Recurring concern

Failure to provide effective regulatory oversight of providers serving vulnerable people

First to latest report 31 Jul 2017 — 26 Mar 2026

Reports that mention this concern
9
Times this concern has been raised
11
Stated actions linked to this concern
9

What this concern includes

Includes failures to establish, provide or maintain effective regulatory inspection, assessment or oversight of providers serving vulnerable people, including unregulated placements for young people, care agencies supplying staff to care homes, and supported accommodation for vulnerable residents.

What is not included
  • Excludes local-authority or commissioner due diligence and placement-suitability checks where no provider-level regulatory oversight deficiency is identified.
  • Excludes failures to inspect or monitor an individual placement after the provider's regulatory oversight arrangements are adequate.
  • Excludes general care quality, staffing, training or safeguarding deficiencies that are not tied to the absence or inadequacy of regulatory oversight of the provider.
  • Excludes regulated clinical or care providers where the reported concern is solely a failure to comply with an otherwise effective regulatory requirement.
  • Excludes generic housing, accommodation or service-provider concerns without a vulnerable-person safety context and a provider-level inspection or regulatory-oversight deficiency.

Reports and published responses 9 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Madison James Bruce SMITH · 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

    Madison James Bruce Smith was found unresponsive in his cot on 18 October 2024 after being placed prone to sleep by a person describing themselves as a maternity nurse. He died in hospital, and the cause of death was unascertained, although prone sleeping was identified as increasing the risk of sudden unexpected death. The report raised concerns about the lack of statutory regulation, training and qualification requirements for maternity nurses and agencies, and the misleading use of the term “nurse”.

    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 statutory regulation of maternity service agencies and individuals

    Wider context from the report

    “1.The inquest heard evidence that there is a significant demand from families with very young children who would like to get their children into a sleep routine at an early stage. To meet that demand there are now agencies and individuals who seek to meet that demand. However, the inquest was told that there is no statutory regulation of these individuals or of the agencies. Consequently, anyone can set up an agency that purports to offer training and expertise in maternity services. They need not have any formal training or any medical qualification. The courses they offer do not need to be quality assured or meet any minimum standards. ”

    Source location

    Madison James Bruce SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Northamptonshire

    AI-generated summary

    Jack Richard BROWN · 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

    Jack Richard BROWN, aged 86, was found unresponsive and died at a care home on 26 January 2023 after remaining asleep on a toilet overnight; the post-mortem examination concluded that he died due to ischemic heart disease. The report raised concerns that care agencies supplying staff to care and nursing homes are not required to register with or be regulated by the CQC or another body, creating risks around recruitment, suitability and training of agency carers.

    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 regulatory inspection of care agency recruitment processes

    Wider context from the report

    “At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. ”

    Source location

    Jack Richard BROWN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Regulated care providers, rather than employment agencies, are responsible for ensuring agency staff are suitably experienced, competent and recruited safely.

    Verbatim wording from the response

    “Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 1 December 2025

    Open published response

  3. Gloucestershire

    AI-generated summary

    Lamarah Grace Scarlett · 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

    Lamarah Grace Scarlett, a 12-year-old girl with alternating hemiplegia of childhood, became distressed and experienced breathing difficulties while being transported home from school on 24 September 2021. Her head became hyperextended, obstructing her airway; she arrived home unresponsive and was pronounced deceased despite resuscitation efforts. Concerns included the regulation, training, safety-plan compliance, handovers, first-aid qualifications, assessment, and oversight of operators providing home-to-school transport for children with special educational needs.

    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 a comprehensive schedule for inspection of transport operators

    Wider context from the report

    “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children? The following specific issues were identified: • The patient safety plans are not always read and understood by transport crew, • Home visits between passenger and transport crew often do not occur when contractually required, • The local authority are often not notified of personnel changes in the transport crew, • The need for proper handovers at drop off and pick up is not understood • There is no requirement for transport crew to be qualified first aiders, • The passenger assessment test requires further improvement, • There is no comprehensive schedule for inspection of transport operators, • There is no mandatory training or forums for operators to attend where information can be cascaded to them. • Operators have to approach multiple organisations which leads to confusion and inconsistency. ”

    Source location

    Lamarah Grace Scarlett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Avon

    AI-generated summary

    Christopher Evans · 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

    Christopher Evans, who was vulnerable and had physical health problems, was found unresponsive and almost completely submerged in a bath of very hot water on 28 September 2020 and was pronounced dead at the scene. The report identified concerns that his supported accommodation was not subject to CQC or HSE oversight and that the regulatory framework did not require assessment or management of scalding risks or provision of engineering controls for vulnerable residents.

