Recurring concern

Insufficient social and community care provision to meet care and discharge needs

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First reported 7 Nov 2014•Latest report 18 Jun 2026

Definition

What this concern includes

Includes inadequate capacity, availability or provision of social and community care services where it leaves people without required care or prevents timely, safe discharge from hospital or other care settings.

Not included

Excludes failures limited to a specific community-care assessment, referral, funding or care-package process where that named process is the unsafe condition.
Excludes acute hospital, ambulance or primary-care capacity deficiencies unless the assertion specifically identifies inadequate social or community care provision as the contributing unsafe condition.
Excludes individual care-quality failures after adequate social or community care provision has been arranged.
Excludes generic health and social care system resource concerns that do not identify insufficient social or community care provision affecting care or discharge.

Reports: 31
Individual concerns: 35
Date range: 2014–2026
Stated actions: 110

Reports 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.

Department of Health and Social Care22

Gwynedd Council4

NHS England4

Betsi Cadwaladr University LHB3

Conwy County Borough Council3

Denbighshire County Council3

Flintshire County Council3

Isle of Anglesey County Council3

Welsh Ambulance Services NHS Trust3

Welsh Government3

Wrexham County Borough Council3

NHS Greater Manchester Integrated Care Board2

NHS Kent and Medway Integrated Care Board2

Association of Ambulance Chief Executives1

Care Quality Commission1

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.

6 Jul2023
North Wales (East and Central)
Concerns raised1
1. Lack of adequate social care placements or community care for patients medically fit for hospital discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Emlyn Victor Roberts · 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

Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.

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 adequate social care placements or community care for patients medically fit for hospital discharge
Wider context from the report
“Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable. It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community). I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions. ”
Source location
Emlyn Victor Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jun2023
North Wales (East and Central)
Concerns raised1
1. Insufficient social care capacity causing hospital patient-flow and ambulance offload delays
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jean Frickel · 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

Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.

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
Insufficient social care capacity causing hospital patient-flow and ambulance offload delays
Wider context from the report
“There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available. I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals). I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. Specifically, I require responses to the following:- 1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and 2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and 3. Extent of Strategic plan of action / improvement plan to address the above issues. ”
Source location
Jean Frickel · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jun2023
North Wales (East and Central)
Concerns raised1
1. Inadequate social care placements or community care for patients medically fit for discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Leonard Charles Harmsworth · 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

Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.

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
Inadequate social care placements or community care for patients medically fit for discharge
Wider context from the report
“Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff. Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community). I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals. I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. ”
Source location
Leonard Charles Harmsworth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Oct2022
Cheshire
Concerns raised1
1. Lack of resources across primary, secondary and social care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  System-wide causes of ambulance delays must be addressed nationally by NHS England, the Department of Health and Social Care, and the wider health system.
  Stated by Association of Ambulance Chief ExecutivesRedirects responsibility
AI-generated summary

Charles Stephen Rothwell · 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

Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.

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 resources across primary, secondary and social care
Wider context from the report
“1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same. 2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.” 3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h. 4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand. 5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care. ”
Source location
Charles Stephen Rothwell · 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
System-wide causes of ambulance delays must be addressed nationally by NHS England, the Department of Health and Social Care, and the wider health system.

Verbatim wording from the response
“As you have laid out in your fifth area above these are system issues and not merely ambulance issues and require a system led response to provide solutions. The following areas are contributing to ambulance response time delays nationally.”

Source location
Response from Association of Ambulance Chief Executives
Page 2 · response
Published 10 October 2022
Open published response
12 Mar2022
North East Kent
Concerns raised1
1. Insufficient funding and replacement support for wrap-around home care
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  Kent County Council is responsible for commissioning social care services in Kent.
  Stated by Kent and Medway Clinical Commissioning GroupRedirects responsibility
1. Position
  The Department cannot comment on matters relating to school support or children’s social care.
  Stated by Department of Health and Social CareUnable to act
2. Position
  Concerns about school support or children’s social care should be raised directly with the Department for Education.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Samuel Alban Stanley · 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

Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.

