care. The District nurses were visiting and reviewed Mr Boyd’s medication and ████████ visited regularly. The decision to move Mr Boyd was based on his deterioration at home and increased risks to his wellbeing which included increased difficulties with transfers and falls which, at that time, did not appear to require a hospital admission or a specific health intervention. The decision was taken in consultation with Mr Boyd, and his family and other professionals involved.”

Source location
2014-0313-Response-by-Milton-Keynes-Council
Page 1 · response
Published 23 May 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
Continued falls were not caused by the type of care and support provided at the care centre.

Verbatim wording from the response
“when he was in the Willows however it is not apparent that this was in any way due to the type of care and support he received when staying there. Mr Boyd continued to try to transfer from his wheelchair unaided and did not use his pendant to call the care staff for assistance hence putting himself at risk of injury.”

Source location
2014-0313-Response-by-Milton-Keynes-Council
Page 2 · response
Published 23 May 2014
Open published response
3 Feb2014
Avon
Concerns raised1
1. Failure to adequately assess babies' wellness, stability and suitability before transfer between neonatal units
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

Scarlett Lucie SINCLAIR · 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

Scarlett Lucie SINCLAIR was born at 28 weeks gestation and transferred to Southmead Hospital’s neonatal unit at 23 days old. Within hours she became unwell, developed a distended abdomen and acute deterioration, and died a few hours after transfer for surgical management of extensive necrosis. The substantive concern was whether the assessment of a baby’s wellness, stability and suitability was sufficient before transfer between neonatal units.

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 adequately assess babies' wellness, stability and suitability before transfer between neonatal units
Wider context from the report
“During the inquest evidence was given from the Consultant Locum Neonatologist at Oxford as to how a baby is assessed as being suitable for transfer to another neonatal unit. I also heard evidence from a Consultant Neonatologist from Bristol who confirmed that the assessment of suitability for transfer from the United Hospitals Bristol NHS Foundation Trust means that a baby is not transferred to another neonatal unit until they are in a much more stable condition. I would therefore ask that you review your policy for assessing a babies wellness, stability and indeed suitability prior to approving that baby fit for transfer between neonatal units ”
Source location
Scarlett Lucie SINCLAIR · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure admission decisions reflect senior clinical assessment of patient suitability

Concerns raised1

Failure to undertake a specific falls risk assessment before or upon care-home placement

Concerns raised1

Lack of relevant information for residential and nursing placement assessments

Concerns raised1

Lack of adequate assessment of individual needs

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to adequately assess babies' wellness, stability and suitability before transfer between neonatal units

Actions described in response 1

Respondent positions 2