Recurring concern

Failure to act appropriately on safeguarding referrals and notices

First to latest report 12 Sep 2014 — 5 Mar 2026

Reports that mention this concern
39
Times this concern has been raised
44
Stated actions linked to this concern
74

What this concern includes

Includes failures of the end-to-end safeguarding response involving safeguarding notices, referrals or identified safeguarding concerns, including inadequate assignment, follow-up, escalation, investigation or protective action.

What is not included
  • Excludes generic communication, documentation or staffing deficiencies unless they are directly tied to the safeguarding response.
  • Excludes failures concerning clinical referrals or other service referrals without an explicit safeguarding concern.
  • Excludes failures to issue general warnings or safety notices that are not safeguarding notices.

Reports and published responses 39 reports

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

  1. Norfolk

    AI-generated summary

    Eileen Marguerite WALSH · 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

    Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.

    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 appropriately identify and refer safeguarding concerns

    Wider context from the report

    “8. The Care Quality Commission carried out an inspection in February 2023, nearly 3 years following Mrs Walsh’s death, and raised similar concerns as raised during this inquest, including: a) Safeguarding concerns had not always been appropriately identified and referred b) Risks relating to falls were not dealt with, including a faulty sensor mat was still in place some days later c) Since a historic issue of staff neglect, further incidents of poor staff performance were identified and effective action had not always been taken. It is stated this failure to learn lessons placed people at risk of harm d) Recent audits carried out by the Home had not identified concerns found by the CQC ”

    Source location

    Eileen Marguerite WALSH · 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

    Provide practical safeguarding and whistleblowing training, including scenario-based exercises, and discuss the Night Working Policy at staff meetings.

    Verbatim wording from the response

    “VIII. Managers discuss the new Night Work policy at staff meetings.”

    Source location

    Response from Broadland View Care Home
    Page 3 · response
    Published 4 August 2023

    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

    Report medication near misses as safeguarding concerns going forward.

    Verbatim wording from the response

    “9. The Registered Manager did not accept many of the concerns raised by the CQC during their attendance and this is a missed opportunity to learn lessons, improve care and prevent future deaths. I. The Registered manager has accepted the concerns raised and did apologise on the day of inspection for any actions of concern missed. II. There was a lesson learnt as the Care Manager was not aware that ‘near misses’ should be raised as Safeguarding. The Care Manager will report these going forward. It is not something they were aware that had to be done in all their years of care experience and training completed. This is the lesson learnt. III. There were concerns over the staff member that was dismissed not signing some meeting notes. The Care Manager apologised and explained that the staff member was suspended and dismissed before there was an opportunity to get the notes signed.”

    Source location

    Response from Broadland View Care Home
    Page 7 · response
    Published 4 August 2023

    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

    The medication events were near misses, not medication errors, and residents received the medication safely.

    Verbatim wording from the response

    “a) Safeguarding concerns had not always been appropriately identified and referred I. The Safeguarding concerns referred to involved one member of staff. The Care Manager apologised on the day of inspection and notifications rectified. II. The Care Manager questioned the Inspector because medication errors referred to were proven to be ‘near misses’ so no errors were made and therefore this was the reason that a safeguarding was not made. The Inspector said that ‘near misses’ must also be raised as safeguarding, which is not something that is usually done. We would like to reiterate that the medication in question was successfully and safely taken by residents. III. This member of staff had given poor personal care on one shift which was addressed and did not happen again. The manager apologised for not raising a safeguarding on this occasion and this was subsequently done. IV.”

    Source location

    Response from Broadland View Care Home
    Page 5 · response
    Published 4 August 2023

    Open published response

  2. Manchester South

    AI-generated summary

    Sylvia Pollitt · 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

    Sylvia Pollitt, an elderly resident, raised a concern about her boiler, but the subcontractor could not contact her and the situation was not escalated. She was found at home on 1 December 2022 and the post-mortem found that she had died from complications of hypothermia. The inquest identified that welfare checks were not carried out and that the Housing Association lacked systems to monitor non-escalation and referral outcomes.