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
Insufficient funding and replacement support for wrap-around home care
Wider context from the report
“(2) Evidence was given at the inquest that the social workers from Kent County Council were fully aware of Sammy’s high-risk behaviour and had on several occasions referred him to their Children with Disabilities team who refused to assess him. Sammy’s behaviour was also having an adverse impact on his three younger siblings. His mother had repeatedly reported that she could not keep Sammy safe without support and had sought assistance from state agencies, Charites and done as much as she possibly could herself. Social workers took steps to try to access support for his family to enable them to care for him but the way services were managed meant those involved had little knowledge of what was available. One social worker gave evidence that Sammy’s behaviour had escalated between August 2019 and January 2020 when he did not have access to support in the home. However, despite being aware that Sammy needed more support to provide wrap around care before and after the school day only very limited support was funded from the end of January 2020. When the advice was given for him to shield in March 2020, due to the Covid 19 pandemic, he now had to isolate and was without the supportive school environment yet no replacement support was provided despite the need being obvious. ”
Source location
Samuel Alban Stanley · 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
Kent County Council is responsible for commissioning social care services in Kent.

Verbatim wording from the response
“Clinical commissioning groups were established as part of the Health and Social Care Act in 2012 and are responsible for commissioning healthcare services for their local populations. They are also system leaders with a key role to play in improving the quality of care and their role does not sit in isolation. However, they are not directly responsible for the provision of services and nor are they responsible for the commissioning of social care services, which in Kent is the responsibility of Kent County Council.”

Source location
Response from Kent and Medway Clinical Commissioning Group
Page 1 · response
Published 17 March 2022
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 Department cannot comment on matters relating to school support or children’s social care.

Verbatim wording from the response
“Finally, I would add that this Department is not able to comment on issues relating to school support or children’s social care. You may, therefore, also wish to raise your concerns directly with the Department for Education, at the below address:”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 17 March 2022
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
Concerns about school support or children’s social care should be raised directly with the Department for Education.

Verbatim wording from the response
“Finally, I would add that this Department is not able to comment on issues relating to school support or children’s social care. You may, therefore, also wish to raise your concerns directly with the Department for Education, at the below address:”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 17 March 2022
Open published response
31 Jan2022
North West Wales
Concerns raised1
1. Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 17
1. Action
  Consider providing nursing care internally at a Gwynedd site to increase nursing provision and stabilise the care market.
  Stated by Gwynedd CouncilStated in progress
2. Action
  Convert general residential beds into residential EMI beds in Council homes, supported by building investment and additional staffing.
  Stated by Gwynedd CouncilStated completed
3. Action
  Extend EMI provision within Council homes.
  Stated by Gwynedd CouncilStated in progress
1. Action
  Develop a new EMI unit at Hafod Mawddach Home.
  Stated by Gwynedd CouncilStated in progress
2. Action
  Develop an additional EMI unit at Plas Hedd Home.
  Stated by Gwynedd CouncilStated planned
3. Action
  Work with the Health Board, social housing partners and neighbouring counties to plan, commission and develop care provision across boundaries.
  Stated by Gwynedd CouncilStated in progress
4. Action
  Complete the statutory population needs assessment to inform future placement requirements.
  Stated by Gwynedd CouncilStated completed
5. Action
  Undertake more localised detailed work to assess whether future placement numbers are sufficient.
  Stated by Gwynedd CouncilStated planned
6. Action
  Present the North Wales care market stability report to the Government during summer 2022.
  Stated by Gwynedd CouncilStated planned
7. Action
  Provide additional funding to strengthen the social care sector and support pandemic-related costs.
  Stated by Welsh GovernmentStated completed
8. Action
  Run the WeCare.Wales national recruitment campaign to support social care workforce recruitment.
  Stated by Welsh GovernmentStated in progress
9. Action
  Increase funding for targeted recruitment initiatives and support people considering social care employment.
  Stated by Welsh GovernmentStated completed
10. Action
  Announce introduction of the Real Living Wage for social care workers.
  Stated by Welsh GovernmentStated completed
11. Action
  Continue working with the Social Care Fair Work Forum to consider further measures to attract people into social care.
  Stated by Welsh GovernmentStated in progress
12. Action
  Develop a national care and support framework setting commissioning standards, with implementation overseen by a National Office.
  Stated by Welsh GovernmentStated planned
13. Action
  Strengthen regional partnership arrangements covering governance, scrutiny, planning, performance, engagement, integrated delivery and social care market rebalancing.
  Stated by Welsh GovernmentStated planned
14. Action
  Write to regional partnership, health board and social services leaders asking them to review older people’s residential care provision and assess sufficiency in forthcoming reports.
  Stated by Welsh GovernmentStated planned
Respondent positions 3
1. Position
  The link between the incident and availability of an EMI placement is not entirely clear.
  Stated by Gwynedd CouncilDisputes the concern
1. Position
  Legislative restrictions prevent the Council from providing nursing care directly, making response to a nursing-home closure challenging.
  Stated by Gwynedd CouncilUnable to act
2. Position
  Local authorities and health boards are responsible for planning and commissioning sufficient residential and nursing care provision.
  Stated by Welsh GovernmentRedirects responsibility
AI-generated summary

