Recurring concern

Failure to escalate welfare concerns after unsuccessful contact

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First reported 29 May 2014•Latest report 6 Mar 2026

Definition

What this concern includes

Includes failures to initiate, consider or complete appropriate welfare escalation after unanswered calls, messages, letters, callbacks or visits where the lack of contact creates a supported concern about the person's safety or need for assistance, including contacting relevant professionals, emergency services or welfare-check responders.

Not included

  • Excludes ordinary unsuccessful contact attempts where no welfare concern or need for protective escalation is identified.
  • Excludes failures to conduct an initial welfare check when no prior failed-contact escalation issue is asserted.
  • Excludes generic communication, staffing or follow-up deficiencies unless they directly concern escalation after unsuccessful contact.
  • Excludes failures limited to emergency-control-room escalation, missing-person response or a separately named safeguarding pathway when that named process provides the more specific supported boundary.
Reports
10

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
18

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.

Aneurin Bevan University LHB1
Care Quality Commission1
Careworld London Limited1
Central London Community Healthcare NHS Trust1
CSS Telecare Service1
Department for Education1
Elmbridge Borough Council1
Epsom & Ewell Borough Council1
Gray's Inn Road Medical Practice1
London Ambulance Service NHS Trust1
London Borough of Tower Hamlets1
North London Mental Health Partnership1
North London NHS Foundation Trust1
Sister of Kala Skinner1
South Western Ambulance Service NHS Foundation Trust1

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. North London

    AI-generated summary

    Asher Blackman · 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

    Asher Blackman died in hospital on 21 September 2025 after collapsing at home, where he was found to be profoundly hypoglycaemic. Concerns included the District Nurses’ failure to record next-of-kin details or procedures for inability to gain access, and a no-access policy that did not address police involvement where the patient’s life might be at risk.

    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 no-access policy to include police involvement where the patient's life may be at risk

    Wider context from the report

    “That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access. The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access. ”

    Source location

    Asher Blackman · 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

    Undertake a comprehensive review to strengthen the no-access policy’s emphasis on immediate escalation for patients at significant clinical risk.

    Verbatim wording from the response

    “Notwithstanding the existence of this Trust policy, the Trust is currently undertaking a comprehensive review informed by recent staff engagement activities. This review is intended to strengthen the policy by placing greater emphasis on the immediate escalation of a “no access” visit where a patient is assessed as being at significant clinical risk, including cases requiring critical interventions such as blood glucose monitoring and insulin administration.”

    Source location

    Response from Central London Community Healthcare NHS Trust
    Page 2 · response
    Published 10 March 2026

    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 existing policy already provides for police involvement where non-access creates immediate, escalating or significant risks to patient safety or life.

    Verbatim wording from the response

    “The No Access: Not Seen: Disengagement Policy states that, while police involvement is not routine, it is both justified and expected where a failure to gain access gives rise to immediate or escalating concerns regarding patient safety or risk to life. The policy further provides for escalation to emergency services, including the police, where urgent visual confirmation of a patient’s wellbeing is required; where access is obstructed by others and there are genuine concerns regarding safety; or where non-access indicates a risk of significant harm or death.”

    Source location

    Response from Central London Community Healthcare NHS Trust
    Page 2 · response
    Published 10 March 2026

    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

    Implemented improvements to no-access arrangements and the proportionate PSIRF response directly address the reported concerns and strengthen patient safeguards.

    Verbatim wording from the response

    “Central London Community Healthcare NHS Trust has formally reviewed the incident in accordance with its Patient Safety Incident Response Framework (PSIRF) and has identified opportunities to enhance existing processes. The Trust is assured that the actions implemented to embed improvements within the No Access: Not Seen: Disengagement arrangements, together with the proportionate PSIRF response, directly address the concerns raised in your report and significantly strengthen safeguards for patients receiving community nursing services.”

    Source location

    Response from Central London Community Healthcare NHS Trust
    Page 3 · response
    Published 10 March 2026

    Open published response
  2. Inner North London

    AI-generated summary

    Maria Patricia Kelly · 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

    Maria Patricia Kelly, who lived alone and was in poor health, was found deceased at home by police on 15 May 2024 after concerns were raised by neighbours and a housing officer. The report identifies prolonged lack of contact with primary care and mental health services, numerous failed encounters, and no welfare check until the neighbours’ concerns were raised; the inquest determined natural causes.

    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 escalate unsuccessful contact attempts for a welfare check

    Wider context from the report

    “Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening. Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts. Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024. ”

    Source location

    Maria Patricia Kelly · 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

    Contact unallocated service users through a welfare-call system and escalate concerns under new guidance.