    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 an audit system for non-escalation following referrals

    Wider context from the report

    “The inquest heard evidence that under the SLA between the Housing Association and Liberty if there is non-contact following a referral then this should be escalated back to the Housing Association so that they can carry out welfare checks and assess the position further. Carrying out of welfare checks for vulnerable adults ensures that they are safe and well. That did not happen in Mrs Pollitt’s case. The evidence before the inquest was that the Housing Association had: 1. No audit system which enabled it to know if this issue of non-escalation by Liberty was a one off or a frequent issue. They had only become aware of the non-contact in this instance following Sylvia Pollitt’s death. 2. No system where they captured/monitored the outcome of each referral to their subcontractor e.g. non-contact; successful attendance. ”

    Source location

    Sylvia Pollitt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review all gas repairs closed outside the agreed service level without reference back, tracing records and identifying closure reasons.

    Verbatim wording from the response

    “As soon as we were aware of the incident and the inquest, we immediately reviewed every other gas repair request which had been closed by Liberty outside of the agreed SLA and without reference back to L&Q.”

    Source location

    Response from L&Q
    Page 2 · response
    Published 21 July 2023

    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

    Record relevant calls centrally and track every repair through the internal housing management system to maintain an auditable trail.

    Verbatim wording from the response

    “Following the inquest and prior to your formal recommendations contained within this Regulation 28 Prevention of Future Deaths report, we had immediately put in place additional processes and checks. This included aligning the process of the former THT with that of L&Q where all calls of this nature are recorded by and within the central call centre prior to being passed to contractors, ensuring that a comprehensive record of all repairs is tracked and managed through our internal housing management system. The previous THT process was to transfer the resident call directly to the contractor, in this incident Liberty.”

    Source location

    Response from L&Q
    Page 2 · response
    Published 21 July 2023

    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

    Hold weekly contractor meetings, reconcile work-in-progress reports with internal records, and review every repair to prevent unauthorised abortion without escalation.

    Verbatim wording from the response

    “That notwithstanding, we have subsequently instituted weekly meetings with Liberty to review every single job raised to trace all those in progress, overdue, completed and requested to be aborted. A full Work In Progress (WIP) report is produced by Liberty which is reconciled against the list held by L&Q and is reviewed by the Gas Compliance Manager weekly to ensure every single repair is accounted for. No jobs are permitted or are possible to be aborted directly by Liberty without reference back to L&Q and the report records all reasons for no access and dates of escalation back to L&Q.”

    Source location

    Response from L&Q
    Page 3 · response
    Published 21 July 2023

    Open published response

  3. Berkshire

    AI-generated summary

    Lucy Anne Walles · 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

    Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.

    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 systems to make involved agencies aware of safeguarding referrals and concerns

    Wider context from the report

    “Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. ”

    Source location

    Lucy Anne Walles · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in review and triage of safeguarding referrals

    Wider context from the report

    “Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. ”

    Source location

    Lucy Anne Walles · 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

    Implement the One Team community mental health model with multi-agency working, clear safety plans, named workers, feedback, and wider community support.

    Verbatim wording from the response

    “NHS Trusts are changing and improving the way mental health services are provided in the community to support people with mental illness. In Berkshire Health Care we are calling this programme of work “One Team”. This transformation of services is happening across the country following the publication of the Community Mental”

    Source location

    Response from Berkshire Healthcare NHS Foundation Trust
    Page 1 · response
    Published 23 June 2023

    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

    Make the Integrated Multi-Disciplinary Team operational to discuss complex cases, share information, formulate risk, and determine suitable pathways and care plans.

    Verbatim wording from the response

    “• Integrated Multi-Disciplinary Team Complex cases can be discussed to enable a clear formulation of risk and needs. This forum will ensure the person gets the most suitable pathway and care plan to enable the patient to achieve their personal and treatment goals. It is also a place where important information can be shared across agencies pathways, for example,the ARRs worker could present a case here to ensure the correct pathway is in place, adult social care staff can attend to share any concerns. This function will be operational by December 2023.”

    Source location

    Response from Berkshire Healthcare NHS Foundation Trust
    Page 4 · response
    Published 23 June 2023

    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

    Add priority flags to safeguarding contacts indicating suicidal ideation or significant self-harm risk.

