Recurring concern

Unreliable interpretation and use of evidence in regulatory inspections

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First reported 10 Mar 2014•Latest report 16 Apr 2024

Definition

What this concern includes

Includes failures in the dedicated evidence-appraisal and evidence-use controls of regulatory inspections, including inadequate enquiry into relevant evidence, misinterpretation, unsupported conclusions, inconsistent consideration of policies or procedures, and unreliable decisions about using evidence for inspection or regulatory action.

Not included

  • Excludes deficiencies in ordinary operational, highway, fire-safety or clinical inspections unless the report specifically concerns evidence appraisal and use within a regulatory inspection decision.
  • Excludes generic inspector training, staffing, documentation or governance deficiencies unless they directly cause unreliable interpretation or use of evidence in a regulatory inspection.
  • Excludes failures to collect or disclose evidence where the concern is not its interpretation, critical appraisal or application to a regulatory inspection or enforcement decision.
  • Excludes clinical interpretation of test results, such as ECGs, CTG traces or imaging, where no regulatory inspection evidence process is involved.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
1

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.

Care Quality Commission2
Ofsted1
Passmonds House Care Home1
Rochdale Borough Council1
South West Yorkshire Partnership Teaching NHS Foundation Trust1
Stars Social Support Limited1
The Limes1

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. Norfolk

    AI-generated summary

    Edith Jane ALDEN · 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

    Edith Jane Alden, a resident assessed at very high risk of falls, left a communal area unnoticed and unsupervised on 13 September 2021, fell in the garden and suffered severe head injuries. She died on 25 September 2021. Concerns included unclear and inconsistent care plans and risk assessments, insufficient supervision and staffing, and the use of unlocked communal-area access for residents at very high risk of falls.

    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 of the inspection report to accurately reflect evidence about staffing and supervision

    Wider context from the report

    “5. The Inspection Report dated 6 October 2022, carried out following Mrs Alden’s death, found “There were enough staff on duty to meet people’s needs and people told us they never had to wait long for assistance. The registered manager had reviewed how staff were working and deployed staff in a way that meant that the right staff were in the right places when needed. This meant people in communal areas were never left alone ...” This sentence is not supported by the evidence heard at inquest. ”

    Source location

    Edith Jane ALDEN · 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

    The CQC report’s staffing assessment was accurate, contrary to the concern that it was unsupported by inquest evidence.

    Verbatim wording from the response

    “I’d respectfully draw Coroner’s attention to the fact that this is a report of the regulator and as such only the regulator can defend their report. We do happen to agree with CQC’s independent assessment dated 5th October 2022. The inspection is a ‘snapshot’ of our service. Our internal auditing processes provide evidence of our staff being allocated to areas throughout the service to effectively meet individual’s needs, which gives us the assurance that the remarks in the CQC report were accurate.”

    Source location

    2024-0196 Response from The Limes Care Home
    Page 10 · response
    Published 29 April 2024

    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

    Only the regulator can defend the accuracy of its inspection report.

    Verbatim wording from the response

    “I’d respectfully draw Coroner’s attention to the fact that this is a report of the regulator and as such only the regulator can defend their report. We do happen to agree with CQC’s independent assessment dated 5th October 2022. The inspection is a ‘snapshot’ of our service. Our internal auditing processes provide evidence of our staff being allocated to areas throughout the service to effectively meet individual’s needs, which gives us the assurance that the remarks in the CQC report were accurate.”

    Source location

    2024-0196 Response from The Limes Care Home
    Page 10 · response
    Published 29 April 2024

    Open published response

  2. Lancashire and Blackburn with Darwen

    AI-generated summary

    Oliver Brassington Weston · 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

    Oliver Brassington Weston was a 17-year-old looked after child placed in a home by Stockton Borough Council. He died at Cumbria View House on the evening of 22 March 2019 following an impulsive act involving ████████. The concerns included deficiencies in the planning, conduct and review of an inspection, failure to consider relevant safeguarding and psychological information, and a lack of guidance about when inspection reports should not be published in exceptional circumstances.

    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 critical appraisal of inspections

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

    Source location

    Oliver Brassington Weston · 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

    Insufficient enquiry during inspections

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

    Source location

    Oliver Brassington Weston · Prevention of Future Deaths report
    Page 1 · 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

    Misinterpretation of available evidence during inspections

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

    Source location

    Oliver Brassington Weston · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. 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

    Lack of consistency in CQC decisions on using evidence for inspections or regulatory action

    Wider context from the report

    “(17)Where CQC are required to decide whether evidence ought to be used for the basis of an inspection OR for regulatory action, they ought to ensure there is a consistent approach to this including the consideration of policies and standard operating procedures. This should be approached on the basis of safeguarding the majority of remaining service users from harm being the priority even where that means prosecutions for breaches of Regulation may be compromised. ”

    Source location

    Anthony Wilkinson · 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

    Review policy on handling evidence shared between inspection, civil enforcement and criminal investigation processes.

    Verbatim wording from the response

    “Evidence gathered during the course of an inspection will feed into inspection reports and where relevant civil enforcement action. The information may lead CQC to carry out a criminal investigation, but the evidence gathered during a criminal investigation will not be detailed in an inspection report. A report must provide an accurate reflection of what is happening at a service, but that does not require the report to detail the criminal investigation.”

    Source location

    2021-0102-Response-from-CQC-Redacted
    Page 8 · 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

    Reports need not detail criminal investigations because inspection reports accurately describe current regulatory findings under the established reporting approach.

    Verbatim wording from the response

    “Evidence gathered during the course of an inspection will feed into inspection reports and where relevant civil enforcement action. The information may lead CQC to carry out a criminal investigation, but the evidence gathered during a criminal investigation will not be detailed in an inspection report. A report must provide an accurate reflection of what is happening at a service, but that does not require the report to detail the criminal investigation.”

    Source location

    2021-0102-Response-from-CQC-Redacted
    Page 8 · 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

  4. Manchester North

    AI-generated summary

    Derrick George RIVERS · 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

    Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.

    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

    Incomplete inspection of CQC Outcomes and the drugs administration system

    Wider context from the report

    “2) That not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time. ”

    Source location

    Derrick George RIVERS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026