Eirlys Wynne Roberts · 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

Eirlys Wynne Roberts, aged 93, suffered a fall at a residential home, fractured her neck of femur, underwent surgery, and died a short time later. The report raised concern about the shortage and lack of timely availability of residential, EMI residential, and EMI nursing placements for elderly people whose cognitive and physical care needs change, potentially putting them at 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
Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs
Wider context from the report
“There was evidence heard during the Inquest that when a residential home was required given the deceased’s needs that the homes in Gwynedd were all full and that consideration would need to be given to placements outside of the area. Eventually a placement was identified. When further deterioration was noted whereby the deceased required a higher level of care by way of an EMI residential placement one was not immediately available. The deceased therefore remained at the residential home. When her needs further increased whereby an EMI nursing placement was required, again there was no availability. I am concerned by the lack of available placements for the elderly as and when their cognitive and physical needs change thereby putting them at risk. The evidence was that there is a shortage of placements and it is concerning that specific needs of the elderly cannot always be met either at all or in a timely manner. ”
Source location
Eirlys Wynne Roberts · Prevention of Future Deaths report
Page 1 · 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
Consider providing nursing care internally at a Gwynedd site to increase nursing provision and stabilise the care market.

Verbatim wording from the response
“As I have already mentioned, we are facing a specific challenge regarding the lack of nursing placements, and particularly nursing homes that are able to provide EMI care. Regrettably, one of our nursing homes has closed recently, and this has added obvious pressure on the entire system. As is the case in every other county in Wales, the Council is not permitted to provide nursing care by itself due to legislative restrictions, and therefore, attempting to respond to the sudden closure of a nursing home is incredibly challenging. Consequently, we as a Council and in partnership with the Health Board, are currently considering the option of stepping in to provide nursing care as an internal provider at a specific site in Gwynedd. We are considering taking this innovative step so that we can stabilise the market somewhat, as well as increase the nursing provision in Gwynedd.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 2 · response
Published 4 February 2022
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
Convert general residential beds into residential EMI beds in Council homes, supported by building investment and additional staffing.

Verbatim wording from the response
“In addition, we are facing a challenge with the availability of residential EMI placements. In terms of general residential placements, the availability of placements against the demand is much better. In order to respond to the lack of residential EMI placements, the Council, for a number of years, has converted general residential beds into residential EMI beds within the internal homes. This work has involved a substantial investment in the buildings and in additional staff. Over the past 5 years, Gwynedd Council has almost doubled the number of Residential EMI beds in our homes.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022
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
Extend EMI provision within Council homes.

Verbatim wording from the response
“Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022
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 new EMI unit at Hafod Mawddach Home.

Verbatim wording from the response
“Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022
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 an additional EMI unit at Plas Hedd Home.

Verbatim wording from the response
“Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022
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
Work with the Health Board, social housing partners and neighbouring counties to plan, commission and develop care provision across boundaries.

Verbatim wording from the response
“In the future, our hope as a local authority will be to develop a residential EMI provision at Plas Gwilym Home (as a part of Canolfan Lleu), Plas Pengwaith Home and within the development of the Penyborth site, Penrhos. We are also working in partnership with the Health Board and partners in the social housing field to develop the market further. An example of this is the plans being developed on the Penyborth site at Penrhos, Llŷn and for Canolfan Lleu, Penygroes.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022
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
Complete the statutory population needs assessment to inform future placement requirements.

Verbatim wording from the response
“A key part of the forward planning that is done in an attempt to secure the appropriate number of care placements is the population needs assessment. This assessment is a statutory requirement and it is carried out every five years. The latest assessment was approved by Gwynedd Council at the Full Council on 3 March this year. Underneath this high”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022
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
Undertake more localised detailed work to assess whether future placement numbers are sufficient.