    Verbatim wording from the response

    “Following the death of Ms Lucy Anne Walles and the lack of timeliness of an appropriate safeguarding response to safeguarding contacts in this case, improvements have been made to the safeguarding service in Reading. Those relating to the resourcing of the service, are referred to below. In relation to improvements in processes, where a safeguarding contact contains information which may indicate the individual has suicidal ideation or is at risk of significant self-harm, a priority flag is added at the point of contact on the client recording system for the Safeguarding Team’s attention, or the responsible adult social care team”

    Source location

    Response from Reading Borough Council
    Page 1 · response
    Published 23 June 2023

    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

    Hold daily consultations between the Safeguarding Team and Customer Contact Centre to support referral processes and priority flagging.

    Verbatim wording from the response

    “The other improvement in process in the management of safeguarding contacts through the Customer Contact Centre and the Safeguarding Team is that, since the creation of a dedicated senior Safeguarding Lead role for Reading in June this year, there are daily consultations between the Safeguarding Team and the Customer Contact Centre to ensure appropriate referral processes are followed and there is priority flagging of high-risk safeguarding referrals.”

    Source location

    Response from Reading Borough Council
    Page 2 · response
    Published 23 June 2023

    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

    Increase dedicated safeguarding referral capacity by appointing three additional full-time safeguarding staff.

    Verbatim wording from the response

    “Following the appointment in June 2023 of a Senior Safeguarding lead, 3 additional full time safeguarding staff were appointed, and this has provided a 30% increase in dedicated staff resource for managing safeguarding referrals. The Senior Safeguarding Lead is accountable to, and works with, the Assistant Director for Safeguarding, Quality and Practice. This has strengthened the managerial oversight of the delivery of the safeguarding service and continues to report performance of safeguarding to the Departmental Management Team, led by the Executive Director.”

    Source location

    Response from Reading Borough Council
    Page 5 · response
    Published 23 June 2023

    Open published response

  4. Lincolnshire

    AI-generated summary

    Colin Robert GUMM · 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

    Colin Robert GUMM, a vulnerable adult receiving a care package, was found collapsed by his carers and died at Lincoln County Hospital on 27 November 2021 despite treatment. The concerns include gaps in Adult Social Care monitoring and safeguarding, the identification of apparent underweight and clinical dehydration only shortly before his death, conflicting evidence about alcohol provision, and the reported premature closure of a safeguarding enquiry before toxicology results were received.

    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 take safeguarding action to mitigate identified risks

    Wider context from the report

    “5.The outcome from the admitted "limited information gathered" was that no risk was identified and no action taken. Despite the toxicology report still to be received the enquiry was closed and never reopened. As a result no appropriate action was taken to mitigate any risks to others. ”

    Source location

    Colin Robert GUMM · 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

    Premature closure of section 42 safeguarding enquiries without gathering material information

    Wider context from the report

    “7.Instead the s.42 reporter according to the live evidence of the principal practitioner of the Adult Safeguarding team of the day, appears to have collated only limited information and closed the inquiry down prematurely without looking at material documents or even awaiting the toxicology report. At the very least it should be reopened to see if there was any missed opportunities from which lessons could be learnt and future deaths prevented and to embody the whole purpose of a s.42 assessment in deciding what action to take to support and protect the person in question. It being reiterated that this assessment was only commissioned after the deceased had passed away. ”

    Source location

    Colin Robert GUMM · 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 toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.

    Verbatim wording from the response

    “Mr Gumm had sadly died and therefore this ended the Local Authority's legal duty to take steps to safeguard Mr Gumm under s.42. However, the Safeguarding Team did progress with a s.42 enquiry (although it should have been recorded as a non s.42 enquiry at that time) to seek wider assurance in relation to the care providers involved and any potential wider risks. (LCC’s processes in relation to s.42 enquiries and more generally is explored below in the section on action by LCC). Proportionate enquiries/fact-findings was undertaken (in so far as the council were able to do so given the circumstances) and no concerns were identified in relation to the services provided to the deceased.”