    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 regulatory oversight and inspection of HMOs accommodating vulnerable persons

    Wider context from the report

    “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat. (2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC. (3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home. (4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability. (5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion. (6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body. ”

    Source location

    Christopher Evans · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. West London

    AI-generated summary

    Lance Scott Walker · 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

    Lance Scott Walker, an 18-year-old looked-after child, was placed in unregulated accommodation in 2016, where another 18-year-old resident was later placed. Eleven days after they were placed together, the other resident fatally stabbed Lance in the afternoon of 15 August 2016. Concerns included the use and oversight of unregulated accommodation, inadequate assessment and communication of the other resident’s risks and needs, shortcomings in placement and provider due diligence, and failures in information-sharing and management.

    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 regulatory oversight of supported accommodation for 18-21 year olds

    Wider context from the report

    “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023. Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it. ”

    Source location

    Lance Scott Walker · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. South Yorkshire (Western)

    AI-generated summary

    Anthony Wilkinson · 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

    Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.

    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 incorporate significant relevant factors into regulatory risk assessment

    Wider context from the report

    “(15)CQC did not take into consideration significant relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile being established and an exaggerated level of confidence being placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator. ”

    Source location

    Anthony Wilkinson · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a monitoring system that analyses service intelligence and generates prioritisation scores to identify services most at risk.

    Verbatim wording from the response

    “CQC’s approach to monitoring services at the beginning of the pandemic in lieu of changes to routine inspections was reviewed in December 2020 and CQC implemented a monitoring system to improve the approach that had been taken up until that date. This system analyses intelligence we hold about services and”

    Source location

    2021-0102-Response-from-CQC-Redacted
    Page 3 · response
    Published 13 April 2021

    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 monitoring, inspecting and regulating the provider with service-user safety as the priority.

    Verbatim wording from the response

    “This ensured during the pandemic, that CQC continued to carry out their regulatory function when there was extreme risk at a service. This was determined on a case by case basis. CQC’s inspection priorities remained under continuous review in line with national priorities, but our monitoring of Stars Social Support as well as their failure to provide a completed action plan in relation to the breach of regulation 19, was not assessed as an ‘extreme’ risk in all of the circumstances. CQC monitored all ASC care providers throughout the pandemic and has implemented several systems to support remote monitoring of services. A decision was taken not to inspect the service at this time and the team considered the providers failure to submit an action plan when reaching this determination.”

    Source location

    2021-0102-Response-from-CQC-Redacted
    Page 3 · response
    Published 13 April 2021

    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

    Earlier reinspection was not undertaken during the pandemic because inspections required an extreme risk threshold and assessed risks did not meet it.

    Verbatim wording from the response

    “CQC acknowledged at the Prevention of Future Deaths hearing that the re-inspection of Stars Social Support (completed on 27 August 2020 to 3 September 2020) fell outside of our usual timeframe of re-inspecting a service, rated requires improvement, 12 months from the last inspection publication date. However at that time, the decision not to inspect the service sooner we feel was justified and proportionate. COVID-19 resulted in CQC adapting its inspection priorities during the pandemic to ensure risk and people’s safety were the highest priority. A decision was taken by the CQC that during the pandemic, CQC would take on a more supportive role, as well as not adding to the overall risk and pressures COVID-19 presented to the rest of the health and social care sector. As at May 2020, there needed to be an “extreme” level of risk for CQC to cross the threshold for inspection.”

    Source location

    2021-0102-Response-from-CQC-Redacted
    Page 3 · response
    Published 13 April 2021

    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

    A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.

    Verbatim wording from the response

    “A decision has been taken by the Registered Manager and Director of Stars Social Support Limited for the organisation to cease to continue. The Registered Manager and Director at Stars Social Support Limited has contacted the Local Authority and the Care Quality Commission to notify them that Stars Social Support Limited will cease to continue.”