Verbatim wording from the response
“A key part of the forward planning that is done in an attempt to secure the appropriate number of care placements is the population needs assessment. This assessment is a statutory requirement and it is carried out every five years. The latest assessment was approved by Gwynedd Council at the Full Council on 3 March this year. Underneath this high”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022
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
Present the North Wales care market stability report to the Government during summer 2022.

Verbatim wording from the response
“We are also considering the care market and its ability to respond to the demand for care services today and in the future, and we intend to present the report on the 'Stability of the Care Market in North Wales' to the Government during the summer 2022. The conclusions within this report will show the steps that need to be addressed in order to ensure a suitable provision to meet the demand.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 4 · response
Published 4 February 2022
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
Provide additional funding to strengthen the social care sector and support pandemic-related costs.

Verbatim wording from the response
“Financial support During the Covid pandemic the Welsh Government has made significant resources available to local authorities and health boards, to ensure that social care providers can meet the additional costs arising because of the pandemic. The recently published Welsh Government budget for 2022-25 provides an additional £180m to local authorities directly to strengthen the social care sector, with further reform and capital funding also being allocated.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 2 · response
Published 4 February 2022
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
Run the WeCare.Wales national recruitment campaign to support social care workforce recruitment.

Verbatim wording from the response
“Workforce Building a sustainable social care workforce remains a key priority for us, and we have been working with the regulator and the social care sector to meet this challenge. As well as the WeCare.Wales national recruitment campaign, which has been running from August 2021, we have increased funding to ensure targeted recruitment initiatives and additional supports to people who are considering entry into social care employment.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022
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
Increase funding for targeted recruitment initiatives and support people considering social care employment.

Verbatim wording from the response
“Workforce Building a sustainable social care workforce remains a key priority for us, and we have been working with the regulator and the social care sector to meet this challenge. As well as the WeCare.Wales national recruitment campaign, which has been running from August 2021, we have increased funding to ensure targeted recruitment initiatives and additional supports to people who are considering entry into social care employment.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022
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
Announce introduction of the Real Living Wage for social care workers.

Verbatim wording from the response
“In addition, our announcement of the introduction of the Real Living Wage provides a starting point for improved terms and conditions for social care workers, and we continue to work with the Social Care Fair Work Forum to consider what more can be done to attract people into the social care sector.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022
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
Continue working with the Social Care Fair Work Forum to consider further measures to attract people into social care.

Verbatim wording from the response
“In addition, our announcement of the introduction of the Real Living Wage provides a starting point for improved terms and conditions for social care workers, and we continue to work with the Social Care Fair Work Forum to consider what more can be done to attract people into the social care sector.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022
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 national care and support framework setting commissioning standards, with implementation overseen by a National Office.

Verbatim wording from the response
“In January 2021 Welsh Government issued the Rebalancing Care and Support White Paper, proposing legislative and other changes we believe are essential to securing the vision set out in the Act.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022
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
Strengthen regional partnership arrangements covering governance, scrutiny, planning, performance, engagement, integrated delivery and social care market rebalancing.

Verbatim wording from the response
“These included the development of a strategic National Framework for care and support, which will set standards for commissioning practice, reduce complexity, and focus on quality and outcomes. The implementation of this Framework will be overseen by a National Office within Welsh Government. In addition, we are committed to strengthening regional partnership arrangements to support stronger partnership working and deliver for local populations, with a focus on governance and scrutiny, planning and performance, engagement and voice, integrated service delivery, and rebalancing the social care market.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022
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
Write to regional partnership, health board and social services leaders asking them to review older people’s residential care provision and assess sufficiency in forthcoming reports.

Verbatim wording from the response
“The Minister for Health and Social Services will write to the Chairs of the seven Regional Partnership Boards in Wales, the Chief Executives of the Health Boards and Directors of Social Services to ask them to review their current provision for older peoples residential care, including EMI beds and to ensure that their imminent Population Needs Assessments and Market Stability Reports robustly explore the sufficiency of provision. Any action to improve the commissioning and sufficiency of such provision should then be set out in their forthcoming Area Plans.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022
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 link between the incident and availability of an EMI placement is not entirely clear.

