Recurring concern

Unreliable shared understanding of funded care and staffing requirements

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First reported 26 Jan 2023•Latest report 6 May 2024

Definition

What this concern includes

Includes failures to establish, communicate, maintain or use a shared and accurate understanding of a person's funded care package, required staffing allocation and expected provision across commissioners, care providers and relevant management functions, including mismatches between funded, planned and delivered support.

Not included

  • Excludes general care-package delays, funding shortages or placement failures where the funded requirements are understood but provision is delayed or unavailable for another reason.
  • Excludes generic inter-agency communication, record-keeping or accountability deficiencies unless they directly cause conflicting or missing understanding of funded care or its staffing requirements.
  • Excludes ordinary care-quality or staffing-capacity failures where no mismatch or misunderstanding of the funded or required support is identified.
  • Excludes clinical care, assessment or treatment failures unrelated to the funded care package and its required staffing allocation.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2023–2024

First to latest report issue date

Stated actions
0

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.

Cygnet Health Care Limited1
Department of Health and Social Care1

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. Nottinghamshire

    AI-generated summary

    Peter Dickens · 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

    Peter Dickens died at Bassetlaw District General Hospital on 22 January 2022 after choking on a sandwich while a resident at The Beeches. The report identified persistent non-compliance with Eating and Drinking guidelines, inadequate recording and monitoring of mealtime strategies, and apparent failure to provide the support funded for Peter.

    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

    Management unawareness of the funded support level and its required staffing allocation

    Wider context from the report

    “d) Apparent failure to provide the level of support that was funded for Peter- the costings and support level were set out in his current care and support plan- the Beeches management team appeared unaware that he was funded for a total of 18 hours per day, which is broken down into 12 hours one to one support per day and 6 hours two to one support per day ”

    Source location

    Peter Dickens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Liverpool and the Wirral

    AI-generated summary

    Matthew Harter DALE · 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 Harter DALE died after swallowing part of an incontinence pad while unsupervised; the item became trapped in his airway. The death was partly contributed to by a missed opportunity to increase supervision, amid confusion between commissioning and care agencies about the care and supervision that should have been provided.

    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 a shared understanding of care funding and provision across agencies

    Wider context from the report

    “It became clear in the inquest that the commission, funding, assessment and provision of care needs is a complex process involving, particularly as in Matthews case, where there are multiple agencies involved due to his own complex and multifaceted needs. In this case it has been established that there was a confusion over the care in how it was funded and expected to be provided, compared to that which was understood to be funded and actually provided on the ground to Matthew. The confusion appears to have arisen over the understanding of a number of care terms and the use of them which has resulted in 2 commissioning agencies and an agency providing the care having differing views about Matthews care and that which should have been in place and that which was in place. ”

    Source location

    Matthew Harter DALE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026