Recurring concern

Unreliable information sharing for people with fluctuating mental capacity

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First reported 11 Aug 2021•Latest report 30 Oct 2024

Definition

What this concern includes

Includes failures in capacity-sensitive information-sharing arrangements for people with potentially fluctuating mental capacity, including determining what information may be shared, clarifying the person's wishes and understanding, recording decisions, applying consent and non-consent safeguards, and revisiting arrangements when circumstances or capacity change.

Not included

  • Excludes generic inter-agency or clinical information-sharing failures where fluctuating or decision-making capacity is not a material part of the asserted concern.
  • Excludes failures limited to assessing mental capacity where information sharing is not the deficient control.
  • Excludes general family involvement, communication or care-planning failures where no capacity-sensitive information-sharing issue is identified.
  • Excludes failures to act on information after it has been appropriately shared and recorded.
  • Excludes the broader Mental Capacity Act application concern where the assertion does not specifically concern information-sharing arrangements.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2021–2024

First to latest report issue date

Stated actions
2

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.

Kent County Council1
West Midlands Police1

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. Birmingham and Solihull

    AI-generated summary

    Sebastian Benjamin OLIVER · 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

    Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.

    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 seek clarification and communicate effectively with medical colleagues about fluctuating or lacking capacity

    Wider context from the report

    “3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call). 4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check". 5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed. 6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres. It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue. 7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity. ”

    Source location

    Sebastian Benjamin OLIVER · 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

    Require officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.

    Verbatim wording from the response

    “(iii) Collaboration with partners: Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded utilising WMP systems and fed back to WMP supervisors and shared with the reporting partner agency. Whilst WMP can professionally challenge partners it is more appropriate to follow the process in the best interest of the public and inaccuracies be fed back within working groups such as Joint Strategic Operation Groups (JSOG) to aid future learning.”

    Source location

    Response from West Midlands Police
    Page 5 · response
    Published 1 November 2024

    Open published response

  2. North East Kent

    AI-generated summary

    Hadley John Savory · 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

    Hadley John Savory was discharged from hospital on 25 September 2019 without evidence of a multi-agency planning meeting, and his care, support and treatment plan was unclear. His presentation later declined in the community, safeguarding referrals did not lead to multi-agency meetings, and he was found dead at home on 13 December 2019; toxicological evidence indicated that he had taken a lethal dose of methadone. The principal concerns related to hospital discharge planning, allocation of care responsibilities, meeting eligible care needs, safeguarding procedures for self-neglect or hoarding, and information sharing where mental capacity may fluctuate.

    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 clear information-sharing arrangements for service users with potentially fluctuating mental capacity

    Wider context from the report

    “(5) It was unclear as to how information sharing operated in respect of service users who are identified as potentially having fluctuating mental capacity in respect of their care and support needs. ”

    Source location

    Hadley John Savory · 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

    Continue participating in the Kent and Medway Information Partnership to support lawful, safe and secure information sharing.

    Verbatim wording from the response

    “Information sharing should be more robust under these new/revised policies and procedures. In addition, KCC remain committed to appropriate information sharing by continuing to be a signatory on the Kent and Medway Information Partnership, which promotes openness and transparency in information sharing, as well as appropriate governance and support, which assists us to share personal information lawfully, safely, and securely.”

    Source location

    Response-from-Kent-County-Council
    Page 5 · response
    Published 19 August 2021

    Open published response
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Data last updated 7 September 2026