First reported 3 Mar 2014•Latest report 23 Sep 2025
Definition
What this concern includes
Includes failures of controls specifically dedicated to best-interests decision-making, including identifying when the process is required, involving the person and appropriate representatives, holding or arranging formal meetings where needed, applying relevant policy, recording the rationale and decisions, and ensuring appropriate oversight.
Not included
Excludes generic clinical documentation deficiencies unless they directly concern recording a best-interests decision or rationale.
Excludes general mental-capacity assessment failures that do not materially concern the subsequent best-interests decision-making process.
Excludes ordinary treatment, care-planning or consent failures where no best-interests decision-making requirement is identified.
Excludes generic staff training or role-clarity deficiencies unless they are explicitly tied to carrying out best-interests decision-making.
Reports
18
Distinct published reports
Individual concerns
26
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
29
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care5
Greater Manchester Health and Social Care Partnership2
Greater Manchester Mental Health NHS Foundation Trust2
Abbey Court Independent Hospital1
Advocacy Together Hub Rochdale1
All Care In One Limited1
All Care In One Ltd1
Ambassador House1
Barts Health NHS Trust1
Bolton Borough Council1
Brighton and Hove City Council1
Care Inspectorate Wales1
Caron Group Ltd1
County Durham and Darlington NHS Foundation Trust1
Crosfield House Limited1
NHS trust8
Ministerial department5
English metropolitan district council4
Health-system partnership3
Healthcare site2
Integrated care board2
Multi-service care provider2
Private limited company2
Domiciliary care provider1
English unitary authority1
Health professional body1
Police force1
Professional body1
Residential care home1
Social care inspectorate1
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.
East London
Concerns raised1
Poor recording of best interest decisions, PEG insertion and subsequent treatment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Reinforce requirements for clearly documenting best-interest discussions, including participants, reasoning, risks, benefits and outcomes.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Reissue documentation guidance to consultants and trainees and disseminate it through governance meetings and resident doctor teaching.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Roll out e-consent in endoscopy with sections for consent form 4 and best-interest discussions.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Discuss standardising e-consent and expanding Concentric Platform access to improve electronic-record integration and reduce paper consent documentation.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 September 2025.
Manchester North
Concerns raised1
Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.
Stated by Oldham Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Create and disseminate a risk-rating framework for safe attendance decisions at other organisations’ medical best-interests meetings, including information-sharing considerations.
Stated by Oldham Council ASCStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Birmingham and Solihull
Concerns raised1
Failure of staff to understand service users' best interests
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Provide supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.
Stated by All Care in OneStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2025.
County Durham and Darlington
Concerns raised2
Insufficient training coverage on capacity and best interests decision making across hospital settings
Failure to carry out capacity assessments and subsequent best interests decision making
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Manchester South
Concerns raised1
Failure to put an IMCA in place to safeguard best interests
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing safeguarding processes for patients with learning difficulties are considered robust, despite failing on this occasion.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Brighton and Hove
Concerns raised1
Failure to use best interests policy appropriately
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review and refresh Mental Capacity Act training, monitor attendance and refresher completion, and communicate attendance requirements to frontline teams.
Stated by Brighton and Hove City CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 May 2021.
South Yorkshire (Western)
Concerns raised4
Inadequate detail in best-interests documentation
Failure of clinical teams to seek the patient's views
Failure to treat best-interests decisions as specific individual decisions
Failure to distinguish clinical decisions from supported or best-interests decision-making
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021.
Action
Strengthen MCA training so all front-line clinical staff have the required knowledge.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Roll out advanced MCA training to senior decision-makers, initially targeting Clinical Directors, and monitor uptake.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Action
Provide accessible intranet resources covering MCA guidance, staff awareness and specialist support contacts.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Manchester South
Concerns raised1
Failure of care coordinators to lead support and best-interests processes in acute settings
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Provide assessment wards and the Emergency Department with a full Integrated Discharge Team service and assign a lead care coordinator for each patient's discharge planning.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide a single hospital-based care coordinator for each patient and record coordination input in electronic and social services records.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Establish a single care-coordinator point of contact, with care coordinators providing hospital in-reach for involved service users.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Bolton Council and GMMHFT will provide the full response to concerns about community care coordination and agency roles.
Stated by Bolton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Greater Manchester Mental Health Foundation Trust addresses care coordinator responsibilities.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised2
Failure to document decision-making rationales in inpatient notes
Failure to hold formal best interests meetings for key inpatient decisions
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Audit use of Best Interest Meetings following the October 2019 launch of Trust guidelines.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 January 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A formal best-interests meeting is not a statutory duty, although decision-makers must comply with the Mental Capacity Act consultation requirements.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised2
Failure to hold a formal best interests meeting during hospital treatment
Failure to hold a best interests meeting for End of Life Care
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Medical treatment decisions fall outside the Council’s responsibility, so it cannot comment on the individual’s hospital treatment.
Stated by Stockport Borough CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
The NHS Trust was responsible for arranging an IMCA and formal best-interests meeting concerning medical treatment.
Stated by Stockport Borough CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A formal best-interests meeting is not legally required; decision-makers must consult appropriate people where practicable and appropriate.
Stated by Helen Whatley MPDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The local NHS is expected to reflect on the LeDeR findings and address identified local failings in care.
Stated by Helen Whatley MPRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of controls specifically dedicated to best-interests decision-making, including identifying when the process is required, involving the person and appropriate representatives, holding or arranging formal meetings where needed, applying relevant policy, recording the rationale and decisions, and ensuring appropriate oversight.
