10 Jun 2026 Lesley Katherine HIGGINSON · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Failure to apply clear criteria for determining whether welfare checks are healthcare related and should be accepted or rejected View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Lesley Katherine HIGGINSON · 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
Lesley Katherine HIGGINSON, a medically vulnerable adult aged 72, was found deceased at home on 18 January 2026 after failed remote welfare and medication contacts. A principal concern was uncertainty about the ambulance service policy for declining welfare-check requests, including whether the request in these circumstances was properly rejected and whether responsibility was affected by the police RCRP policy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to apply clear criteria for determining whether welfare checks are healthcare related and should be accepted or rejected
Wider context from the report “It is important to know whether there is an established policy for declining welfare calls, and if so, when it was introduced. It leaves patients in a difficult position when aligned with the constabulary Right Care Right Person (RCRP) policy which was published nationally on 23 June 2023 and implemented in the Cheshire region in January 2024. The RCRP policy states that the police in Cheshire (and in other areas nationally) will not respond to welfare check calls when healthcare are best placed to support those who may be in crisis. It is unclear from the ambulance service response whether a request for a welfare check, in the circumstances of this death, is to be deemed to be healthcare related and whether the ambulance service properly rejected the request, on the grounds stated.
” Source location Lesley Katherine HIGGINSON · Prevention of Future Deaths report
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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 and implement Concern for Welfare Response Criteria Guidelines governing receipt, recording, escalation and ambulance responses.
Verbatim wording from the response “This advice was in accordance with the NWAS Concern for Welfare policy, which covers the receipt, recording, escalation and NWAS responses in relation to concern for welfare of a patient. Where such calls are received, the guidelines provide that the patient’s location needs to be known and there needs to be a confirmed medical need.” Source location Response from North West Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with Okay Each Day and explain when ambulances will and will not be deployed for concern-for-welfare calls.
Verbatim wording from the response “NWAS have also met with the Okay Each Day service who have been advised as to the circumstances in which an ambulance will and will not be deployed when concern for welfare calls are received. It was recommended by NWAS that Okay Each Day explore whether they could set up a pathway with other agencies to make initial contact with a patient where their exact location cannot be determined or for them to consider their own response team to conduct these enquiries.” Source location Response from North West Ambulance Service
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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 Concern for Welfare policy was sufficient because the call lacked a verified location and confirmed physical or mental health need.
Verbatim wording from the response “The NWAS Mental Health and Suicide Prevention Lead has listened to the 999 calls made in respect of Ms Higginson and has confirmed that the 999 call from Okay Each Day at 15:16 hrs was handled appropriately and in line with the concern for welfare policy. It could not be determined that Ms Higginson was at the specified location nor could it be determined that she had a confirmed physical or mental health complaint. It was therefore correct that NWAS did not deploy an ambulance to Ms Higginson based on the information provided at the time of the call.” Source location Response from North West Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other services must independently investigate whether an uncontactable person requires physical or mental healthcare.
Verbatim wording from the response “As an ambulance service, our primary function is to prioritise and respond to the medical needs of our patients whether this is face-to-face or via other methods. A confirmed physical or mental health complaint means that the caller has evidence or good reason to believe that the patient or service user is currently suffering from a physical or mental health issue that requires either a face-to-face assessment or telephone response. It cannot be assumed that an individual being uncontactable, means that they require medical assistance. Nor do NWAS have the capacity to conduct thorough enquiries, on behalf of other services, to determine whether an individual is experiencing physical or mental health concerns. It is incumbent upon these services to arrange for and execute such inquiries autonomously.” Source location Response from North West Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NWAS cannot unilaterally provide welfare callouts for people whose needs or locations cannot be established.
Verbatim wording from the response “The Concern for Welfare Response Criteria Guidelines Policy was introduced in May 2024, in response to the Right Care, Right Person (RCRP) National Partnership Agreement. NWAS have been clear and transparent with local system partners, including the Police, Acute Trusts, Mental Health Organisations and Councils regarding the deployment of ambulances when concern for welfare calls are made to the service and the circumstances in which an ambulance will and will not be deployed. NWAS and other system partners have previously noted that there is a gap in services for members of the public who may need concern for welfare call outs and this has been discussed in both strategic and tactical RCRP meetings, but not something that NWAS are able to fulfil unilaterally.” Source location Response from North West Ambulance Service
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19 May 2026 Catherine Mary MORGAN · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure to use a viable welfare-check pathway when the resident is not known to be at the address View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
College of Policing Metropolitan Police Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
College of Policing
Review Right Care Right Person and Missing Persons guidance jointly to identify clarifications supporting operational decision-making.