    Source location

    Response from Lincolnshire County Council
    Page 5 · response
    Published 3 May 2023

    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

    The Commercial Team and, where appropriate, CQC decide assurance actions after limited safeguarding fact-finding.

    Verbatim wording from the response

    “However, if necessary, limited fact-finding enquiries will be made by the safeguarding team in order to ascertain whether further consideration of potential risk to others is required. This information is shared with the Commercial Team and, if appropriate, CQC, who will consider the information and decide any assurance actions, which may include if appropriate, a visit to the provider. Every contract for services with the council has its own contracts officer allocated to that provider. In the first instance, depending on the circumstances, it is likely that the contracts office will visit.”

    Source location

    Response from Lincolnshire County Council
    Page 6 · response
    Published 3 May 2023

    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 council quality-assurance and multi-agency arrangements provide appropriate assurance about risks to other individuals.

    Verbatim wording from the response

    “However, the council also has significant other quality assurance methods which may be used to monitor and improve services and work with the regulator who has the power to take formal action or in the worst-case scenario work with the regulator, who has the authority to close down an unsafe provision.”

    Source location

    Response from Lincolnshire County Council
    Page 6 · response
    Published 3 May 2023

    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

    The statutory safeguarding duty did not apply to a deceased individual, so a section 42 enquiry was inappropriate in these circumstances.

    Verbatim wording from the response

    “Pursuant to LCC’s duties under s.42, a Local Authority is not required by law to carry out enquiries for those individuals who do not meet the criteria for safeguarding as set out in this section of the Act. In particular, the care act duty can have no application to a deceased individual as the purpose of the enquiry is to decide what action is to be taken in relation to the individual and by whom. In some cases, LCC may have had a safeguarding referral during the individual’s life and appropriate information about LCC’s safeguarding actions will be provided to the coroner.”

    Source location

    Response from Lincolnshire County Council
    Page 6 · response
    Published 3 May 2023

    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

    Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.

    Verbatim wording from the response

    “We can only reiterate that LCC was not providing care to Mr Gumm at the time. LCC are not therefore in a position to determine whose evidence can or should be believed”

    Source location

    Response from Lincolnshire County Council
    Page 5 · response
    Published 3 May 2023

    Open published response

  5. Inner North London

    AI-generated summary

    Richard Thomas SHANNON · 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

    Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.

    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 adequately investigate safeguarding explanations and evidence

    Wider context from the report

    “7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death. In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done. There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate. ”

    Source location

    Richard Thomas SHANNON · Prevention of Future Deaths report
    Page 5 · 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

    Share safeguarding learning with staff and introduce automatic internal safeguarding-team escalation for relevant incidents.

    Verbatim wording from the response

    “• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.”

    Source location

    Response from Central London Community Healthcare
    Page 3 · response
    Published 8 December 2022

    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

    Identify potential conflicts of interest when interviewing the organisation’s care staff.

    Verbatim wording from the response

    “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.”

    Source location

    Response from Kapital Care
    Page 3 · response
    Published 8 December 2022

    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 potential interview conflicts of interest with the Local Authority to identify the appropriate interviewing lead.

    Verbatim wording from the response

    “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.”

    Source location

    Response from Kapital Care
    Page 3 · response
    Published 8 December 2022

    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

    Revise safeguarding supervision practice to assess whether conversations should be delegated or conducted directly, including conflicts of interest.

    Verbatim wording from the response

    “• The Safeguarding Service has revised its practice so that when reviewing cases in professional supervision, it will explore whether delegated or direct conversations should take place, factoring in whether there are conflicts of interest in individual agencies being asked to conduct parts of the safeguarding enquiry.”

    Source location

    Response from City of Westminster
    Page 3 · response
    Published 8 December 2022

    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

    Identify potential conflicts of interest when interviewing care staff and discuss appropriate interview leadership with the Local Authority.

    Verbatim wording from the response

    “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.”

    Source location

    Response from Kapital Care (UK) Limited
    Page 3 · response
    Published 8 December 2022

    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

    Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.

    Verbatim wording from the response

    “We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.”

