Recurring concern

Unreliable best-interests decision-making processes

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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

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. Manchester North

    AI-generated summary

    Hazel Maureen Lewis · 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

    Hazel Maureen Lewis died in hospital on 28 November 2018 after an unwitnessed fall caused a hip fracture; the medical cause of death was metastatic breast cancer, with the fracture contributing. Concerns were raised about the best-interest decision-making process, including inadequate consultation, failure to formally instruct an IMCA, insufficient exploration of support to help her engage with investigations, and uncertainty about the advocate’s role.

    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 identify and consult relevant consultees in Mental Capacity Act decisions

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”

    Source location

    Hazel Maureen Lewis · 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 correctly apply Mental Capacity Act capacity requirements to decisions about investigations

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”

    Source location

    Hazel Maureen Lewis · 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 follow the required order of Mental Capacity Act best-interest decision-making steps

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”

    Source location

    Hazel Maureen Lewis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Julie Ann Barrow · 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

    Julie Ann Barrow, who had significant learning disabilities, was admitted to hospital on several occasions for perianal pain, rectal bleeding and haemorrhoids. Following treatment for adjustment disorder and significant sedation, she fell at her family home on 1 April 2019, sustained an unsurvivable brain injury and died in hospital the next day. The principal concerns included the absence of a best interests meeting and reasonable adjustment care plan, ineffective communication and understanding of her needs, inadequate support for her parents, and the loss of the learning disability liaison role.

    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 hold best interests meetings to discuss inpatient care

    Wider context from the report

    “1. The inquest heard that despite two in-patient stays, there was no best interests meeting held to discuss her care; ”

    Source location

    Julie Ann Barrow · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. South Wales Central

    AI-generated summary

    Barbara Humphreys · 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

    Barbara Humphreys was admitted to Crosfield House in July 2018 and later experienced repeated entrapment of her leg and foot between bed rails and the mattress. She underwent a right lower-leg amputation and died in hospital on 28 November 2018; the reported medical cause was thrombosis and the inquest conclusion was natural causes. The principal concerns included the lack of a bed-rail risk assessment, unsuitable mattresses, staff training, bed-rail policies, care planning, and communication with family about medical attendance, palliative care and DNAR decisions.

    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

    Delays in completing care plans and best interests assessments

    Wider context from the report

    “5. The fifth issue is directed to Crosfield house Ltd and Care Inn limited which is there was evidence that the completion of care plans and best interests assessments was required to be fitted round other duties and as such may not be completed in a timely fashion. The group and the care home shall consider whether assigning a set or allotted period of time for a RGN to complete the care plan and assessment in the working day would help ensure that the care plan is most accurate and appropriately detailed. ”

    Source location

    Barbara Humphreys · 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

    Agree and undertake an unannounced joint monitoring visit, including review of Deprivation of Liberty Safeguards and Best Interest decisions.

    Verbatim wording from the response

    “reference as part of the wider sharing of lessons. Through our care home governance framework, the health board will continue to monitor the standards of care and treatment provided to Powys residents. A planned date for a joint monitoring visit with Powys County Council was in place but was subsequently postponed whilst the regular visits from the Health and Safety Executive and Care Inspectorate Wales took place. Importantly, a new date is currently being agreed for the visit which will be unannounced. The team that undertakes review visits has also been strengthened with a new addition to the team representing pharmacy and medicines management.”

    Source location

    2019-0246-Response-by-Powys-Teaching-Health-Board
    Page 2 · response
    Published 9 September 2019

    Open published response

  4. West Yorkshire Eastern

    AI-generated summary

    Eileen Cooke · 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 Cooke, an 80-year-old woman with dementia, frailty, contractures and a fractured left ankle, died in Pinderfields Hospital on 21 December 2017. Concerns included the lack of a best-interests multidisciplinary meeting, her discharge to a nursing home with unresolved medical and care needs, inadequate preparation for wound dressing and pain control, and the risk posed to other patients by precipitously arranged hospital discharges.

