Recurring concern

Unreliable welfare-check request handling and follow-up

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First reported 28 May 2014•Latest report 10 Jun 2026

Definition

What this concern includes

Includes failures in the dedicated welfare-check request process, including deciding whether a request should be accepted or rejected, gathering and updating relevant information, managing information received after closure, communicating actions, and following up requests when the expected response is not received.

Not included

  • Excludes general missing-person, patient-location or emergency-response failures where a welfare-check request process is not the deficient control.
  • Excludes failures limited to locating or treating a person after a welfare check has been reliably arranged and followed up.
  • Excludes generic communication, training or documentation deficiencies unless they directly impair welfare-check request handling or follow-up.
  • Excludes welfare callbacks made when a patient cannot receive calls, where the distinct welfare-callback process is the supported concern.
  • Excludes safeguarding, adult-protection or care-assessment processes where the assertion does not specifically concern a welfare-check request.
Reports
12

Distinct published reports

Individual concerns
18

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
23

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.

London Ambulance Service NHS Trust2
Metropolitan Police Service2
North London NHS Foundation Trust2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Cardiff & Vale University LHB1
College of Policing1
Department of Health and Social Care1
Home Office1
Kent and Medway Mental Health NHS Trust1
Leicestershire Partnership NHS Trust1
National Police Chiefs’ Council1
North West Ambulance Service NHS Trust1
South London and Maudsley NHS Foundation Trust1
The Unite Group PLC1
Welsh Ambulance Services NHS Trust1

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 North London

    AI-generated summary

    Stephen Anthony WARD · 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

    Stephen Anthony Ward, who had a long history of depression and other mental health problems, was found hanging by a close friend on 28 February. The principal concern was that, after the crisis team contacted police to request a welfare check, nobody followed up when police did not call back within one or two hours; the police later said they could not locate his flat, by which time Mr Ward had been found hanging.

    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 follow up police welfare-check requests when no response is received

    Wider context from the report

    “However, at around 7.30pm on Thursday, 27 February, a member of the crisis team placed a call to police asking for a welfare check to be carried out. What concerns me is that, when the police did not call back within an hour or two, nobody from the crisis team followed this up with the police. The next contact was at around 8.15am on the morning of Friday, 28 February, when the police rang the crisis team to say that they were outside Mr Ward’s building and could not locate his flat. In fact, Mr Ward’s friend had by this time found him hanging. Mr Ward did not have any personal contact with anyone after Tuesday, 25 February, so by the time the alarm was raised on Thursday evening, he might well have already died. However, he might not. In any event, following up with the police might be critical for another person in his position. ”

    Source location

    Stephen Anthony WARD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review existing community mental health service practice to inform safer police-requested check arrangements.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish guidance requiring requests for checks to be followed up within six hours across community mental health teams.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue the check-follow-up guidance to staff across the organisation.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a full organisational protocol for police-contact follow-up, including further work with Metropolitan Police colleagues.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Obtain Trust Quality Committee ratification and formally issue the full protocol as a Trust protocol.

    Verbatim wording from the response

    “The guidance is due to be issued to staff across the organisation on 21st July 2014, with the ratification of the full protocol due at the Trust Quality Committee in September 2014 for formal issuing as a Trust Protocol by 1st October 2014.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 2014

    Open published response

  2. Leicester City and South Leicestershire

    AI-generated summary

    Laura Page · 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

    Laura Page experienced social stresses, sought medical support, and later took overdoses requiring psychiatric care. She died on 4 December 2012 after taking a substantial overdose. Concerns included failed community-team home visits, inadequate escalation and welfare-check thresholds, incomplete discharge arrangements, and poor inter-agency communication.

    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 maintain an appropriate threshold for requesting welfare checks

    Wider context from the report

    “Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning. (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate. (2) The escalation policy should be reviewed to consider specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. ”

    Source location

    Laura Page · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reconsider and clarify the threshold for requesting welfare checks in the failed-visit flowchart.

    Verbatim wording from the response

    “(3) The threshold for requesting a welfare check should be reconsidered.”

    Source location

    2014-0254-Response
    Page 2 · response
    Published 28 May 2014

    Open published response
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Data last updated 7 September 2026