Recurring concern

Failure to maintain contact with vulnerable people after initial engagement

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First reported 26 Sep 2013•Latest report 10 Jul 2024

Definition

What this concern includes

Includes failures of agency contact, follow-up or engagement arrangements that allow vulnerable people to become unreachable after an initial claim, visit, referral, shelter placement or other service contact, including where unstable accommodation or lack of contact details is a contributing circumstance.

Not included

  • Excludes failures limited to clinical follow-up of patients who disengage from care where no broader vulnerable-person contact-maintenance concern is identified.
  • Excludes generic inter-agency communication or information-sharing deficiencies where maintaining contact with the person is not the unsafe condition.
  • Excludes ordinary difficulty contacting a person where no safety, support-access or agency-follow-up risk is identified.
  • Excludes failures concerning contact with professionals, families or agencies when the vulnerable person’s own continuing accessibility is not at issue.
Reports
7

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
5

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.

Department of Health and Social Care2
Covid-19 Pandemic Response Service1
Ministry of Housing, Communities and Local Government1
NHS Cornwall and the Isles of Scilly Integrated Care Board1
NHS Greater Manchester Integrated Care Board1
NHS Kernow Clinical Commissioning Group1
NHS Pathways1
South London and Maudsley NHS Foundation Trust1
South Tyneside Borough Council1
South Tyneside Safeguarding Adults Board1
Universities UK1
University of Reading1

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. Berkshire

    AI-generated summary

    Benjamin Faux · 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

    Benjamin Faux was a taught research Master's student at the University of Reading who had severe mental health difficulties, disengaged from his studies, and took his own life in his student accommodation on or around 5 August 2023. The concerns included inadequate pastoral support and monitoring, the absence of a process to ensure completion of study-suspension arrangements, unclear responsibility for resolving his academic situation, and a lack of University contact with him before his death.

    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 contact with vulnerable students during unresolved academic situations

    Wider context from the report

    “(5) By March 2023 Ben’s department at Reading University knew that Ben was a student with severe mental health concerns linked to management of his academic work, who had not taken any exam and had not completed sufficient research to file a dissertation and by late June they also knew that he had not completed paperwork to suspend his studies and yet: a. The University staff who knew this did not appear to appreciate what it meant for Ben and his continuing risk of vulnerability; and b. There was no individual who was given or took responsibility for what should happen next with regard to resolving Ben’s academic situation; and c. Apart from brief further contact from the Student Support Centre the suspension forms, no-one from the University contacted Ben between 24 April 2023 and when he took his life on or around 5 August 2023; ”

    Source location

    Benjamin Faux · Prevention of Future Deaths report
    Page 3 · 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

    Provide every Master’s by Research student with two academic points of contact and monthly meetings throughout the programme.

    Verbatim wording from the response

    “This change was an institutional decision made to reflect the view that it was more appropriate for academic staff to focus on providing academic and general pastoral support, with trained professionals providing more specialist welfare support where required. | 1. Strengthen support system for MbR programmes to ensure that all MbR students have monthly meetings with two academic points of contact.”

    Source location

    Response from Reading University
    Page 1 · response
    Published 29 July 2024

    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

    Flag vulnerable students discussing withdrawal or suspension to relevant Student Support Centres and Student Wellbeing Services teams.

    Verbatim wording from the response

    “3 | There will be a range of circumstances in which students, outside of our formal fitness to study process, may need to consider the possibility of suspending their studies. Our system for supporting students through to the conclusion of such discussions, is a weakness that the Coroner has correctly identified.”

    Source location

    Response from Reading University
    Page 2 · response
    Published 29 July 2024

    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

    Assign SDATs responsibility for ensuring Master’s by Research student-support processes are completed.

