Recurring concern

Unreliable assessment and recording of patients’ mental capacity

First to latest report 16 Dec 2013 — 10 Mar 2026

Reports that mention this concern
35
Times this concern has been raised
39
Stated actions linked to this concern
90

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.

What is 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 and published responses 35 reports

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

  1. Nottinghamshire

    AI-generated summary

    Elsie Marjorie 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

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    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 assess mental capacity

    Wider context from the report

    “1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed. ”

    Source location

    Elsie Marjorie 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

    A formal capacity assessment was not considered necessary because capacity was presumed unless evidence showed that Mrs Brown lacked capacity.

    Verbatim wording from the response

    “The Company also, since 2010, have had corporate documentation and procedures in place to assess the mental capacity of residents. These are regularly updated, eg when there are changes in legislation. Mrs Brown’s capacity was not formally assessed as it was not deemed that she lacked capacity, and the Mental Capacity Act states that capacity must always be assumed unless it is proved otherwise.”

    Source location

    Elsie-Brown-Response
    Page 1 · response
    Published 4 December 2015

    Open published response

  2. Norfolk

    AI-generated summary

    CHRISTOPHER WATSON · 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 Watson, who had become isolated after losing his job, was found dead in his home on 7 January 2015 after having been dead for some weeks. The concerns focused on Norfolk County Council Adult Social Care closing his file after sending a letter that Mr Watson might not receive, open or understand, and on the lack of direct contact to ensure he understood that help was available and to assess whether his capacity needed assessment. The inquest recorded that he died from exsanguination after cutting his own arm, with his intention not known.

    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 assess capacity where required

    Wider context from the report

    “(2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. “painfully thin, unwashed and dishevelled”. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed. ”

    Source location

    CHRISTOPHER WATSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Mary Fenton · 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

    Mary Fenton was admitted to Tameside Hospital on 26 April 2014 needing an urgent heart pacemaker and died on 30 April 2014 after delays and missed opportunities. Concerns included limited cardiology cover and facilities, shortages of Isoprenaline, failures relating to capacity and consent, delays in inserting pacing wires, inadequate facilities to manage complications, and poor communication.

    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 assess patients’ mental capacity

    Wider context from the report

    “4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital) ”

    Source location

    Mary Fenton · 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

    Failure to document patients’ mental capacity

    Wider context from the report

    “4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital) ”

    Source location

    Mary Fenton · Prevention of Future Deaths report
    Page 1 · 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

    Employ a specialist nurse in adult safeguarding, mental capacity and deprivation of liberty safeguards.

    Verbatim wording from the response

    “The Trust has employed a specialist nurse in safeguarding adults, MCA and DOLS to support medical and nursing staff and to ensure that a thorough and correct assessment relating to mental capacity is completed and that any decisions made are in the best interests of the patient. During 2013/14 the Trust has seen a significant increase in activity (146%) and profile of adult safeguarding. Therefore, an assertive training programme has been put in place and we have seen over 828 staff trained to date. The Trust’s solicitor, Weightmans have also been utilised in providing training and they have provided an extensive training course throughout the year titled “The Legal Principles of the Mental Health Act; Mental Capacity Act and Deprivation of Liberty”.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 4 · response
    Published 13 October 2014

    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

    Deliver an assertive adult safeguarding and mental-capacity training programme to Trust staff.

    Verbatim wording from the response

    “The Trust has employed a specialist nurse in safeguarding adults, MCA and DOLS to support medical and nursing staff and to ensure that a thorough and correct assessment relating to mental capacity is completed and that any decisions made are in the best interests of the patient. During 2013/14 the Trust has seen a significant increase in activity (146%) and profile of adult safeguarding. Therefore, an assertive training programme has been put in place and we have seen over 828 staff trained to date. The Trust’s solicitor, Weightmans have also been utilised in providing training and they have provided an extensive training course throughout the year titled “The Legal Principles of the Mental Health Act; Mental Capacity Act and Deprivation of Liberty”.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 4 · response
    Published 13 October 2014

    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

    Roll out refresher training on mental-capacity, consent and communication policies.

    Verbatim wording from the response

    “As to the actions of the particular staff involved in the care of Mrs Fenton, and with particular reference to the assessment and documentation of mental capacity, consent and communication, we have reminded the clinicians of the relevant policies and advised them that we will be rolling out refresher training. All Cardiology staff have also been informed by the Lead Consultant Cardiologist that no usage of Isoprenaline should be permitted in the CCU / Ward 31 without the consent of a Consultant Cardiologist / the on-call Cardiologist for pacing out of hours.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 5 · response
    Published 13 October 2014

    Open published response

  4. Surrey

    AI-generated summary

    Lillian Rose Robinson · 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

    Lillian Rose Robinson was admitted to Brockhurst Care Home, transferred to Upper Halliford nursing home after deteriorating, and died from bronchopneumonia on 28 December 2012. The substantive concerns were communication about mental-capacity assessments, unqualified carers evaluating capacity in patients with mild or moderate dementia, and poor note-taking and continuity of care.

    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

    Use of unqualified medical carers to evaluate capacity appropriateness in patients with mild/moderate dementia

    Wider context from the report

    “Unqualified medical carers evaluating the appropriateness of capacity in patients with mild/moderate dementia ”

    Source location

    Lillian Rose Robinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Nottinghamshire

    AI-generated summary

    Cynthia Fretwell · 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

    Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

    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 fully assess patients’ mental capacity when they refuse medical treatment or hospital admission

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”

    Source location

    Cynthia Fretwell · Prevention of Future Deaths report
    Page 1 · 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

    Update and provide staff access to the Mental Capacity Act policy.

    Verbatim wording from the response

    “1. The Practice has updated its MENTAL CAPACITY ACT 2005 POLICY. This is saved on the ‘shared drive’ for all the staff to access it as necessary. See attached.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 1 · response
    Published 16 December 2013

    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 a Mental Capacity Act summary on the shared drive for staff reference.

    Verbatim wording from the response

    “2. A summary of the Mental capacity Act 2005 is also saved on the ‘shared drive’ for more detailed reference.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 1 · response
    Published 16 December 2013

    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 the Mental Capacity Act during medical meetings to update staff on its principles, purposes and best-interests requirements.

    Verbatim wording from the response

    “4. We have discussed the Mental Capacity Act during our Medical Meetings so that we are all updated on it. Particular attention has been paid to sections relating to the Principles of the Act, Purposes of the Act and Best interests, as highlighted in the copy of summary of Mental Capacity Act attached.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 1 · response
    Published 16 December 2013

    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 staff Mental Capacity Act training through appropriate courses and e-learning.

    Verbatim wording from the response

    “Capacity Act and PREVENT. This event addressed the principles and application of the Mental Capacity Act, amongst other issues. They will continue to keep themselves updated by attending appropriate future courses. ████████ will be attending such course in the very near future. The Practice staff have attended a course to learn about Mental capacity Act in 2009 and will update themselves with e-learning this subject on ‘blue stream academy’.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 3 · response
    Published 16 December 2013

    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

    Conduct a full mental capacity assessment when patients refuse medical treatment or hospital admission, following the practice policy.

    Verbatim wording from the response

    “2. A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital will be made in accordance with the guidelines in the Practice’s mental capacity policy attached.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 3 · response
    Published 16 December 2013

    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