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College of Policing
Identify emerging risk-based operational practice, including escalation routes to specialist missing person teams for uncertain incident classifications.
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College of Policing
Produce interoperability guidance for ambiguous Right Care Right Person and Missing Persons cases, including escalation to appropriately trained specialist teams.
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Metropolitan Police Service
Develop an updated Concern for Welfare policy with practical scenarios addressing deployment and Local Missing Hub referral decisions.
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Metropolitan Police Service
Review guidance, training and quality-assurance arrangements so advice to callers is practical, achievable and aligned with partner-agency responsibilities.
View source
Metropolitan Police Service
Reinforce escalation and supervisory review when agency responsibility is uncertain, disputed or associated with increasing concern.
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Metropolitan Police Service
Incorporate learning from the case into ongoing MetCC training, briefings and governance processes.
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Catherine Mary MORGAN · 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
Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to use a viable welfare-check pathway when the resident is not known to be at the address
Wider context from the report “2. A call handler informed SLAM to call London Ambulance Service to do a welfare check at
the home address of the patient in circumstances where the ambulance service will only
attend an address if the resident is known to be there ;
” Source location Catherine Mary MORGAN · Prevention of Future Deaths report
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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 Right Care Right Person and Missing Persons guidance jointly to identify clarifications supporting operational decision-making.
Verbatim wording from the response “The College has already commenced work to address this issue through the following activity:” Source location Response from College of Policing
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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 Identify emerging risk-based operational practice, including escalation routes to specialist missing person teams for uncertain incident classifications.
Verbatim wording from the response “2. Identification of emerging operational practice” Source location Response from College of Policing
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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 Produce interoperability guidance for ambiguous Right Care Right Person and Missing Persons cases, including escalation to appropriately trained specialist teams.
Verbatim wording from the response “2. Development of interoperability guidance between RCRP and Missing Persons frameworks” Source location Response from College of Policing
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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 Develop an updated Concern for Welfare policy with practical scenarios addressing deployment and Local Missing Hub referral decisions.
Verbatim wording from the response “In addition, the MPS is developing an updated Concern for Welfare policy, supported by practical scenarios to assist decision making. This will support increased clarity around when deployment is required or when referral to LMHs is appropriate, particularly in circumstances involving vulnerability and potential missing person risk.” Source location Response from MPS
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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 guidance, training and quality-assurance arrangements so advice to callers is practical, achievable and aligned with partner-agency responsibilities.
Verbatim wording from the response “The MPS has reviewed the circumstances of this aspect of the incident. We recognise the importance of ensuring that advice provided by Met Command and Control (MetCC) staff is consistent with the responsibilities and capabilities of partner agencies and reflects the processes set out within RCRP and associated arrangements.” Source location Response from MPS
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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 Reinforce escalation and supervisory review when agency responsibility is uncertain, disputed or associated with increasing concern.
Verbatim wording from the response “In response to the concern raised by the Coroner, the MPS will review guidance, training and quality assurance arrangements to reinforce that where police are not the appropriate agency to respond, advice provided to callers should be practical, achievable and consistent with the responsibilities of the agency to which they are being directed. This will include reinforcing escalation and supervisory review where there is uncertainty, disagreement or increasing concern regarding the most appropriate agency response. Learning from this case will be incorporated into ongoing training, briefing and governance processes within MetCC.” Source location Response from MPS
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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 Incorporate learning from the case into ongoing MetCC training, briefings and governance processes.
Verbatim wording from the response “In response to the concern raised by the Coroner, the MPS will review guidance, training and quality assurance arrangements to reinforce that where police are not the appropriate agency to respond, advice provided to callers should be practical, achievable and consistent with the responsibilities of the agency to which they are being directed. This will include reinforcing escalation and supervisory review where there is uncertainty, disagreement or increasing concern regarding the most appropriate agency response. Learning from this case will be incorporated into ongoing training, briefing and governance processes within MetCC.” Source location Response from MPS
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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 Healthcare providers must undertake initial reasonable enquiries when a patient leaves a healthcare setting, using the most appropriate agency or agencies.