    Verbatim wording from the response

    “5b and 5c | The University has clarified that the student support in place for MbR students should be aligned as far as possible with those on taught programmes. Therefore, it is the relevant SDAT who is responsible for ensuring that student support processes are seen through to completion for these students. | 1. New notification system to be implemented whereby the SDAT emails reminders to relevant academic staff at regular intervals to monitor and report engagement of MbR students. SSCs to provide”

    Source location

    Response from Reading University
    Page 3 · response
    Published 29 July 2024

    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 organisation lacks regulatory authority to mandate specific mental-health actions by member universities.

    Verbatim wording from the response

    “UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

    Source location

    Response from Universities UK
    Page 2 · response
    Published 29 July 2024

    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

    Individual universities are responsible for their own governance, procedures and decisions on specific mental-health actions.

    Verbatim wording from the response

    “UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

    Source location

    Response from Universities UK
    Page 2 · response
    Published 29 July 2024

    Open published response
  2. Manchester South

    AI-generated summary

    Tobias Ryse Mannering-Jones · 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

    Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.

    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 of public service contact arrangements for people without a stable address

    Wider context from the report

    “3. Evidence was also heard that a person who has to rely on a homeless shelter can then become uncontactable to public service providers as they have no address for contact which means they then have even less chance of accessing support. ”

    Source location

    Tobias Ryse Mannering-Jones · Prevention of Future Deaths report
    Page 3 · 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

    Continue supporting night shelters through training resources, high-quality accommodation requirements and specialist outreach roles funded through the Rough Sleeping Initiative.

    Verbatim wording from the response

    “In DLUHC, I will continue to support the night shelter sector in line with the actions in the second matter of concern, including training resources on best practice for engagement; and will continue to ensure that areas in receipt of RSI funding have in place ending rough sleeping plans that include high quality off the street accommodation and specialist outreach roles that are designed to directly engage and support people on the streets. Shelters play a valuable role providing accommodation to those experiencing homelessness and lessons from matter of concern five are particularly pertinent in considering how this provision fits in and engages with other services.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 4 · response
    Published 20 March 2024

    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

    Support NICE guidance improving access to coordinated, multidisciplinary health and social care for people experiencing homelessness.

    Verbatim wording from the response

    “The Department recognises the importance of reducing barriers to services for those experiencing rough sleeping. This is why we supported the development of NICE guidance which provides recommendations on ways to improve access to, and engagement with, health and social care services for people experiencing homelessness. It also provides advice on how commissioners, planners, providers and practitioners across disciplines and agencies can work together as part of a multi-disciplinary team to support and improve outcomes for people experiencing homelessness.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 March 2024

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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

    Health-related concerns are led by DHSC, with DHSC and Manchester Integrated Care Board providing a separate, more detailed response.

    Verbatim wording from the response

    “My responses to the matters of concern are set out in turn below. I have worked closely with the other public bodies that have received the Report, including the Department of Health and Social Care (DHSC) and NHS England, in collaboration with Manchester Integrated Care Board. A separate response will be provided by DHSC and Manchester Integrated Care Board, which will respond in greater detail to the first, third and fifth matter of concern.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 2 · response
    Published 20 March 2024

    Open published response
  3. Manchester South

    AI-generated summary

    Diane Margaret Austin-Martin · 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

    Diane Margaret Austin-Martin was a vulnerable adult with multiple sclerosis and significant care needs who was found severely underweight, with multiple pressure ulcers, in filthy and squalid living conditions on 22 March 2021. The report identified concerns about failures to notify Stockport Social Services of her move, the absence of adequate quality assurance for private care, and her becoming unseen by agencies after an initial benefits claim and GP visit.

    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

    Loss of agency visibility of vulnerable people after initial contact

    Wider context from the report

    “4. After her initial claim for payment and her initial GP visit she dropped out of sight of agencies until she was found. ”

    Source location

    Diane Margaret Austin-Martin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Established GP registration processes, assessment, referrals and follow-up were considered appropriate for managing the patient’s long-term conditions.

