First reported 16 Dec 2013•Latest report 10 Mar 2026
Definition
What this concern includes
Includes failures to recognise when capacity assessment is required, conduct or document the assessment, record its outcome and rationale, and make the result available for subsequent care or decision-making.
Not included
Excludes general care-record deficiencies where mental capacity is not the material subject.
Excludes Mental Capacity Act best-interests, deprivation-of-liberty and advocacy failures when the capacity-assessment and recording process itself is not deficient.
Excludes failures to follow a valid capacity assessment after it has been completed and recorded.
Excludes generic consent or treatment-decision failures that do not concern assessment or recording of the patient’s mental capacity.
Reports
35
Distinct published reports
Individual concerns
39
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
90
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.
Department of Health and Social Care7
Care Quality Commission3
Greater Manchester Mental Health NHS Foundation Trust3
London Borough of Redbridge2
Manchester University NHS Foundation Trust2
Ministry of Justice2
NHS England2
Norfolk and Suffolk NHS Foundation Trust2
Tameside and Glossop Integrated Care NHS Foundation Trust2
Abbey Court Independent Hospital1
A & B Healthcare Limited1
Achieve Together Limited1
Bolton Borough Council1
Brunswick Ward at Lindridge1
Cambridge Nursing Home Ltd1
NHS trust21
Ministerial department10
Healthcare site7
Integrated care board4
Private limited company4
Type not available4
English county council3
English metropolitan district council3
Executive non-departmental public body3
Health and social care service regulator3
London borough council3
English unitary authority2
Local health board2
Multi-service care provider2
Coronial office1
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.
Manchester South
Concerns raised1
Failure to recognise lack of decision-making capacity
This report raised 9 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Strengthen and ratify the Mental Capacity Act policy to clarify assessment responsibilities, decision makers and Independent Mental Capacity Advocate referrals.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Review and revise Mental Capacity Act training provision to clarify roles and responsibilities for relevant clinical staff.
Stated by Bolton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Provide bespoke Mental Capacity Act training to designated staff cohorts.
Stated by Bolton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Make Mental Capacity Act forms available for completion by all staff designations on the Electronic Patient Record.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Share inquest learning with senior management and leadership teams and put an action plan in place to keep staff current with Best Interest, Capacity and CPA training.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
GMMHFT will provide a further response concerning mental capacity assessment and advocacy arrangements.
Stated by Bolton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester West
Concerns raised1
Failure to make contemporaneous records and document decision-making rationale including capacity assessments
This report raised 1 other concern. 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.
South London
Concerns raised1
Failure to formally review mental capacity to consent to treatment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2019.
Action
Continue auditing MDT template use, capacity assessments, and responses to family concerns.
Stated by Oxleas NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2019.
Action
Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Action
Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Action
Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 19 January 2019.
Action
Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Wiltshire and Swindon
Concerns raised1
Failure to undertake a mental capacity assessment for a serious and complex decision
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester City
Concerns raised1
Failure to assess mental capacity during admission and transfer
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised2
Failure to properly assess mental capacity
Incomplete mental-capacity documentation at discharge
This report raised 24 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.
Manchester City
Concerns raised1
Failure to undertake or arrange review of a mental capacity assessment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Implement the new care plan incorporating falls management, capacity, substance and alcohol misuse, and food and nutrition risks.
Stated by Human Support GroupStated completedThe respondent said that this action was complete when they made their response on 30 December 2016.
Action
Complete Mental Capacity Act work with the Sale team through meetings, posters and leaflets.
Stated by Human Support GroupStated completedThe respondent said that this action was complete when they made their response on 30 December 2016.
Action
Coordinate the national rollout of Mental Capacity Act materials.
Stated by Human Support GroupStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2016.
Action
Update the Sale office care planning matrix and maintain weekly review of required care plan reviews.
Stated by Human Support GroupStated completedThe respondent said that this action was complete when they made their response on 30 December 2016.
Action
Conduct the scheduled internal audit of the Sale office care planning matrix and related care planning arrangements.
Stated by Human Support GroupStated plannedThe respondent said that this action was planned when they made their response on 30 December 2016.
Leicester City and South Leicestershire
Concerns raised1
Failure to record consideration and outcome of the patient's capacity
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 A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The medical records showed no cognitive decline requiring a formal capacity assessment, so capacity was assumed for the GP change process.
Stated by Hazelmere Medical CentreDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Capacity assessments are not routinely undertaken unless there is a medical need.
Stated by Hazelmere Medical CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cheshire
Concerns raised1
Failure to identify lack of capacity
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.
Manchester City
Concerns raised2
Failure to undertake formal mental capacity assessments in the community
Failure to formally assess and recognise mental capacity on hospital admission
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Continue implementing frailty and delirium screening tools, including a unified tool across Trafford and the central site.
Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2016.
Action
Provide monthly DoLS training on the process and completion of DoLS and mental capacity assessments.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2016.
Action
Arrange external training sessions on mental capacity and DoLS with the Trust’s solicitor partnership firm.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2016.
Action
Mandate level 3 Adult Safeguarding training for all registered nurses, covering DoLS and mental capacity.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2016.
Action
Provide bespoke safeguarding sessions to areas needing additional support with completing DoLS and mental capacity assessments.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2016.
Action
Consider including safeguarding, particularly DoLS and mental capacity, at quarterly Audit and Clinical Effectiveness Days and make implementation plans.
Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2016.
Action
Discuss the coroner’s concerns at the Trust Clinical Effectiveness Committee to consider how to improve consideration of mental capacity assessments and DoLS authorisations.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2016.
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Includes failures to recognise when capacity assessment is required, conduct or document the assessment, record its outcome and rationale, and make the result available for subsequent care or decision-making.