Verbatim wording from the response
“The situation of waiting for a bed in an alternative placement is quite common for a number of individuals across the country. Of course, we have given careful consideration to the notice, however as I have previously noted, the link between the circumstances of the incident and the availability of an EMI placement is not entirely clear. However, wherever a higher level of care is needed when attempting to find or secure an appropriate placement, more advanced care arrangements are put in place in order to safeguard the individual until a solution is reached. This is based on appropriate risk assessments and care plans.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 4 · response
Published 4 February 2022
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
Legislative restrictions prevent the Council from providing nursing care directly, making response to a nursing-home closure challenging.

Verbatim wording from the response
“As I have already mentioned, we are facing a specific challenge regarding the lack of nursing placements, and particularly nursing homes that are able to provide EMI care. Regrettably, one of our nursing homes has closed recently, and this has added obvious pressure on the entire system. As is the case in every other county in Wales, the Council is not permitted to provide nursing care by itself due to legislative restrictions, and therefore, attempting to respond to the sudden closure of a nursing home is incredibly challenging. Consequently, we as a Council and in partnership with the Health Board, are currently considering the option of stepping in to provide nursing care as an internal provider at a specific site in Gwynedd. We are considering taking this innovative step so that we can stabilise the market somewhat, as well as increase the nursing provision in Gwynedd.”

Source location
2022-0034-Response-from-Gwynedd-Council_Published
Page 2 · response
Published 4 February 2022
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
Local authorities and health boards are responsible for planning and commissioning sufficient residential and nursing care provision.

Verbatim wording from the response
“Integrated planning and commissioning Welsh Government has put in place mechanisms to enable Local Authorities and the NHS to better meet changing population needs. They have clear responsibilities to plan and commission care and support services that meet the needs of their local populations, including the commissioning of residential and nursing care for those who need it. Under the Act, local authorities and health boards are required to work together, through the Regional Partnership Boards, to produce five yearly Population Needs Assessments and Market Stability Reports. These must be based upon assessments of local population needs, the range and level of services required to meet those needs, sufficiency of provision, and the stability and sustainability of the market for regulated services such as domiciliary and residential care.”

Source location
2022-0034-Response-from-Welsh-Government_Published
Page 2 · response
Published 4 February 2022
Open published response
25 Feb2019
East London
Concerns raised2
1. Insufficient care support for a safe discharge home
2. Unavailability of community support arrangements
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Use care-planning documentation to record identified risks, mitigation, equipment, training requirements and available community support.
  Stated by Barts Health NHS TrustStated planned
2. Action
  Require acceptance by an appropriate community team and clear risk mitigation before discharging patients requiring 24-hour supervision.
  Stated by Barts Health NHS TrustStated completed
3. Action
  Include reviewed carer guidelines in discharge information and provide accessible onward-referral and joint-planning contact details.
  Stated by Barts Health NHS TrustStated planned
Respondent positions 1
1. Position
  Responsive community care was unavailable at the time because stroke Early Supportive Discharge provision for Redbridge residents was limited.
  Stated by Barts Health NHS TrustUnable to act
AI-generated summary

Brenda Kathleen GOWAN · 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

Brenda Gowan suffered a moderately severe stroke and was discharged home for a trial period despite being assessed as requiring 24-hour supervision and being at risk of falls. Five days after discharge, she fell near her bed in the early hours and sustained catastrophic head injuries, from which she died. Concerns included insufficient care and equipment, inadequate advice and assessment of night-time falls risk, and failure to reconsider the care plan after the family reported that she was getting up frequently at night.

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
Insufficient care support for a safe discharge home
Wider context from the report
“(1) Brenda was discharged home, less than 3 weeks after a moderately severe stroke, for a “trial period”. She required 24 hour supervision, but only 4 hours of social care was provided. Her family were expected to provide 20 hours of care. Her family did not consider that adequate steps had been taken to ensure that systems were in place to allow Brenda’s safe return home. The family were concerned about the amount of care support in place; the equipment required and the access to community services. There is no evidence that the family’s views were taken into account by the discharging team. ”
Source location
Brenda Kathleen GOWAN · 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
Unavailability of community support arrangements
Wider context from the report
“(4) There were no community support arrangements in place for the family to access, as the OT services had no contractual arrangement in place with Brenda’s registered GP. ”
Source location
Brenda Kathleen GOWAN · 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
Use care-planning documentation to record identified risks, mitigation, equipment, training requirements and available community support.

