Recurring concern

Failure to ensure appropriate risk assessment during welfare visits

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First reported 3 Oct 2018•Latest report 23 Nov 2023

Definition

What this concern includes

Includes failures of the welfare-visit process to identify, undertake, record, oversee or follow up appropriate health and safety or risk assessments, including failures to ensure that a risk assessment follows a visit when circumstances warrant one.

Not included

  • Excludes generic risk-assessment failures not connected to a welfare visit or comparable visit-based welfare process.
  • Excludes failures limited to conducting welfare checks or care visits when no risk-assessment deficiency is identified.
  • Excludes safeguarding, clinical, property-maintenance or care-planning deficiencies unless the report specifically identifies failure to assess risk during or after a welfare visit.
  • Excludes generic oversight or documentation deficiencies that do not directly impair the welfare-visit risk-assessment process.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2018–2023

First to latest report issue date

Stated actions
6

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.

Diocese of Northampton2
East Coast Community Healthcare C.I.C.2
Archdiocese of Westminster1
Patrick Stead Hospital1
Surrey County Council1

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. Surrey

    AI-generated summary

    Kevin Stephen O’Hara · 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 Stephen O’Hara, who was bedbound and lived alone with carers visiting four times a day, died in a fire at his home on 7 February 2023 after a lit cigarette ignited debris on a mattress used as a crash mat. The fire produced significant smoke and was detected only after smoke seeped through a closed living-room door to a hallway alarm. Concerns included inadequate review and oversight of Safe and Well Visits by Surrey Fire and Rescue Service, and insufficient oversight by Surrey Adult Social Care to ensure that required risk assessments followed visits.

    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

    Lack of oversight to ensure that appropriate risk assessments follow visits

    Wider context from the report

    “Evidence was given that the visit to Mr O’Hara by ASC on 23 January 2023 should have resulted in a risk assessment. Although ASC has policy (some of which predated Mr O’Hara’s death) about when to conduct a risk assessment it does not appear to have in place a system of oversight to ensure that where appropriate, risk assessments follow a visit. ”

    Source location

    Kevin Stephen O’Hara · Prevention of Future Deaths report
    Page 4 · 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

    Implement managerial oversight, allocation, recording and sign-off controls for Adult Social Care contacts, referrals, visits and Section 9 assessment decisions.

    Verbatim wording from the response

    “In relation to the concern regarding managerial oversight, SCC has procedures in place for managerial oversight of such visits, however, the coroner was not provided with evidence of these at the Inquest, SCC apologises for this. Several significant changes have been implemented following the death of Mr O’Hara to ensure robust management oversight following home visits and in relation to decision making around Section 9 assessments is in place and understood by all staff.”

    Source location

    Response from Surrey
    Page 2 · response
    Published 29 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

    Consider the risk-assessment policy and framework as a priority through the Practice Improvement Board.

    Verbatim wording from the response

    “The SCC Practice Improvement Board will be established from February 2024 and will have oversight of practice needs and improvements across the whole of ASC. This will be managed by the Principal Social Worker, Principal OT and the Safeguarding Lead and consideration of the risk assessment policy and framework has been confirmed as a priority.”

    Source location

    Response from Surrey
    Page 3 · response
    Published 29 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

    Implement the risk-based Safe and Well Visit points system and new assessment form service-wide.

    Verbatim wording from the response

    “SFRS have in place a risk-based points system for SWVs. Staff have received training on how to apply this points system and it is embodied in a new form (Appendix I). This system is aligned to the NFCC guidance on persons at risk from fire and the allocated points that are attached to the answers also align with national guidance. This allows SFRS to see those at most risk across the County and will allow SFRS to follow up with any further visits and liaise closely with other support agencies that may be involved with the individual. If further support and engagement is recommended, SFRS can revisit to try and engage, build relations and make progress on behaviour change to improve safety and mitigate risk. This process will be implemented service wide in 2024 when the new system is embedded in the Service.”

    Source location

    Response from Surrey
    Page 5 · response
    Published 29 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

    Develop and implement formal Safe and Well Visit quality assurance, including annual team shadowing, recording and safe-to-deliver certification.