    Source location

    Response from University College London Hospitals
    Page 6 · response
    Published 8 December 2022

    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

    The Local Authority should determine which person or agency is most appropriate to lead interviews where Kapital Care has a potential conflict of interest.

    Verbatim wording from the response

    “• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview.”

    Source location

    Response from Kapital Care
    Page 3 · response
    Published 8 December 2022

    Open published response

  6. Cornwall and Isles of Scilly

    AI-generated summary

    HARRY JOSEPH PENGELLY ARMSTRONG 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

    Harry Joseph Pengelly Armstrong Evans died by hanging on 24 June 2021 during an acute mental health crisis, following academic pressures and concerns about his wellbeing. The report identified concerns about the university’s lack of proactive personal engagement, failures in safeguarding alert follow-up, insufficient staff awareness of information-sharing policies, and reliance on email and online forms to access welfare support.

    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 welfare case management system to ensure follow-up of safeguarding alerts

    Wider context from the report

    “5) Welfare services case management system The court heard evidence that systems failures led to safeguarding alerts not being followed up and the case marked closed. The university is invited to review whether the welfare case management system is fit for purpose, whether it is sufficient to capture and ensure actions on welfare concerns raised by students or third parties. ”

    Source location

    HARRY JOSEPH PENGELLY ARMSTRONG EVANS · 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 case-management mitigations, including welfare tracking, safe voicemail referral storage, staff reminders, procedural guidance and individual training support.

    Verbatim wording from the response

    “As was noted during the Inquest, following Harry’s death the University had already undertaken a robust review of its current Case Management System (“CMS”). Steps had already been taken to identify technical issues and options for mitigation. All relevant colleagues have been made aware of the potential weaknesses in the existing system and appropriate mitigations are in place to minimise, as far as is possible, repeat issues occurring before the new system is implemented as soon as possible in 2023 with a view to the system being operational within the Academic Year 2023/24. These mitigations include:”

    Source location

    Response from Vice-Chancellor's
    Page 4 · response
    Published 7 November 2022

    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

    Procure and integrate a replacement welfare case-management system for operation during the 2023/24 academic year.

    Verbatim wording from the response

    “As was noted during the Inquest, following Harry’s death the University had already undertaken a robust review of its current Case Management System (“CMS”). Steps had already been taken to identify technical issues and options for mitigation. All relevant colleagues have been made aware of the potential weaknesses in the existing system and appropriate mitigations are in place to minimise, as far as is possible, repeat issues occurring before the new system is implemented as soon as possible in 2023 with a view to the system being operational within the Academic Year 2023/24. These mitigations include:”

    Source location

    Response from Vice-Chancellor's
    Page 4 · response
    Published 7 November 2022

    Open published response

  7. Manchester South

    AI-generated summary

    Kate Hedges · 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

    Kate Hedges died at Gatley Station on 27 November 2020 as a consequence of injuries sustained in an event that is redacted in the supplied text. The concerns included separate computerised record-keeping systems that could mean staff lacked relevant information for risk assessments and care plans, and an alleged failure to follow safeguarding policy. The report also raised concerns that mental health services were not consistently trauma-informed and that the ward environment could be distressing and difficult for people who had experienced trauma.

    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 follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient

    Wider context from the report

    “2. It is also a matter of concern that, following disclosure by Ms Hedges at a multidisciplinary meeting of a serious allegation to the effect that she was touched inappropriately by another patient, the Trust’s own safeguarding policy was not followed. ”

    Source location

    Kate Hedges · 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

    Implement twice-weekly patient safety meetings and include sexual safety as a standing topic in meetings and staff supervision.

    Verbatim wording from the response

    “GMMH is taking part in the Sexual Safety National Collaborative with the Royal College of Psychiatrists that aims to increase the percentage of service users and staff who feel safe from sexual harm within mental health and learning disabilities services. Bronte Ward has been involved in this project and has implemented changes over the past two years including twice weekly patient safety meetings that have sexual safety on the agenda and give staff and patients opportunity to discuss any concerns or ideas for improvements, and sexual safety is a standard agenda item in staff supervision.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 5 May 2022

    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

    Staff followed safeguarding processes after the reported sexual harassment, although the team acknowledged that transfer to a single-sex ward should have been considered.