Verbatim wording from the response “The MPS Right Care, Right Person policy and toolkit place responsibility on healthcare providers to undertake initial reasonable enquiries when a patient leaves a healthcare setting. Those enquiries should be progressed through the most appropriate agency or agencies based on the circumstances and should not rely on referral to a single service as a default position. The MPS also recognises the importance of clear escalation routes where there are concerns that the available arrangements are insufficient to manage the presenting risk.” Source location Response from MPS
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20 Jan 2025 Student A · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Delays in actioning welfare checks and physically attending rooms View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Unite Students
Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.
View source
Unite Students
Review Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.
View source
Unite Students
Provide 24/7 staffing at all sites to support student welfare and response capacity.
View source
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AI-generated summary
Student A · 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
Student A was found unresponsive in his student accommodation on 28 July 2024 and paramedics verified his death shortly thereafter; the medical cause was asphyxiation and the inquest conclusion was suicide. The principal concerns were delays in carrying out the welfare check and calling emergency services, limited assessment of Student A’s condition, failure to provide basic assistance or first aid, and possible inadequacy or ineffectiveness of staff training and procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in actioning welfare checks and physically attending rooms
Wider context from the report “1. On 28 July 2024, the request for a welfare check was received by staff at Somerset Court, from the Emergency Control Centre (the ECC) for Unite Students, at approximately 07:00. The basis of the request was that Student A’s mother had been unable to contact her son. The member of staff advised the ECC that they would try to ‘call the student and if he did not answer I would then go to his room.’ At approximately 10:15, the staff member called Student A’s mobile telephone three times, ‘but it did not ring it only beeped.’ At approximately 10:50, the staff member went upstairs to Student A’s room and received a call from the ECC but ‘ignored the call’ to go to Student A’s room.
While at the material time there was no way of knowing whether this was an emergency or not, the concern here is that it nevertheless took hours for the request for a welfare check to be actioned in any way . Further, on getting no response from attempts at contact by telephone, there was further delay in physically attending Student A’s room .
” Source location Student A · Prevention of Future Deaths report
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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 Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.
Verbatim wording from the response “We recognise that a second staff member could have attended sooner to facilitate a room entry after the call escalation at 11:00. The steps that we are taking to address this are twofold:” Source location Response from Unite Students
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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 Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.
Verbatim wording from the response “More generally, we are reviewing all our procedures for dealing with calls made to the ECC to effectively triage calls received, and to ensure that appropriate questions are asked to understand the basis and potential seriousness of enquiries.” Source location Response from Unite Students
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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 Provide 24/7 staffing at all sites to support student welfare and response capacity.
Verbatim wording from the response “To prepare our teams for this, they all receive training specific to the roles which they perform but, unfortunately, sometimes find themselves confronted by some of the most difficult situations imaginable. We have in recent years made the decision to have 24/7 staffing at all our sites and offer student welfare programmes; however, our teams are not emergency service professionals or staff providing supported living. We will, of course, work through the learnings from this tragic incident and will implement additional measures as necessary.” Source location Response from Unite Students
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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 concern that the welfare-check request took hours to action is based on misinterpreted evidence, and the pre-escalation response was reasonable.
Verbatim wording from the response “First, we noted your concern that it “took hours for the request for a welfare check to be actioned in any way”. From our review of the information available, and in particular the witness statements you kindly disclosed, post inquest, we believe this concern is based on an understandable misinterpretation of the witness evidence given by one member of staff ████████.” Source location Response from Unite Students
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25 Apr 2024 Dr Jonathan Harvey Shaw · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Lack of a legal requirement to request a welfare check before releasing consignments View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Home Office
Explore legislative and policy options to control the substance and address ethical frontline responses to welfare concerns.
View source
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AI-generated summary
Dr Jonathan Harvey Shaw · 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
Dr Jonathan Harvey Shaw took his own life by intentionally ingesting the contents of a package purchased online from a Malaysian company. The package had been stopped by UK Border Force but was released without consultation with Greater Manchester Police, after which Dr Shaw used its contents to end his life. The report identifies concerns about the 30-day limit on holding the consignment and the absence of national guidance or training for police and UK Border Force on managing such consignments and coordinating welfare checks or safe destruction.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a legal requirement to request a welfare check before releasing consignments
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force .
” Source location Dr Jonathan Harvey Shaw · Prevention of Future Deaths report
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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 Explore legislative and policy options to control the substance and address ethical frontline responses to welfare concerns.