    Verbatim wording from the response

    “Once assessed as competent, SWVs will be carried out by a staff member without being shadowed. However, there is a system of informal support throughout the Community Safety Team and any questions or concerns can be highlighted at any time before, during or after a visit, with assistance being given from the Partnership coordinator or any team member. This is currently an informal process that is not documented in a policy. As a result of the Coroner’s concerns and an His Majesty's Inspectorate of Constabularies and Fire Rescue Services (HMICFRS) inspection, a formal Quality Assurance process is now being developed (see below).”

    Source location

    Response from Surrey
    Page 4 · response
    Published 29 November 2023

    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 practitioner conducting the January 2023 visit was not required to be a qualified Occupational Therapist or Social Worker, provided competency requirements were met.

    Verbatim wording from the response

    “In relation to the concern that the practitioner who visited Mr O’Hara in January 2023 was not a qualified Occupational Therapist or Social Worker, SCC employ registered and unregistered staff to carry out their duties under the Care Act 2014. All new members of staff complete a 6-month probation period and induction programme to ensure they are aware of the requirements for their particular role. All staff receive supervision and appropriate training is provided to ensure the workforce is competent. Performance is regularly reviewed, including observational visits. The steps taken to improve managerial oversight will highlight practice and actions required ensuring the necessary assessments are taken by an appropriate practitioner.”

    Source location

    Response from Surrey
    Page 3 · response
    Published 29 November 2023

    Open published response

  2. Suffolk

    AI-generated summary

    Brian Alban Frost · 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

    Brian Alban Frost, a 92-year-old retired Roman Catholic priest who lived alone, died after an unwitnessed fall at home on 30 June 2018, sustaining severe head injuries. The report raised concerns about loose kitchen floor tiles presenting a trip hazard and about the inadequacy of welfare checks and health-and-safety risk assessments for retired clergy living in diocesan properties.

    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 undertake health and safety or risk assessments during welfare visits

    Wider context from the report

    “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. 9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home. ”

    Source location

    Brian Alban Frost · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Suffolk

    AI-generated summary

    Brian Alban Frost · 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

    Brian Alban Frost died after an unwitnessed fall at home in which he sustained severe head injuries. The report identifies loose kitchen floor tiles as a serious trip hazard and raises concerns that welfare checks for retired priests living in diocesan properties did not include independent health and safety or risk assessments, allowing hazards to remain unidentified and unrepaired.

    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

    Lack of independent health and safety assessment in welfare checks

    Wider context from the report

    “9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents who lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost’s home. 11. Given that this is the case I am concerned that other residents of ‘grace and favour’ homes provided by the Bishop of each dioceses, may now also be living in premises that may no longer be considered safe for their occupation. ”

    Source location

    Brian Alban Frost · Prevention of Future Deaths report
    Page 2 · concerns

    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 undertake health and safety or risk assessments during welfare visits

    Wider context from the report

    “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer, and if the retired priest was subject to ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost's home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. ”

    Source location

    Brian Alban Frost · 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

    Have a diocesan surveyor accompany the Clergy Welfare Officer on at least annual visits to retired priests.

    Verbatim wording from the response

    “• All Priests will continue to receive at least annual visits from the Diocesan Clergy Welfare Officer, but the Welfare Officer will be joined on those visits by one of the Diocesan Surveyors;”

    Source location

    2018-0362-Response
    Page 3 · response
    Published 26 April 2019

    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 full internal, external, fabric, condition, and health and safety assessments informed by each priest’s health and mobility.

    Verbatim wording from the response

    “• The Surveyor will carry out a full external and internal assessment of the property’s fabric and condition, together with a Health and Safety Assessment informed by the advice of the Welfare Officer about the health and mobility of the Priest;”

    Source location

    2018-0362-Response
    Page 4 · response
    Published 26 April 2019

    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 Diocese considered family support and annual pastoral visits sufficient to identify accommodation safety issues, rather than requiring day-to-day welfare safeguarding.

    Verbatim wording from the response

    “It also had no other legal obligations in relation to the welfare of Canon Frost merely because he was a retired priest of the Diocese. While it did ensure that a yearly pastoral visit was made to him, it was not thereby assuming a day to day responsibility to safeguard his welfare while resident at ████████ ████████. As you know certain other financial provision was made but this did not bring with it an obligation to ensure, for example, that nothing about the internal fabric of the house presented a day to day risk.”

    Source location

    2018-0362-Response
    Page 3 · response
    Published 26 April 2019

    Open published response
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Data last updated 7 September 2026