    Verbatim wording from the response

    “Your fourth and final concern noted that Ms Austin Martin dropped out of sight of agencies. NHS England has noted that there are robust processes in place across the Stockport GP population around the management of newly registered patients. The expectation is that following registration, an initial appointment will be offered to the patient which would include an assessment of medical needs, the prescribing of medications, and a plan agreed for how care will be managed moving forward and when any regular medications will be reviewed. The GP Practice where this patient was registered, have confirmed that Ms Austin-Martin was seen at a face-to-face consultation on 6th November 2019 shortly after registering on 30th October.”

    Source location

    Response from Department of health and Social Care
    Page 2 · response
    Published 6 October 2022

    Open published response
  4. Cumbria

    AI-generated summary

    Patricia Ann Douglas · 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

    Patricia Ann Douglas contacted NHS 111 with severe breathlessness and a history of anaemia requiring a blood transfusion. Her referral to a Covid assessment service contained an incomplete telephone number, so the doctor could not contact her and the call was closed; she later deteriorated, collapsed at A&E and could not be resuscitated. Concerns included the initial triage pathway, the failure to follow up the referral, and a potentially missed opportunity to investigate and treat her.

    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 accurate telephone contact details to support appropriate action after call handling

    Wider context from the report

    “(2) The call was closed by CCAS without further action due to an incorrect telephone number being recorded. The call was from an elderly lady who on the face of it seemed significantly unwell. Would referrals in similar circumstances to local providers [GP or out of hours services] who may be better placed to follow up be worth considering? ”

    Source location

    Patricia Ann Douglas · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Cornwall and Isles of Scilly

    AI-generated summary

    Miriam Roach · 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

    Miriam Roach, who had a history of depression, anxiety, alcohol dependency and self-harm, was discharged from hospital on 30 June 2017 after assessment following an overdose. She died by suicide on 1 July 2017 by hanging. The substantive concerns related to aftercare and the absence of arrangements to contact patients discharged home with moderate to high risks of self-harm or suicide.

    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 put in place contact arrangements for patients discharged home at moderate to high risk of self-harm or suicide

    Wider context from the report

    “(1) Regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide. (2) Specifically the obligations for putting in place contact arrangements for such patients. ”

    Source location

    Miriam Roach · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Inner South London

    AI-generated summary

    Gary Richards · 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

    Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

    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 reliable communication pathways for follow-up

    Wider context from the report

    “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”

    Source location

    Gary Richards · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Follow-up was attempted using the patient’s recorded telephone number and messages through A&E, rather than wholly failing through absent communication pathways.

    Verbatim wording from the response

    “A further review of Mr Richards’ records indicates that when he was seen in the outpatient clinic in June, the service was aware of his mobile phone number. In fact, he had been called the day before by a social worker at the community team and asked to attend the outpatient appointment on 14 June as his GP had been concerned that he had again reported suicidal ideation.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 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

    Further contact was constrained because the patient remained homeless and his sole recorded telephone number became unobtainable.

    Verbatim wording from the response

    “She tried, using the number on file, but it was unobtainable. There was no other way of making contact with Mr Richards, so she left a message at the A&E department asking him to make contact with her should he re-present as he had booked an appointment to see her on 2 October.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 3 · response
    Published 9 May 2014

    Open published response
  7. Gateshead and South Tyneside

    AI-generated summary

    Joan Farran · 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

    Joan Farran, who had multiple co-morbidities and was cared for by her adult son, died at home from bronchopneumonia due to chronic obstructive pulmonary disease and Alzheimer’s disease. The report states that her death from a potentially treatable pneumonia was contributed to by neglect in obtaining medical support and treatment. Concerns included inadequate coordination and information-sharing between agencies, limited assessment of the home environment, withdrawal of community visits without replacement services, and the cancellation of a GP home visit without further follow-up.

    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 follow-up contact and home visits after service withdrawal or missed review

    Wider context from the report

    “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death. 8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present. 9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing. 10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however. 11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December. 12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency. 13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism. 14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided. 15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them. 16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after. 17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services. 18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies. ”

    Source location

    Joan Farran · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026