Verbatim wording from the response “I am determined that we must ensure that all reasonable steps to prevent further loss of life are taken and the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and similar substances) including how to ensure front line officers respond ethically to circumstances where the welfare of individuals is concerned.” Source location Response from Home Office
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10 Jan 2019 Christopher Michael SEAL · Prevention of Future Deaths report Avon
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Concerns raised 1
Absence of a welfare-check policy for primary care View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Christopher Michael SEAL · 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
Christopher Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a welfare-check policy for primary care
Wider context from the report “6. I was told that there is no “welfare check policy” for those in primary care ; that the policy which exists is for secondary or tertiary care and is therefore not applicable to the service users or staff in primary care . I was told that Avon and Somerset Constabulary are in the process of writing a “welfare check policy” and it may be beneficial for there to be liaison with the police forces in the AWP area to ensure that any new policy that you consider is appropriate is in line with their expectations as to what a police officer can and will do following such a call. This would also raise the question of training.
” Source location Christopher Michael SEAL · Prevention of Future Deaths report
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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 Request close liaison and joint working with Avon and Somerset Police on welfare checks.
Verbatim wording from the response “AWP have contacted Avon and Somerset Police to request close liaison and joint working regarding their ‘Welfare Check Policy’ to ensure understanding and expectations are aligned. The local representative for the Avon & Somerset Crisis Concordat will maintain close follow” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The police are responsible for the welfare-check policy, while the Trust will liaise and work jointly with them.
Verbatim wording from the response “No “welfare check policy” for those in primary care” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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30 Jul 2018 Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Delays in making and chasing-up welfare calls View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mr Richard Thomas Peter Barrett · 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
On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in making and chasing-up welfare calls
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back . It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” Source location Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report
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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 Remind clinical contact centre leads to handle Protocol 23 overdose cases promptly.
Verbatim wording from the response “Following this specific incident, an email was sent to the Clinicians on the Clinical Support Desk on the 15th May 2018 by the CCC Clinical Lead. The email identified the importance of attempting to review protocol 23 (overdose) calls when there were delays in responding as these may be time critical. If there was no reply the clinicians should use their critical thinking skills to determine how likely unconsciousness or death would be based on what the patient is recorded as having taken and act accordingly.” Source location 2018-0249-Response-by-University-Health-Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Demand-related capacity constraints make it challenging to undertake a robust welfare-call procedure consistently.
Verbatim wording from the response “The welfare call is undertaken by an identified member of Clinical Contact Centre (CCC) staff from either the call taking or dispatch function depending on who has the most capacity. The Demand Management Plan identifies that ‘It is recognised that delays are often a reflection of demand and as such capacity to undertake a robust welfare call procedure is challenging. Every effort should be made to facilitate this process to maintain good customer practice where possible’. All callers are informed to ring back if the patient’s condition deteriorates.” Source location 2018-0249-Response-by-University-Health-Board
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Concerns raised 1
Lack of clear mandatory criteria for requesting police welfare checks for patients rated 'Red' View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Julie Margaret Rose · 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
Julie Margaret Rose, who had long-standing depression, anxiety and Obsessive Compulsive Disorder, was found dead at home on 26 April 2015 after unsuccessful attempts by mental health services to contact her and a delayed police welfare check. The concerns were that the Trust’s protocol was insufficiently clear about when a police welfare check was mandatory for high-risk patients, and that a shift co-ordinator was not familiar with the protocol despite it having been reinforced.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear mandatory criteria for requesting police welfare checks for patients rated 'Red'
Wider context from the report “(1) Although the Trust's 'Unable to Make Contact Protocol' ("the Protocol") has been reviewed since Miss Rose's death, I am concerned that it is insufficiently clear as to when Crisis Resolution Home Treatment Team members should request a police welfare check in respect of patients who have been identified as 'Red' for the purposes of the Trust's R A G Rating System.
In particular, I am concerned the Protocol does not specifically stipulate circumstances where a request for a welfare check is mandatory (for example, after a certain period of time has elapsed since contact was last made, and / or after a certain number of attempts at contact and / or after attempts at telephone contact and a home visit have both been unsuccessful);
(2) In the course of the hearing, I heard evidence that the Protocol has been 'reinforced' across the Crisis Resolution Home Treatment Team. Notwithstanding this, a shift co-ordinator who gave evidence was clearly not conversant with the Protocol, raising questions as to the adequacy of the steps taken by the Trust to date in this respect.