    Source location

    2021-0102-Response-from-Stars-Social-Support-Ltd-Redacted
    Page 1 · response
    Published 13 April 2021

    Open published response

  7. Derby and Derbyshire

    AI-generated summary

    Jacob Andrew Bates · 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

    Jacob Andrew Bates, who had autism, mental health problems and a history of serious self-harm, died by suicide on 15 July 2017 after placing plastic ties around his neck as ligatures. The report raised serious concerns that vulnerable young people, including those with complex needs and significant risks, were being placed in unregulated settings without statutory oversight of staff competency, policies or procedures.

    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

    Placement of vulnerable 16-to-18-year-olds in unregulated placements

    Wider context from the report

    “Evidence was given at the inquest hearing by two former employees at the placement that they had no prior experience of working with young people (indeed no experience of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight). The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place; it effectively accepted the assurances of the provider. The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residential/supported provision is solely for young people aged 16 to 18 that provision falls outside of the statutory regime of inspection and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised. 1. Vulnerable young people, aged 16 to 18, are being placed in unregulated placements. 2. Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is likely that young people with complex needs and at significant risk are being placed in such placements; indeed this was the case for Jacob. 3. As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers. This is clearly a very concerning situation given the very high level needs that some of the young people will have. 4. The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe. Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are ‘safe’, given the pressures on local authorities it cannot be the case that they are in a position to mirror the type and nature of inspection and oversight that might be provided by a regulator such as Ofsted. 5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and there is a realistic possibility that deaths may occur. ”

    Source location

    Jacob Andrew Bates · 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

    Lack of statutory requirements for provider staff competency, training, policies and procedures

    Wider context from the report

    “Evidence was given at the inquest hearing by two former employees at the placement that they had no prior experience of working with young people (indeed no experience of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight). The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place; it effectively accepted the assurances of the provider. The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residential/supported provision is solely for young people aged 16 to 18 that provision falls outside of the statutory regime of inspection and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised. 1. Vulnerable young people, aged 16 to 18, are being placed in unregulated placements. 2. Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is likely that young people with complex needs and at significant risk are being placed in such placements; indeed this was the case for Jacob. 3. As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers. This is clearly a very concerning situation given the very high level needs that some of the young people will have. 4. The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe. Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are ‘safe’, given the pressures on local authorities it cannot be the case that they are in a position to mirror the type and nature of inspection and oversight that might be provided by a regulator such as Ofsted. 5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and there is a realistic possibility that deaths may occur. ”

    Source location

    Jacob Andrew Bates · 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

    Absence of regulatory inspection and assessment of placement providers

    Wider context from the report

    “Evidence was given at the inquest hearing by two former employees at the placement that they had no prior experience of working with young people (indeed no experience of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight). The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place; it effectively accepted the assurances of the provider. The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residential/supported provision is solely for young people aged 16 to 18 that provision falls outside of the statutory regime of inspection and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised. 1. Vulnerable young people, aged 16 to 18, are being placed in unregulated placements. 2. Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is likely that young people with complex needs and at significant risk are being placed in such placements; indeed this was the case for Jacob. 3. As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers. This is clearly a very concerning situation given the very high level needs that some of the young people will have. 4. The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe. Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are ‘safe’, given the pressures on local authorities it cannot be the case that they are in a position to mirror the type and nature of inspection and oversight that might be provided by a regulator such as Ofsted. 5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and there is a realistic possibility that deaths may occur. ”

    Source location

    Jacob Andrew Bates · 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

    Launch a consultation on proposals to ensure unregulated provision is used appropriately and meets young people’s needs.

    Verbatim wording from the response

    “I share your concerns that unregulated settings are not always good enough, and that some children are being placed at risk or in settings that cannot meet their needs. It is clear that reform is urgently needed, and this is why on 12 February 2020 I launched a consultation on a range of proposals to ensure that unregulated provision is being used appropriately and meets the needs of the young people placed there.”

    Source location

    2019-0456-Response-from-the-Secretary-of-State-for-Education
    Page 1 · response
    Published 8 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

    Consider responses to the consultation on unregulated provision reforms.

    Verbatim wording from the response

    “It is a priority for this Government that children and young people in care have the support, protection and care they deserve. The independently led Care Review will also take a fundamental look across children’s social care with the aim of better supporting, protecting and improving the outcomes of vulnerable children and young people. However, I am clear that the issue of unregulated provision cannot wait and requires immediate and decisive action to be taken. Following the consultation we will consider the responses received and publish a response which will include a timetable for any reforms that will be taken forward.”