Verbatim wording from the response
“The Care Planning documentation will address the risks identified and how they are to be managed; the equipment required and whether it will be installed prior to discharge; the plan for any required training and detail of the community support available. Where equipment is required as essential for discharge this provision will be in place prior to discharge and checked as part of the discharge checklist. The completion of the Discharge Checklist will be monitored by the Ward Manager to ensure correct completion. Where needs change these will be re-assessed by a senior professional and where risks are identified this could include urgent re-admission to the stroke pathway.”

Source location
2019-0064_Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 2 June 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
Require acceptance by an appropriate community team and clear risk mitigation before discharging patients requiring 24-hour supervision.

Verbatim wording from the response
“We are however aware that the provision of responsive community care was not readily available for Mrs Gowan due to the limitations in stroke Early Supportive Discharge (ESD) provision at the time for Redbridge residents. Though a service does now exist, in order to ensure the safety of a patient requiring 24 hour supervision, Barts Health would not allow the discharge of such a patient without the acceptance from such a team and clear identification of risk mitigation.”

Source location
2019-0064_Response-by-Barts-Health-NHS-Trust
Page 3 · response
Published 2 June 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
Include reviewed carer guidelines in discharge information and provide accessible onward-referral and joint-planning contact details.

Verbatim wording from the response
“The current provision of carer guidelines has been reviewed and will be included in the discharge information provided to the patient and family on leaving hospital as part of the discharge checklist. This will ensure that contact details in regards to onward referral and joint health and social care planning are accessible.”

Source location
2019-0064_Response-by-Barts-Health-NHS-Trust
Page 3 · response
Published 2 June 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
Responsive community care was unavailable at the time because stroke Early Supportive Discharge provision for Redbridge residents was limited.

Verbatim wording from the response
“We are however aware that the provision of responsive community care was not readily available for Mrs Gowan due to the limitations in stroke Early Supportive Discharge (ESD) provision at the time for Redbridge residents. Though a service does now exist, in order to ensure the safety of a patient requiring 24 hour supervision, Barts Health would not allow the discharge of such a patient without the acceptance from such a team and clear identification of risk mitigation.”

Source location
2019-0064_Response-by-Barts-Health-NHS-Trust
Page 3 · response
Published 2 June 2019
Open published response
8 Sep2017
Black Country
Concerns raised1
1. Lack of post-discharge community aftercare
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Melvin James and Anne-Marie James · 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

Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.

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 post-discharge community aftercare
Wider context from the report
“3. Evidence also emerged during the inquest that after discharge, there was no formal referral or contact made with Mental Health services or his General Practitioner based in the Wolverhampton area. There was no evidence of any aftercare being delivered after discharge back into the community. ”
Source location
Melvin James and Anne-Marie James · Prevention of Future Deaths report
Page 3 · concerns
Open source report
14 Feb2017
Exeter and Greater Devon
Concerns raised1
1. Delays in discharge caused by inadequate social and community care resources
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
  Stated by Devon Partnership NHS TrustStated completed
2. Action
  Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.
  Stated by Devon Partnership NHS TrustStated completed
3. Action
  Provide temporary step-down care using spare recovery and rehabilitation ward capacity.
  Stated by Devon Partnership NHS TrustStated completed
1. Action
  Develop further alternatives to acute admission, including improved community support and additional step-down provision.
  Stated by Devon Partnership NHS TrustStated in progress
2. Action
  Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.
  Stated by NHS Devon Integrated Care BoardStated completed
3. Action
  Participate in workshops mapping current and future discharge and panel-approval processes.
  Stated by NHS Devon Integrated Care BoardStated completed
4. Action
  Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.
  Stated by NHS Devon Integrated Care BoardStated in progress
5. Action
  Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
  Stated by NHS Devon Integrated Care BoardStated in progress
6. Action
  Offer DPT additional management and consultative support from the urgent-care commissioning team.
  Stated by NHS Devon Integrated Care BoardStated completed
7. Action
  Work with Devon County Council on care-home commissioning and market sufficiency for older people.
  Stated by NHS Devon Integrated Care BoardStated in progress
AI-generated summary

Wendy Louise Telfer · 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

Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.