    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 complete multidisciplinary best-interests decision-making and formulate a management plan

    Wider context from the report

    “1. Consideration was given to an amputation of her left leg at her groin but it was recognised this would entail significant risks for a frail lady aged 80 with a range of co-morbidities. A ‘best interests’ multi-disciplinary meeting was mooted but never organised. 2. She was nevertheless deemed medically fit to be discharged from hospital on 7 November 2017 despite the progressive deterioration of the soft tissues around her left ankle fracture site and painful ulceration between her thighs. At this point in time the question of amputation or an alternative management plan were unresolved. The discharge letter was produced by a ‘Trust Grade Doctor-Career Grade Level’ unknown to the family. ”

    Source location

    Eileen Cooke · 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

    Provide Care of the Elderly consultations for frail patients outside elderly care areas, including guidance on complex care and discharge planning.

    Verbatim wording from the response

    “Wherever possible frail elderly patients are admitted to one of the Acute Care of the Elderly (ACE) Units. This ensures that a holistic approach is taken and a comprehensive geriatric assessment completed. When frail patients are admitted to other areas the care of the elderly department does offer consultations to help guide clinical care and discharge planning.”

    Source location

    2018-0311-Response-Mid-Yorkshire-Hospitals
    Page 1 · response
    Published 23 February 2019

    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 daily multidisciplinary board rounds and safety huddles to review treatment, discharge plans, patient needs and emerging concerns.

    Verbatim wording from the response

    “Each of our Care of the Elderly wards has access to therapy teams who attend daily board rounds which occur on a Monday to Friday. Treatment and prospective discharge plans are discussed. This allows issues to be raised and concern addressed: such as how someone is going to manage at home or whether further information or time is needed. At these daily board rounds and safety huddles, therapists, nurses, doctors and discharge coordinators are present. Each of our care of the elderly wards has a dedicated discharge coordinator, who helps to facilitate safe and timely discharges of frail older patients. Once a patient is deemed medically fit, the therapists work to establish the baseline and whether a patient’s current needs have changed.”

    Source location

    2018-0311-Response-Mid-Yorkshire-Hospitals
    Page 3 · response
    Published 23 February 2019

    Open published response

  5. Bedfordshire and Luton

    AI-generated summary

    ETHELINE DE-GALE · 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

    Etheline De-Gale fell while mobilising from bed at a care setting on the night of 7/8 March 2016. Hospital admission was declined, follow-up with a doctor did not occur as recommended, and an ambulance attended the following afternoon; she later underwent surgery, contracted bronchopneumonia and died from a pulmonary embolism on 16 March 2016. Concerns included an insufficiently clear care plan, inadequate guidance on risk assessments, limited staffing, and the apparent failure to follow paramedic recommendations.

    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

    Insufficient staffing capacity for best-interests decisions and hospital accompaniment

    Wider context from the report

    “(4) There were only 2 members of staff on duty, which potentially could compromise decisions made in the best interests of a resident. One carer accompanying a resident to hospital would clearly create a problem and that could potentially be seen as a basis for not admitting a resident to hospital. ”

    Source location

    ETHELINE DE-GALE · 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

    Staffing levels complied with regulations and did not make hospital admission inappropriate.

    Verbatim wording from the response

    “The numbers of staff on duty at the time of the incident were in line with regulation and are allocated based on need of our residents. At night time the residents are in bed and mostly sleep. There is a requirement of staff to regularly check those residents who require care and to attend residents when they call for assistance. It would be rare for two residents to call at the same time, however, should this be the case, a staff member would attend each resident independently, assess the need for the call, ensure the resident was safe and then prioritise the tasks with their colleague in order to assist the residents. The duty of the care staff attending a resident is to acknowledge the individual risk. In this case LR willingly left EDG on the side of the bed, without thought of her falling.”

