Recurring concern

Unreliable social-care case review and closure decisions

First to latest report 2 Dec 2015 — 14 Nov 2023

Reports that mention this concern: 3
Times this concern has been raised: 3
Stated actions linked to this concern: 3

What this concern includes

Includes failures in social-care case review and closure arrangements, including deciding whether further assessment is required, keeping cases open while risks or needs remain unresolved, convening appropriate senior or multi-professional review, documenting the rationale for closure and ensuring agreed further action or support is initiated.

What is not included

Excludes routine community-care assessment delays or omissions where the specific concern is not a case-review or closure decision; these may belong to the existing community-care-assessment parent.
Excludes failures to provide care packages or placements after a case has been appropriately assessed and kept open.
Excludes generic management review, incident investigation or organisational-learning failures without a social-care case review or closure context.
Excludes clinical, police, prison and safeguarding case processes unless the assertion explicitly concerns the same social-care review and closure arrangement.
Excludes disagreements with a social-care decision where the case was appropriately reviewed, the rationale was documented and required action was taken.

Trends

Reports over time

Reports mentioning this concern, 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.

Denbighshire County Council1

Milton Keynes City Council1

Westmorland and Furness Council1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

14 Nov2023
Cumbria
Concerns raised1
1. Reablement Team closure of cases contrary to a social worker's care-assessment recommendation without further discussion or rationale
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Westmorland and Furness Council
Stated actions 3
1. Westmorland and Furness Council
  Establish weekly meetings between reablement and adult social care teams to discuss cases, highlight concerns and agree actions.
2. Westmorland and Furness Council
  Require recorded explanations for case deallocation and provide management oversight of all case closures.
3. Westmorland and Furness Council
  Conduct regular case-file audits of chronology and completed actions.
AI-generated summary

Gerald Goodwin · 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

Gerald Goodwin, who had Alzheimer’s dementia and had consumed a significant amount of alcohol, was struck by a train while walking along a railway track on 10 November 2022; his death was confirmed at 00:17 on 11 November 2022. The principal concerns were that safeguarding and care-assessment referrals were rejected, closed, or not actioned, with multiple teams and systems failing to communicate effectively and potentially exposing other vulnerable adults to risk.

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
Reablement Team closure of cases contrary to a social worker's care-assessment recommendation without further discussion or rationale
Wider context from the report
“(2) The witness statement on behalf of the Adult Social Care team explains that after the refusal to conduct a safeguarding enquiry, Mr Goodwin was nevertheless referred for the Social Work team to 'engage' with him. A social worker took steps to engage with Mr Goodwin and his family and concluded that a care assessment was appropriate. Despite this the 'Reablement Team' referred the case for closure indicating that they did not consider that such an assessment was required. I am concerned that this indicates further circumstances in which the needs of a vulnerable person might be overlooked. After a social worker considered that a care assessment was needed the Reablement Team appear to be able to come to an alternative view and close the case without further discussion or rationale. In another case this might lead to a vulnerable person being disregarded. ”
Source location
Gerald Goodwin · 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
Establish weekly meetings between reablement and adult social care teams to discuss cases, highlight concerns and agree actions.

Verbatim wording from the response
“In some situations the threshold for a statutory safeguarding enquiry is not met and this can also apply in circumstances where self-neglect is a factor. In this case the practitioner recognised that although a formal safeguarding enquiry was not necessary, there needed to be further involvement via Adult Social Care in order to engage with Mr. Goodwin regarding the concerns that had been raised. As stated earlier reablement was identified as appropriate but it was an error not to refer the case back to the social work team when Mr Goodwin declined reablement input. It is recognised that the reablement team and the social work team should have worked together more closely in relation to Mr. Goodwin in order to promote engagement. We now have weekly meetings between reablement and adult social care which provides an opportunity for similar situations to be discussed.”

Source location
Response from Adult Social Services
Page 3 · response
Published 22 November 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
Require recorded explanations for case deallocation and provide management oversight of all case closures.

Verbatim wording from the response
“Following completion of the witness statement a process was put in place and a directive was shared with Adult Social Care staff on 10th October 2023. This instructs staff that if a case is picked up to be allocated and is subsequently de-allocated this must be recorded as a case note on the electronic case recording system with a clear explanation of why the case is being closed, thus ensuring a clear audit trail is in place. We have also implemented a system where there is management oversight of all case closures to provide increased governance in this area.”

Source location
Response from Adult Social Services
Page 4 · response
Published 22 November 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
Conduct regular case-file audits of chronology and completed actions.

Verbatim wording from the response
“Regular case file audits are already in place which do look at the case chronology to ensure that appropriate actions have been taken.”

Source location
Response from Adult Social Services
Page 4 · response
Published 22 November 2023
Open published response
22 May2017
Milton Keynes
Concerns raised1
1. Failure to convene senior professionals to consider cases and prepare a plan
This report raised 6 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.
AI-generated summary

Kevin George 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

Kevin George Morgan, who had poorly controlled type 1 diabetes, was found deceased in his flat after family contacted police when they had not heard from him for several weeks. His body was heavily decomposed, and there were no suspicious circumstances. The principal concerns were the lack of effective follow-up by social services and housing, inadequate responses to safeguarding and safety concerns, and the absence of a post-death serious incident or 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 convene senior professionals to consider cases and prepare a plan
Wider context from the report
“(5) It was accepted by the Adult Social Care Access Team that a meeting of senior professionals should have been called to consider the case and prepare a plan. ”
Source location
Kevin George Morgan · Prevention of Future Deaths report
Page 1 · concerns
Open source report
2 Dec2015
North Wales (East and Central)
Concerns raised1
1. Failure to conduct further assessments when action is required
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.
AI-generated summary

Laura Beth Newlands · 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 Beth Newlands was known to Denbighshire Social Services because of concerns about self-harm related to difficult home circumstances. After her case was closed, a delay in arranging a professionals’ meeting meant that further support was not provided before she took her own life by overdose four days before the scheduled meeting. The report identified concerns about incomplete safety-plan input, delays in responding to risk, and the decision to close and not reopen the case.

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 conduct further assessments when action is required
Wider context from the report
“3. The decision to close the case (and then not to reopen the same) by DSS resulted in there being no further assessments conducted at a time when action should have been taken and could have resulted in additional support for the deceased and her family. Such a decision may not have been made if the case had been reviewed by a senior staff member who was not directly involved in the investigation. ”
Source location
Laura Beth Newlands · Prevention of Future Deaths report
Page 1 · concerns
Open source report