” Source location Julie Margaret Rose · Prevention of Future Deaths report
Open source report
12 Nov 2015 Matthew Marc GROOM · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to convey the need for urgent police intervention in a welfare-check request View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
North London NHS Foundation Trust Whittington Health NHS Trust
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Matthew Marc GROOM · 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
Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to convey the need for urgent police intervention in a welfare-check request
Wider context from the report “5. The nurse who then contacted the police did not then convey this to them , but requested a welfare check that would be satisfied by knowing he was with a family member .
” Source location Matthew Marc GROOM · Prevention of Future Deaths report
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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 patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.
Verbatim wording from the response “The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this the assessors have to consider the persons capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.” Source location Matthew-Groom-Response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient was not considered an immediate risk requiring detention, restraint, or an active police search.
Verbatim wording from the response “The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this assessment, staff have to consider the person’s capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.” Source location 2015-0503-Response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing joint police protocols already govern communication about people who abscond or go missing, including conveying immediate-risk information.
Verbatim wording from the response “Improvement in response to concern
For the reasons described above (in response to concern 3) Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that indicated that he was at immediate risk of harm to himself or others to require that the police perform an active search for him. Had this been the case then the Trusts practice is to convey this information to the police. Camden & Islington NHS FT already has joint protocols with the Police, concerning people who have absconded and / or go missing.
As I understand it the police were alerted that if they were to see Mr Groom, they should consider bringing him back to hospital if the family members he left with were concerned. As we understand it, this would also normally entail the police’s consideration of the use of section 136 legislation if thought appropriate.” Source location 2015-0503-Response
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21 Jul 2015 Anne Wilson · Prevention of Future Deaths report South London
View report summary
Concerns raised 7
Lack of checklist or question examples for eliciting sufficient welfare concern information View source Lack of guidance on updating involved parties about changes in MPS actions View source Failure to inform the GP when a welfare check request is downgraded View source
Lack of guidance on managing additional information received after welfare check closure View source Failure to share welfare check policy changes with the London Ambulance Service View source Failure to seek further clarification of the GP’s concerns before downgrading a welfare check request View source Lack of guidance on managing welfare checks concerning an individual’s mental health View source See 4 more concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Anne Wilson · 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
Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London Ambulance Service.
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× 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 checklist or question examples for eliciting sufficient welfare concern information
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Source location Anne Wilson · Prevention of Future Deaths report
Open source report × 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 guidance on updating involved parties about changes in MPS actions
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Source location Anne Wilson · Prevention of Future Deaths report
Open source report × 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 inform the GP when a welfare check request is downgraded
Wider context from the report “(4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson’s flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek further clarification of his concerns.
” Source location Anne Wilson · Prevention of Future Deaths report
Open source report × 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 guidance on managing additional information received after welfare check closure
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed .
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Source location Anne Wilson · Prevention of Future Deaths report
Open source report × 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 share welfare check policy changes with the London Ambulance Service
Wider context from the report “(1) In 2014 the Metropolitan Police Service (MPS) introduced a new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest. The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time .
” Source location Anne Wilson · Prevention of Future Deaths report
Open source report × 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 seek further clarification of the GP’s concerns before downgrading a welfare check request
Wider context from the report “(4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson’s flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek further clarification of his concerns .
” Source location Anne Wilson · Prevention of Future Deaths report
Open source report × 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 guidance on managing welfare checks concerning an individual’s mental health
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Source location Anne Wilson · Prevention of Future Deaths report
Open source report
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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 Provide the current Metropolitan Police welfare-check briefing note to address uncertainty about the policy version in force.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
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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 Incorporate the March 2015 Metropolitan Police welfare-check policy into the LAS/MPS Joint Memorandum of Understanding through the annual review process.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
31 Jul 2014 Toni Elizabeth SKILLINGTON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to take appropriate action after unanswered welfare-check callbacks View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Toni Elizabeth SKILLINGTON · 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
Toni Elizabeth Skillington took an excess of methadone and alcohol and contacted family members, who alerted the London Ambulance Service. Emergency paramedics arrived almost three hours later, after failures to follow procedures following unanswered welfare checks and other concerns about call handling and dispatch.
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 take appropriate action after unanswered welfare-check callbacks
Wider context from the report “3. Two welfare checks were made via ring backs without any reply gained, yet neither of these was followed by the appropriate action . Even accepting how busy and under staffed the service was that night, a call child at least have been made to the police asking for attendance.
” Source location Toni Elizabeth SKILLINGTON · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.