    Source location

    2019-0456-Response-from-the-Secretary-of-State-for-Education
    Page 2 · response
    Published 8 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

    Publish a response to the consultation, including a timetable for reforms taken forward.

    Verbatim wording from the response

    “It is a priority for this Government that children and young people in care have the support, protection and care they deserve. The independently led Care Review will also take a fundamental look across children’s social care with the aim of better supporting, protecting and improving the outcomes of vulnerable children and young people. However, I am clear that the issue of unregulated provision cannot wait and requires immediate and decisive action to be taken. Following the consultation we will consider the responses received and publish a response which will include a timetable for any reforms that will be taken forward.”

    Source location

    2019-0456-Response-from-the-Secretary-of-State-for-Education
    Page 2 · response
    Published 8 January 2020

    Open published response

  8. Somerset

    AI-generated summary

    Robin Damien Richards · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.

    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 inspect CQC-registered placement suitability

    Wider context from the report

    “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests. (2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected. (3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified; a) Poor communication with family and between Trust staff. b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement. c) An inadequate handover. d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him. e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards ”

    Source location

    Robin Damien Richards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Manchester South

    AI-generated summary

    Michael Bingham · 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

    Michael Bingham fell down stairs at Hilltop Court Care Home on 22 September 2016 after an emergency door release caused internal secure doors to open. He sustained C1/C2 fractures, was not diagnosed with a CT scan, later developed aspiration pneumonia, and died on 24 September 2016; concerns included door security alarms, guidance and inspection procedures, clarity about CT scans for older people with cognitive impairment, and the resulting risk of further deaths.

    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 inspection procedures for Registered Persons’ compliance with internal secure door safety and security requirements

    Wider context from the report

    “I accept that on the present Regulations it is for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, I ask you to review, in light of the evidence I have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel. I also ask you to review your inspection procedures in respect of a Registered Person’s compliance with the Regulations in respect of the safety and security of internal secure doors. ”

    Source location

    Michael Bingham · 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

    Undertake further inspections to verify internal-door alarms or key-box panels at Hilltop Court and screech-alarm installation across Harbour Healthcare locations.

    Verbatim wording from the response

    “The registered provider Harbour Healthcare has copied CQC into correspondence sent to yourself confirming the action they have taken following the death of Mr Bingham and the additional action they have taken in response to your Regulation 28 Report.”

    Source location

    2017-0322-Responses
    Page 9 · response
    Published 3 December 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

    Review Regulation 28 lessons in regional regulatory-risk meetings and explore how to better inform inspectors about risks identified by the incident.

    Verbatim wording from the response

    “However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings. Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident, and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this year. We will also explore how they can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises.”

    Source location

    2017-0322-Responses
    Page 7 · response
    Published 3 December 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

    Discuss internally how lessons from the incident should inform inspection practice and consider associated changes for the next assessment-framework iteration.

    Verbatim wording from the response

    “However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings. Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident, and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this year. We will also explore how they can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises.”

    Source location

    2017-0322-Responses
    Page 7 · response
    Published 3 December 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

    Explore how incident lessons can inform a planned premises-safety checklist for care-home inspectors.

    Verbatim wording from the response

    “However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings. Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident, and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this year. We will also explore how they can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises.”

    Source location

    2017-0322-Responses
    Page 7 · response
    Published 3 December 2017

    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

    Existing non-prescriptive inspection arrangements were considered appropriate because providers and service users have differing circumstances and risks.

    Verbatim wording from the response

    “Premises safety forms part of the assessment we make of care home providers when we ask our key question ‘Is the service safe?’ There is a Key Line of Enquiry in our inspection assessment framework that asks: How are risks to people assessed and their safety monitored and managed so they are supported to stay safe and their freedom is respected? Inspectors explore how premises and the safety of communal and personal spaces are checked and managed to support people to stay safe when following this line of enquiry. As noted in your report, neither the regulations nor our assessment frameworks are prescriptive on how providers who are registered with us should do this. This is because each service is different and the needs of the people they care for and support can and do vary substantially.”

    Source location

    2017-0322-Responses
    Page 7 · response
    Published 3 December 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026