    Source location

    2017-0058-Response-Ambassador-House-Home
    Page 2 · response
    Published 6 March 2017

    Open published response

  6. Cheshire

    AI-generated summary

    Brian Gerrard · 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

    Brian Gerrard had moderately severe mixed Alzheimer’s/vascular dementia, depression and intermittent infections, and died after becoming undernourished because he was not eating sufficiently. The inquest concluded that he died from natural causes, namely lack of eating due to dementia. Concerns related to staff understanding and management of best-interests meetings, identification of lack of capacity, and implementation of Deprivation of Liberty Safeguarding procedures, including inaccurate and contradictory information in an application.

    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 ensure that best interests meeting minutes accurately reflect participants’ views

    Wider context from the report

    “The MATTERS OF CONCERN relate to (1) the understanding of staff in relation to the proper management of a best interests meeting, (2) the identification of lack of capacity and (3) the implementation of Deprivation of Liberty Safeguarding procedures. All such deficiencies appeared to warrant an amendment of procedures and a requirement for appropriate training. On 26th September 2014 a best interests, multidisciplinary meeting was called at your hospital to decide upon what action to take to address the fact that the deceased was not eating sufficiently and might be close to death. Those present at the meeting included the deceased’s named nurse who took the minutes of the meeting, the deceased’s wife, a psychiatrist who was the deceased’s responsible clinician and a General Practitioner from the deceased’s medical practice. The meeting decided that it was in the deceased’s best interests to remain at your hospital rather than being transferred to a general hospital for treatment. In that regard the minute of the meeting correctly reflected what had been agreed. However, it was also minuted that the deceased had determined to die and that to achieve this aim he was deliberately not eating and that he had capacity to make such a decision. Such did not represent the opinion of the psychiatrist / responsible clinician nor the opinion of the general practitioner, both of whom were of the view that the deceased did not have capacity and that he had not formulated a plan to die but that his lack of eating was a product of his illness. Thereafter an application for a Deprivation of Liberty Safeguard contained inaccurate and contradictory information and appeared to demonstrate a lack of familiarity with procedures. For instance, the application asserted that the deceased had capacity to make decisions with regard to his care needs when such did not represent the opinions of the clinicians responsible for the deceased’s care. ”

    Source location

    Brian Gerrard · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Dennis Bennett · 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

    Dennis Bennett had dementia and was admitted under the Mental Health Act before receiving end-stage palliative care on a mental health ward, where he died of natural causes on 7 February 2016. Concerns included an urgent deprivation of liberty application made while he was already detained under Section 3, uncertainty about the application’s continuation, confusion about place-specific authorisations, and limited consideration of whether the application was needed while he was compliant and receiving palliative care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to consider whether DOLS are necessary when patients are compliant with treatment

    Wider context from the report

    “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act. 2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. 3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific. 4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients. ”

    Source location

    Dennis Bennett · 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 end-of-life care and consider the most appropriate legal framework for depriving a patient of liberty.

    Verbatim wording from the response

    “The Trust’s Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services is currently undertaking a review of end of life care. She has been asked to build into the review consideration of the most appropriate legal framework to use.”

    Source location

    Dennis-Bennett-Response
    Page 3 · response
    Published 12 April 2016

    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 Trust considers the decision to use DoLS rather than best-interests treatment was available to clinicians in this particular case.

    Verbatim wording from the response

    “Finally, you note Mr Bennett was then on the end stage palliative care and entirely compliant with treatment, there was little consideration as to why a DoLs was applied for as opposed to treating the deceased in his best interests.”

    Source location

    Dennis-Bennett-Response
    Page 3 · response
    Published 12 April 2016

    Open published response

  8. Inner South London

    AI-generated summary

    Kirabo Kiwanuka · 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

    Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

    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 involve family in best-interests decisions for sectioned patients lacking capacity

    Wider context from the report

    “3. Where a patient lacks capacity and is under section, the involvement of the family in determining her best interests is required but here it was limited and yet they had concerns about the risks of treatment. The parents were not given the opportunity to contribute their views to the decision to administer Acuphase, but decisions had to be taken in situations of acute disturbance. What is the role of each of psychiatrists, physicians and next of kin in reaching critical care decisions for sectioned patients with acute medical and psychiatric problems? ”

    Source location

    Kirabo Kiwanuka · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026