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
Delays in discharge caused by inadequate social and community care resources
Wider context from the report
“(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided. The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation. ”
Source location
Wendy Louise Telfer · 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
Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.

Verbatim wording from the response
“We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.”

Source location
2017-0046-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 5 March 2017
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
Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.

Verbatim wording from the response
“We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.”

Source location
2017-0046-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 5 March 2017
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
Provide temporary step-down care using spare recovery and rehabilitation ward capacity.

Verbatim wording from the response
“We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.”

Source location
2017-0046-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 5 March 2017
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 further alternatives to acute admission, including improved community support and additional step-down provision.

Verbatim wording from the response
“We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.”

Source location
2017-0046-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 5 March 2017
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
Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.

Verbatim wording from the response
“Monitoring of timely discharge performance data”

Source location
2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Page 1 · response
Published 5 March 2017
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
Participate in workshops mapping current and future discharge and panel-approval processes.

Verbatim wording from the response
“5. NEW Devon CCG, with Devon County Council representatives have participated in a series of workshops facilitated by DPT aimed at mapping current and future discharge and panel approval processes. NEW Devon CCG is awaiting the final report and recommendations for improvement in these processes from DPT;”

Source location
2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Page 2 · response
Published 5 March 2017
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
Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.

Verbatim wording from the response
“6. NEW Devon CCG is already leading a process, working in partnership with Devon County Council to streamline current processes for the approval of joint funding of s117 aftercare and are working towards a simplified s117 aftercare funding agreement;”

Source location
2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Page 2 · response
Published 5 March 2017
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
Work with DPT to identify solutions for additional step-down bed capacity in Exeter.

Verbatim wording from the response
“7. DPT have indicated a need for additional step down beds to be made available in the Exeter area and NEW Devon CCG is working with DPT to identify solutions for this need;”

Source location
2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Page 2 · response
Published 5 March 2017
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
Offer DPT additional management and consultative support from the urgent-care commissioning team.

Verbatim wording from the response
“8. NEW Devon CCG has offered DPT additional management and consultative support from its urgent care commissioning team who have had success in working with acute hospital providers to reduce delays in discharge;”

Source location
2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Page 2 · response
Published 5 March 2017
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
Work with Devon County Council on care-home commissioning and market sufficiency for older people.

Verbatim wording from the response
“9. NEW Devon CCG is working closely with Devon County Council with regard to care home commissioning and market sufficiency for older people.”

Source location
2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
Page 2 · response
Published 5 March 2017
Open published response
20 Oct2016
Leicester City and South Leicestershire
Concerns raised2
1. Lack of effective community psychiatric nurse involvement
2. Unavailability of community support for patients with challenging presentations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Ensure team staff understand the process for allocating a community worker after assessment, including through new-starter induction.
  Stated by Leicestershire Partnership NHS TrustStated completed
2. Action
  Implement comprehensive community-based mental health pathways so people access care at the right time and place.
  Stated by Department of Health and Social CareStated planned
3. Action
  Provide £400 million of additional investment through 2020/21 to improve community mental health provision.
  Stated by Department of Health and Social CareStated completed
1. Action
  Develop an integrated clinical pathway and care model for people with personality disorders, including a proposed bespoke enhanced community service.
  Stated by Leicestershire Partnership NHS TrustStated in progress
2. Action
  Continue negotiating commissioner contracts for provision of the proposed personality-disorder services.
  Stated by Leicestershire Partnership NHS TrustStated in progress
Respondent positions 3
1. Position
  The lack of effective community psychiatric nurse input was an isolated incident, not evidence that community support generally did not exist.
  Stated by Leicestershire Partnership NHS TrustDisputes the concern
1. Position
  Providing an enhanced community service for people with severe and complex personality disorder is outside the Trust’s current commissioning remit.
  Stated by Leicestershire Partnership NHS TrustOutside remit
2. Position
  Commissioners are responsible for developing and commissioning the proposed enhanced severe and complex personality disorder community service.
  Stated by Leicestershire Partnership NHS TrustRedirects responsibility
AI-generated summary

Victoria Georgia Halliday · 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

Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.

