Recurring concern

Failure to provide required annual Care Act reviews

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First reported 3 Jan 2020•Latest report 28 May 2021

Definition

What this concern includes

Includes failures of the annual Care Act review process for eligible service users, including missed, delayed or inadequately completed reviews and failures of the arrangements needed to ensure reviews occur when due.

Not included

Excludes general community care assessments, care planning or reviews that are not explicitly annual Care Act reviews for eligible service users.
Excludes failures to provide care packages or support after a review unless the review process itself was deficient.
Excludes generic staffing, documentation or governance deficiencies unless they directly cause or constitute failure to complete a required annual Care Act review.

Reports: 2
Individual concerns: 3
Date range: 2020–2021
Stated actions: 4

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.

Brighton and Hove City Council1

Department of Health and Social Care1

National Institute for Health and Care Excellence1

NHS Surrey and Sussex Integrated Care Board1

Stockport Borough Council1

Sussex 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.

28 May2021
Brighton and Hove
Concerns raised1
1. Failure to repeat Care Act assessments annually
This report raised 11 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 1
1. Action
  Review Care Act training and adjust it to refresh multi-agency coordination and consideration of review.
  Stated by Brighton and Hove City CouncilStated planned
AI-generated summary

KEVIN JOHN FITTON · 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 Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.

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 repeat Care Act assessments annually
Wider context from the report
“(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented. It should have been repeated annually – it was not. ”
Source location
KEVIN JOHN FITTON · 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
Review Care Act training and adjust it to refresh multi-agency coordination and consideration of review.

Verbatim wording from the response
“• We will review our Care Act training on offer and make any adjustments necessary to ensure that the key aspect of co-ordination in multi-agency work, and consideration of review, are refreshed features.”

Source location
2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
Page 4 · response
Published 27 May 2021
Open published response
3 Jan2020
Manchester South
Concerns raised2
1. Failure to provide annual Care Act Reviews to eligible service users
2. Insufficient resources for councils to undertake annual Care Act reviews
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.
Actions described in response 3
1. Action
  Create a dedicated team of six social workers and a manager to address the Learning Disabilities Service review backlog during 2020/21.
  Stated by Stockport Borough CouncilStated in progress
2. Action
  Evaluate staffing resources and develop a sustainable model for managing Learning Disabilities Service reviews from April 2021.
  Stated by Stockport Borough CouncilStated planned
3. Action
  Provide councils with access to additional social care funding to support rising demand and stabilise services.
  Stated by Department of Health and Social CareStated in progress
Respondent positions 1
1. Position
  Stockport Council is responsible for meeting its statutory duty to conduct regular care-plan reviews.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

James Thomas Wheeler · 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

James Thomas Wheeler, who had refractory epilepsy alongside cerebral palsy and severe learning disability, was found unresponsive at Cheddle Lodge on 22 January 2018 and died shortly afterwards. The inquest concluded that he died following a nocturnal epileptic seizure while unobserved and not actively monitored. Concerns included the lack of authoritative UK guidance on monitoring people with refractory epilepsy and assistive technology, failures to provide required annual Care Act Reviews, and insufficient resources for local authorities to fulfil those duties.

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 provide annual Care Act Reviews to eligible service users
Wider context from the report
“2. To Ms Pam Smith, Chief Executive, Stockport Metropolitan Borough Council The court heard evidence that, notwithstanding the Local Authority’s statutory obligations under the Care Act 2014 in this regard, Mr Wheeler (and indeed many other eligible service users) did not receive annual Care Act Reviews as required by law. Whilst the court heard evidence about the process of transformation of adult social care underway within the Local Authority, it is a matter of concern that the default position still appears to be that an obligatory Care Act Review will not take place, unless some exceptional circumstance is identified about the case. ”
Source location
James Thomas Wheeler · Prevention of Future Deaths report
Page 3 · 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
Insufficient resources for councils to undertake annual Care Act reviews
Wider context from the report
“3. To Rt. Hon. Matt Hancock, Secretary of State for Health and Social Care The court heard evidence that, whilst parliament had conferred on Local Authorities a statutory duty to undertake annual reviews pursuant to the Care Act 2014, insufficient resources had been made available to enable councils to discharge this duty alongside existing statutory obligations. ”
Source location
James Thomas Wheeler · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Create a dedicated team of six social workers and a manager to address the Learning Disabilities Service review backlog during 2020/21.

Verbatim wording from the response
“However, at present Stockport Council is in the process of addressing these matters. A business case has been presented and agreed, in order to fund and create a dedicated review team comprising initially of six social workers plus a team manager - including an option to increase staff numbers as required - with a view to addressing the entire backlog of reviews throughout the financial year 2020/21. Furthermore, additional work will be undertaken with the intention of evaluating Stockport Council’s staffing resource and implementing a sustainable model for managing reviews from April 2021 onwards.”

Source location
2020-0001-Response-from-Stockport-Metropolitan-Borough-Council-Redacted
Page 1 · response
Published 22 January 2020
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
Evaluate staffing resources and develop a sustainable model for managing Learning Disabilities Service reviews from April 2021.

Verbatim wording from the response
“However, at present Stockport Council is in the process of addressing these matters. A business case has been presented and agreed, in order to fund and create a dedicated review team comprising initially of six social workers plus a team manager - including an option to increase staff numbers as required - with a view to addressing the entire backlog of reviews throughout the financial year 2020/21. Furthermore, additional work will be undertaken with the intention of evaluating Stockport Council’s staffing resource and implementing a sustainable model for managing reviews from April 2021 onwards.”

Source location
2020-0001-Response-from-Stockport-Metropolitan-Borough-Council-Redacted
Page 1 · response
Published 22 January 2020
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 councils with access to additional social care funding to support rising demand and stabilise services.

Verbatim wording from the response
“To support local authorities, we are providing councils with access to an additional £1.5billion for adults and children’s social care next year. This includes an additional £1billion of grant funding for adults and children’s social care, and a proposed 2 per cent precept⁴ that will enable councils to access a further £500million for adult social care. This £1.5billion is on top of maintaining the £2.5billion of existing social care grants and will support local authorities to meet rising demand and continue to stabilise the social care system.”

Source location
2020-0001-Response-from-the-Department-of-Health-and-Social-Care-Redacted-1
Page 2 · response
Published 22 January 2020
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
Stockport Council is responsible for meeting its statutory duty to conduct regular care-plan reviews.

Verbatim wording from the response
“I am deeply concerned that the inquest into Mr Wheeler’s death found that annual reviews of his care were not conducted as required by the Social Care Act 2014¹. I am equally concerned at the suggestion in your report that Stockport Metropolitan Borough Council social services may not be carrying out annual reviews of care apart from under exceptional circumstances. I expect Stockport Council to look into this matter thoroughly.”

Source location
2020-0001-Response-from-the-Department-of-Health-and-Social-Care-Redacted-1
Page 1 · response
Published 22 January 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to repeat Care Act assessments annually

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.1

Concerns raised2

Failure to provide annual Care Act Reviews to eligible service users

Insufficient resources for councils to undertake annual Care Act reviews

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.3

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

Actions described in response 1

Actions described in response 3

Respondent positions 1