    Verbatim wording from the response

    “For service users who are still unallocated, we have implemented a welfare call system. These patients are regularly contacted to check in on their well-being. New guidance has also been put in place to ensure effective management of these patients, including clear instructions on when to escalate concerns. This initiative forms part of an ongoing Quality Improvement (QI) project aimed at improving care continuity and safety.”

    Source location

    Response from North London NHS Trust
    Page 2 · response
    Published 27 September 2024

    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

    Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.

    Verbatim wording from the response

    “The MaST tool will play a key role in improving caseload management and prioritisation. Staff training is currently underway, with sessions delivered throughout October to enable the implementation of MaST. A MaST Champion has been appointed to guide the team through the implementation process. Training will be completed by November 2024, after which MaST will enable real-time tracking and prioritisation of high-risk service users. This will ensure close monitoring of service users on the waiting list, and timely follow-up.”

    Source location

    Response from North London NHS Trust
    Page 2 · response
    Published 27 September 2024

    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

    Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.

    Verbatim wording from the response

    “We have reinforced our case tracking procedures using the RAG-rating system which identifies levels of risk (Red, Amber, Green). Weekly allocation meetings are held to ensure that high-risk cases are prioritised for follow-up. While we await MaST full implementation,”

    Source location

    Response from North London NHS Trust
    Page 2 · response
    Published 27 September 2024

    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 staff guidance on RCRP protocols, including escalation within the police system when welfare-check requests are declined.

    Verbatim wording from the response

    “6. Right Care Right Person (RCRP) Guidance We have provided guidance to staff on the use of the Right Care Right Person (RCRP) protocols to ensure effective escalation to external agencies (specifically the Police) to support the management of welfare checks and missing persons. This includes escalating within the Police system when requests for support with welfare checks are declined by Police.”

    Source location

    Response from North London NHS Trust
    Page 3 · response
    Published 27 September 2024

    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

    Clarify whether reported welfare-check arrangements have been completed in future cases.

    Verbatim wording from the response

    “However, we will of course endeavour to clarify if things have been sorted in future, and if not, possibly call Adult Social Care (we have recently been told by police about other cases that they do not do welfare checks anymore). We have discussed this with practice management here and the clinical lead - myself.”

    Source location

    Response from Gray's Inn Medical Group
    Page 1 · response
    Published 27 September 2024

    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 welfare-check clarification arrangements with practice management and the clinical lead.

    Verbatim wording from the response

    “However, we will of course endeavour to clarify if things have been sorted in future, and if not, possibly call Adult Social Care (we have recently been told by police about other cases that they do not do welfare checks anymore). We have discussed this with practice management here and the clinical lead - myself.”

    Source location

    Response from Gray's Inn Medical Group
    Page 1 · response
    Published 27 September 2024

    Open published response
  3. Gwent

    AI-generated summary

    Diane Greenslade · 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

    Diane Greenslade was found moaning on her bedroom floor with a chest of drawers on top of her after ambulance responses were delayed. She suffered a cardiac arrest and died, with the inquest concluding that she died from natural causes following a fifteen-and-a-half-hour delay in ambulance intervention. The substantive concerns included the initial call categorisation without clinical assessment, failure to consider escalation or a police welfare check, high ambulance demand and hospital delays, and a nearby rapid response vehicle being unavailable because it was reserved for higher-priority calls.

    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 escalate calls appropriately after unsuccessful contact

    Wider context from the report

    “(2) After failing to make contact, no consideration was given to either upgrading the call category or to contacting the Police to ask them to carry out a welfare check. ”

    Source location

    Diane Greenslade · 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 policies and procedures for establishing contact with patients or callers at scene.

    Verbatim wording from the response

    “2. After failing to make contact, no consideration was given to either upgrading the call category or to contacting Police to ask them to carry out a welfare check. Whilst we have set out in this correspondence that we are reviewing our policies and procedures around establishing contact with a patient or caller at scene, we are of the view that it would not be appropriate to request police attendance to undertake welfare checks for 999 calls to the ambulance service, as police officers are not suitably trained to make a clinical assessment. However, we are working collaboratively with our Police Force colleagues to develop a Memorandum of Understanding regarding this issue.”

    Source location

    2018-0401-Response-by-Welsh-Ambulance-Services
    Page 4 · response
    Published 21 December 2018

    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

    Develop a Memorandum of Understanding with police regarding the issue.

    Verbatim wording from the response

    “2. After failing to make contact, no consideration was given to either upgrading the call category or to contacting Police to ask them to carry out a welfare check. Whilst we have set out in this correspondence that we are reviewing our policies and procedures around establishing contact with a patient or caller at scene, we are of the view that it would not be appropriate to request police attendance to undertake welfare checks for 999 calls to the ambulance service, as police officers are not suitably trained to make a clinical assessment. However, we are working collaboratively with our Police Force colleagues to develop a Memorandum of Understanding regarding this issue.”