    Verbatim wording from the response

    “Ms Hedges reported at the multi-disciplinary meeting held on 20th October 2020 that she was being sexually harassed by a male patient on the ward and was considering reporting this to the police. On reviewing Ms Hedges’ clinical record staff were aware of this and had followed Trust safeguarding processes by recording the discussions and putting plans in place with Ms Hedges to address on 18th October 2020. In this instance the male patient was due to be discharged from the ward, this was progressed, and Ms Hedges agreed to be supported by staff with increased observations. Transfer of Ms Hedges to another ward did not happen because Ms Hedges was having leave from the ward and was planning for discharge and the fact the male”

    Source location

    Response from Greater Manchester Mental Health
    Page 2 · response
    Published 5 May 2022

    Open published response

  8. Manchester City

    AI-generated summary

    Name not published · 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

    The deceased had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.

    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 consider safeguarding referral and assessment for vulnerable adults with serious mental disorder

    Wider context from the report

    “6. A significant failure to consider a safeguarding referral and assessment for a vulnerable adult suffering from serious mental disorder. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. East London

    AI-generated summary

    Mrs Helena Opoku · 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

    Mrs Helena Opoku was pronounced deceased at home on 4 April 2021 after dying from carbon monoxide toxicity associated with using charcoal braziers for cooking and heating after her gas and electricity had been disconnected. The report raised concerns about social services’ failure to investigate safeguarding referrals, appoint social workers within a reasonable timeframe, and assess vulnerable residents’ homes during January to March 2021.

    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 properly investigate safeguarding referrals

    Wider context from the report

    “1. During January- March 2021 the London Borough of Redbridge social services adult social care team in Cranbrook and Loxford were unable to; properly investigate all but the most acute safeguarding referrals made to them; ”

    Source location

    Mrs Helena Opoku · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Cumbria

    AI-generated summary

    Charlotte Duffield · 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

    Charlotte Duffield, aged 40, was found deceased at home on 4 February 2021 after concerns that she had not been seen for several weeks; the exact cause of death could not be determined because of advanced decomposition. Concerns were raised that, after a referral to Adult Social Care and unsuccessful telephone contact, no physical visit or further safeguarding action appeared to have been taken despite concerns for her safety.

    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 take safeguarding action following significant safety concerns

    Wider context from the report

    “(1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS ████████ of Cumbria Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken. (2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person. ”

    Source location

    Charlotte Duffield · 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

    Failure to make an in-person visit after unanswered safeguarding contact attempts

    Wider context from the report

    “(1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS ████████ of Cumbria Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken. (2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person. ”

    Source location

    Charlotte Duffield · 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

    Complete a systematic review of safeguarding adults self-neglect policies and procedures to clarify roles, responsibilities and duties.

    Verbatim wording from the response

    “1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system.”

    Source location

    2021-0334-Response-from-Cumbria-County-Council_Published
    Page 1 · response
    Published 14 October 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

    Review and revise operational guidance for self-neglect concerns to require face-to-face visits for assessment and safety assurance.

    Verbatim wording from the response

    “2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards.”

    Source location

    2021-0334-Response-from-Cumbria-County-Council_Published
    Page 1 · response
    Published 14 October 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

    Implement a countywide operational Safeguarding Adults service with a dedicated team providing consistent responses to safeguarding concerns.

    Verbatim wording from the response

    “3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect.”

    Source location

    2021-0334-Response-from-Cumbria-County-Council_Published
    Page 1 · response
    Published 14 October 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

    Deliver training sessions across partner organisations to embed revised self-neglect policy, procedure and guidance.

    Verbatim wording from the response

    “4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance.”

    Source location

    2021-0334-Response-from-Cumbria-County-Council_Published
    Page 1 · response
    Published 14 October 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

    Undertake a practice learning session with the involved team to establish a clear operational response to self-neglect concerns.

    Verbatim wording from the response

    “5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns.”

    Source location

    2021-0334-Response-from-Cumbria-County-Council_Published
    Page 2 · response
    Published 14 October 2021

    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