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 effective community psychiatric nurse involvement
Wider context from the report
“2) There was no, or no effective, community psychiatric nurse involvement and this was a missed opportunity to monitor and assist Victoria when she was in the community. ”
Source location
Victoria Georgia Halliday · 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
Unavailability of community support for patients with challenging presentations
Wider context from the report
“3) The “community support” referred to by the in-patient clinicians does not exist in reality for patients with this challenging presentation, leaving discharged patients and their families without adequate support. ”
Source location
Victoria Georgia Halliday · 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
Ensure team staff understand the process for allocating a community worker after assessment, including through new-starter induction.

Verbatim wording from the response
“In this case, the lack of effective CPN input during the time Victoria was a community patient was an isolated incident, with the assessing CPN failing to follow the standard operating team process, whereby the assessing worker accepts the person onto their case load if they have capacity. If they don’t have capacity the assessing worker should present the outcome of the assessment at the next Multi-Disciplinary team (MDT) meeting in order to allocate to a Community Worker/CPN within the Team.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 20 October 2016
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 comprehensive community-based mental health pathways so people access care at the right time and place.

Verbatim wording from the response
“We want to eliminate unnecessary out of area placements for adult acute mental health care by 2020/21 and reduce significantly delayed transfers of care so that people can move from hospital to care in the community, ensuring that beds are available for those most in need. We appreciate that this will not happen overnight but we are committed to delivering change. Also, through the Five Year Forward View, we will implement a comprehensive set of community-based mental health pathways of care so that people have access to care at the right time in the right place.”

Source location
2016-0370-Response-by-Department-of-Health
Page 2 · response
Published 20 October 2016
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
Provide £400 million of additional investment through 2020/21 to improve community mental health provision.

Verbatim wording from the response
“The Government announced an additional £400m investment up to 2020/21 to improve the quality of community mental health provision as an effective and safe alternative to hospital admission. This builds on the successful National Mental Health Crisis Care Concordat which has seen every local area develop a crisis care action plan to ensure that no-one in crisis is turned away.”

Source location
2016-0370-Response-by-Department-of-Health
Page 2 · response
Published 20 October 2016
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 an integrated clinical pathway and care model for people with personality disorders, including a proposed bespoke enhanced community service.

Verbatim wording from the response
“However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 20 October 2016
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
Continue negotiating commissioner contracts for provision of the proposed personality-disorder services.

Verbatim wording from the response
“Further to our response to concern 3, LPT is not commissioned to provide an “enhanced service” to provide support and treatment for people with a severe and complex personality disorder (SCPD) in the community. A group of our senior clinical and operational leaders, with support from Commissioners, are working together to develop an integrated clinical pathway and model for care for people with Personality Disorders. As part of this proposal a dedicated team to provide this enhanced service is proposed, the purpose of which is to provide an intensive community based treatment support for both patients in treatment, and in crisis. The aim is to link the pathway together with supporting services in primary care, social care, and Police. We continue to work with our commissioners to negotiate our 2017/2018 contracts for provision of services, of which this remains an ambition to provide.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 4 · response
Published 20 October 2016
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 lack of effective community psychiatric nurse input was an isolated incident, not evidence that community support generally did not exist.

Verbatim wording from the response
“A standard community service exists within LPT for people with personality disorder in the form of community mental health team (CMHT), Crisis Resolution Team (CRT) and Specialist Personality Disorder Service (FDL). Victoria was accessing all these services during the course of her contact with LPT. An identified Community Psychiatric Nurse (CPN) from the CMHT, CRT was present during professional and CPA meetings whilst Victoria was an inpatient. Due to the nature of Victoria’s presentation of presenting in different areas of the country in a crisis covering CPNs and CRT professionals tried to ensure continuity as much as possible.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 20 October 2016
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
Providing an enhanced community service for people with severe and complex personality disorder is outside the Trust’s current commissioning remit.

Verbatim wording from the response
“However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 20 October 2016
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
Commissioners are responsible for developing and commissioning the proposed enhanced severe and complex personality disorder community service.

Verbatim wording from the response
“However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 20 October 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of adequate social care placements or community care for patients medically fit for hospital discharge

Concerns raised1

Insufficient social care capacity causing hospital patient-flow and ambulance offload delays

Concerns raised1

Inadequate social care placements or community care for patients medically fit for discharge

Concerns raised1

Lack of resources across primary, secondary and social care

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Insufficient funding and replacement support for wrap-around home care

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.17

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Respondent positions 1

Respondent positions 3

Actions described in response 17

Respondent positions 3