    Source location

    2018-0401-Response-by-Welsh-Ambulance-Services
    Page 4 · response
    Published 21 December 2018

    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

    Police attendance for ambulance 999 welfare checks is considered inappropriate because police officers lack training for clinical assessment.

    Verbatim wording from the response

    “2. After failing to make contact, no consideration was given to either upgrading the call category or to contacting Police to ask them to carry out a welfare check. Whilst we have set out in this correspondence that we are reviewing our policies and procedures around establishing contact with a patient or caller at scene, we are of the view that it would not be appropriate to request police attendance to undertake welfare checks for 999 calls to the ambulance service, as police officers are not suitably trained to make a clinical assessment. However, we are working collaboratively with our Police Force colleagues to develop a Memorandum of Understanding regarding this issue.”

    Source location

    2018-0401-Response-by-Welsh-Ambulance-Services
    Page 4 · response
    Published 21 December 2018

    Open published response
  4. London Inner (North)

    AI-generated summary

    William Lugg · 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

    William Lugg lived alone and received daily care visits, but after an unwitnessed fall on or by the morning of 3 March 2018, carers received no answer and he was not found until 6 March 2018, when he was discovered deceased at his residence. The concerns included failures to follow and coordinate failed-visit procedures, inaccurate information about his welfare, inadequate recording of keyholder and call details, insufficient prominence given to contacting police, and the absence of a clear Monday-morning referral-prioritisation system.

    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 failed visits policies to give sufficient prominence to police involvement

    Wider context from the report

    “(5) Neither Tower Hamlets or Careworld’s Failed Visits policy gives any / any sufficient prominence to the possibility of involving the police if other attempts to confirm the individual’s welfare following a failed visit have proved unsuccessful; ”

    Source location

    William Lugg · 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

    Update the Failed Visits policy to align with relevant local-authority procedures and strengthen escalation, communication recording and police involvement.

    Verbatim wording from the response

    “(ii) The Failed Visits policy itself has been updated - a copy is at Appendix B - and all Careworld London staff (both office staff and care workers) have been re-trained in respect of the content of the revised policy and in respect of the fundamental principles involved in safeguarding adults. All such training was completed by 3 August 2018.”

    Source location

    2018-0200-Response-by-Careworld-London-Ltd
    Page 2 · response
    Published 10 July 2018

    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

    Formally launch the revised Failed Visits Procedure to Adult Social Care staff and commissioned providers.

    Verbatim wording from the response

    “17. The Council’s Failed Visits Procedure has been reviewed and following consultation, including with our provider services, it is being revised. The revised policy will be signed off and formally launched with the Adult Social Care and commissioned providers in August 2018.”

    Source location

    2018-0200-Response-by-London-Borough-of-Tower-Hamlets
    Page 6 · response
    Published 10 July 2018

    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

    Introduce a prominent emergency police-call checklist and clarify that any officer may call police when serious harm is suspected.

    Verbatim wording from the response

    “20. The Council’s revised Failed Visits Procedure now includes a one-page checklist which makes more prominent the requirement to call the Police in an emergency situation, following some quick checks to locate the person:-”

    Source location

    2018-0200-Response-by-London-Borough-of-Tower-Hamlets
    Page 7 · response
    Published 10 July 2018

    Open published response
  5. Surrey

    AI-generated summary

    Derek Clifford Dudley · 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

    Derek Clifford Dudley was found deceased from hypothermia outside the back door of his home on 6 March 2017, after previously activating his community alarm following a fall. Concerns included the call being ended before he had got up, limited follow-up after a later unanswered call, unsupervised trainee operators, the absence of pro forma questions, and insufficient background information for assessing service users’ needs.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to take further action when follow-up contact after an unanswered alarm call fails

    Wider context from the report

    “The operator attempted to contact Mr Dudley by telephone again 1.5 hours later, which ████████ again stated was in breach of Telecare’s policy, but there was no answer and no further action was taken. ”

    Source location

    Derek Clifford Dudley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    Chadrack Mbala MULO · 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

    Chadrack Mbala Mulo, aged four, died of dehydration and acute protein-energy malnutrition after his mother died unexpectedly at home and he was left alone for approximately a fortnight. He was found about 48 hours after his death. The substantive concerns were that the school had contact details only for his mother, did not immediately visit the home when he failed to attend, and did not immediately contact the police when staff could not gain access.

    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 immediately contact police when no one answers at the family home

    Wider context from the report

    “3. If there is no answer at the family home when staff members attend, they now immediately contact the police, who in most cases are likely to force entry. This protocol seems very sensible, but is clearly driven by the appalling tragedy of Chadrack’s death. It seems unlikely that other schools in Hackney, elsewhere in London, or indeed in the rest of England & Wales, have such a system in place. ”

    Source location

    Chadrack Mbala MULO · 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

    Identify how to reinforce guidance on escalating child safety or welfare concerns to children’s social care services or police.

    Verbatim wording from the response

    “I would anticipate that guidance will continue to make clear that professional judgement should be used in deciding when child safety or welfare concerns should be escalated to children’s social care services and/or the police. I have also asked the Department to identify the best way to reinforce this point further in the attendance and safeguarding guidance.”

    Source location

    2017-0120-Response-by-Department-for-Education
    Page 1 · response
    Published 2 June 2017

    Open published response
  7. Inner West London

    AI-generated summary

    Patricia Mercieca · 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

    Patricia Mercieca, who had severe COPD and asthma and lived in assisted accommodation, pulled her emergency cord on 14 July 2015 and said that she could not breathe. She arrested shortly afterwards and was found deceased when the ambulance service arrived. Concerns included failures to provide correct information and follow up when she did not respond, to contact the resident manager, and to pass on relevant medical history and information requested by emergency 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 to raise immediate concerns with appropriate agencies after no response from an emergency call system user

    Wider context from the report

    “(4) That call handlers be trained such that if they get no response when contacting a person who has contacted them and that person is a user of the emergency call system, then immediate concerns should be raised with the appropriate agencies for example the LAS and resident scheme manager. ”

    Source location

    Patricia Mercieca · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Avon

    AI-generated summary

    Ms. Kala Michelle Skinner · 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

    On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.

    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 make sufficient and timely welfare calls when no response is provided

    Wider context from the report

    “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition (3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased. (4) There was failure to make sufficient and timely welfare calls when a response could not be provided. (5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors. (6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors. (7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed. (8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs. (9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary. (10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis. ”

    Source location

    Ms. Kala Michelle Skinner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Inner North London

    AI-generated summary

    Toni Elizabeth SKILLINGTON · 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

    Toni Elizabeth Skillington took an excess of methadone and alcohol and contacted family members, who alerted the London Ambulance Service. Emergency paramedics arrived almost three hours later, after failures to follow procedures following unanswered welfare checks and other concerns about call handling and dispatch.

    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 appropriate action after unanswered welfare-check callbacks

    Wider context from the report

    “3. Two welfare checks were made via ring backs without any reply gained, yet neither of these was followed by the appropriate action. Even accepting how busy and under staffed the service was that night, a call child at least have been made to the police asking for attendance. ”

    Source location

    Toni Elizabeth SKILLINGTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  10. Inner North London

    AI-generated summary

    Stephen Anthony WARD · 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

    Stephen Anthony Ward, who had a long history of depression and other mental health problems, was found hanging by a close friend on 28 February. The principal concern was that, after the crisis team contacted police to request a welfare check, nobody followed up when police did not call back within one or two hours; the police later said they could not locate his flat, by which time Mr Ward had been found hanging.

    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 up police welfare-check requests when no response is received

    Wider context from the report

    “However, at around 7.30pm on Thursday, 27 February, a member of the crisis team placed a call to police asking for a welfare check to be carried out. What concerns me is that, when the police did not call back within an hour or two, nobody from the crisis team followed this up with the police. The next contact was at around 8.15am on the morning of Friday, 28 February, when the police rang the crisis team to say that they were outside Mr Ward’s building and could not locate his flat. In fact, Mr Ward’s friend had by this time found him hanging. Mr Ward did not have any personal contact with anyone after Tuesday, 25 February, so by the time the alarm was raised on Thursday evening, he might well have already died. However, he might not. In any event, following up with the police might be critical for another person in his position. ”

    Source location

    Stephen Anthony WARD · 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 existing community mental health service practice to inform safer police-requested check arrangements.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 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

    Establish guidance requiring requests for checks to be followed up within six hours across community mental health teams.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 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

    Issue the check-follow-up guidance to staff across the organisation.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 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

    Develop a full organisational protocol for police-contact follow-up, including further work with Metropolitan Police colleagues.

    Verbatim wording from the response

    “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 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

    Obtain Trust Quality Committee ratification and formally issue the full protocol as a Trust protocol.

    Verbatim wording from the response

    “The guidance is due to be issued to staff across the organisation on 21st July 2014, with the ratification of the full protocol due at the Trust Quality Committee in September 2014 for formal issuing as a Trust Protocol by 1st October 2014.”

    Source location

    2014-0248-Response-by-Camden-Islington-NHS-Trust
    Page 1 · response
    Published 29 May 2014

    Open published response
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Data last updated 7 September 2026