Recurring concern

Unreliable case allocation and resolution of allocation disputes

First to latest report 20 Dec 2013 — 4 Sep 2025

Reports that mention this concern
8
Times this concern has been raised
10
Stated actions linked to this concern
20

What this concern includes

Includes failures of a defined case-allocation process, including delayed allocation, unclear allocation responsibility, failure to record allocation disagreements, and failure to resolve such disagreements promptly where these affect the safe progression of cases.

What is not included
  • Excludes responsibility disputes concerning housing, accommodation or other services where the issue is not allocation of cases within a service process.
  • Excludes generic record-keeping, escalation or dispute-resolution deficiencies that are not directly tied to case allocation.
  • Excludes delays in case progression after allocation when no case-allocation or allocation-dispute failure is identified.
  • Excludes generic service capacity or staffing deficiencies unless they directly cause unreliable case allocation.

Reports and published responses 8 reports

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

  1. Birmingham and Solihull

    AI-generated summary

    Khalif Mohammed · 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

    Khalif Mohammed, who was detained in hospital under section 3 of the Mental Health Act, failed to return from unescorted leave on 6 January 2025 and was found deceased at his flat the following day. The medical cause of death was recorded as haemopericardium and haemothorax due to a stab wound, and the inquest conclusion was suicide. The report raised concerns about insufficient police resources and a significant delay in allocating officers to his priority missing-person case.

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    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 resources for timely allocation of police officers to priority cases

    Wider context from the report

    “1. The inquest heard that West Midlands Police had insufficient resources to allocate police officers to deal with Khalif's case on 06/01/25 which was classed as a priority case with expected allocation of resources within an hour. As a result, there was a significant delay in officers being allocated to the case. Whilst it could not be shown that this affected the outcome for Khalif, there is a risk of future deaths if the available resources are not sufficient to deal with the large numbers of cases received each day and in my view, action should be taken. ”

    Source location

    Khalif Mohammed · Prevention of Future Deaths report
    Page 2 · concerns

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    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 increased police funding for 2025–26 settlements, pay awards, employer contributions and officer maintenance.

    Verbatim wording from the response

    “The Chancellor has announced a real terms increase in police spending power over the next three years. For this financial year, the 2025-26 final police funding settlement provides funding of up to £19.6 billion for the policing system in England and Wales. This is an overall increase of up to £1.2 billion when compared to the 2024-25 settlement. West Midlands Police will receive up to £846.9 million in funding in 2025-26, an increase of up to £56.5 million (7.2%) when compared to the 2024-25 police settlement.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 16 September 2025

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    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 £200 million nationally to kickstart recruitment of 13,000 additional neighbourhood-policing officers, PCSOs and special constables.

    Verbatim wording from the response

    “In addition to the funding announced at the settlement, we are providing £120 million of in-year funding to support forces in meeting the cost of the 2025-26 pay award. The settlement also includes funding to support the costs of the 2024-25 pay award, the increase in the employer national insurance contributions, funding for officer maintenance and an additional £200 million nationally to kickstart the first phase of recruiting 13,000 additional police officers, PCSOs and special constables into neighbourhood policing roles.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 16 September 2025

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    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

    Set expectations for forces to reduce inefficiencies and maximise productivity through the Police Efficiency and Collaboration Programme.

    Verbatim wording from the response

    “It is the responsibility of locally elected Police and Crime Commissioners, Mayors and Chief Constables to take decisions around their resourcing according to local needs. However, the Government recognises the challenges faced by police chiefs in prioritising finite resources and is committed to ensure that police forces can effectively tackle a wide range of public safety issues. We have set out our expectation to forces to reduce inefficiencies and maximise productivity driven through a new Police Efficiency and Collaboration Programme. This will free up cashable savings and officer time to reinvest in frontline activities. The Government will continue to engage with forces to ensure that”

    Source location

    Response from Home Office
    Page 1 · response
    Published 16 September 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Local Police and Crime Commissioners, Mayors and Chief Constables are responsible for resourcing decisions according to local needs.

    Verbatim wording from the response

    “It is the responsibility of locally elected Police and Crime Commissioners, Mayors and Chief Constables to take decisions around their resourcing according to local needs. However, the Government recognises the challenges faced by police chiefs in prioritising finite resources and is committed to ensure that police forces can effectively tackle a wide range of public safety issues. We have set out our expectation to forces to reduce inefficiencies and maximise productivity driven through a new Police Efficiency and Collaboration Programme. This will free up cashable savings and officer time to reinvest in frontline activities. The Government will continue to engage with forces to ensure that”

    Source location

    Response from Home Office
    Page 1 · response
    Published 16 September 2025

    Open published response

  2. South Wales Central

    AI-generated summary

    Lewis Rhys Thomas Petryszyn · 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

    Lewis Rhys Thomas Petryszyn died in his shared cell at HMP Parc on 15 April 2022 after inhaling synthetic cannabinoids without intending to end his life. The principal concern was the absence of specified timeframes for intervention, ongoing support and case-load allocation for prisoners at risk of substance misuse, creating a risk of delayed support and intervention.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Absence of specified prescribed timeframes for intervention, ongoing support and case load allocation for prisoners at risk of substance misuse

    Wider context from the report

    “(1) There was, and remains, an absence of specified prescribed timeframes in policies and procedures within which intervention, ongoing support, and/or case load allocation to/from Dyfodol must occur for prisoners likely to be at risk of substance misuse. (2) The absence of prescribed timeframes poses the real risk of delayed support and intervention to drug users ”

    Source location

    Lewis Rhys Thomas Petryszyn · 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

    Embed agreed intervention, support and caseload timeframes in the revised service specification for future procurement.

    Verbatim wording from the response

    “While the current service specification does not explicitly define timeframes for intervention, ongoing support, or case allocation, Dyfodol and CTM work to mutually agreed timeframes that are reviewed monthly. These timeframes will be formally embedded into the revised service specification as part of the future procurement process, once the existing contract expires.”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 1 · response
    Published 31 July 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Reduce the brief-intervention waiting period to the four-week target through recruitment and improved waiting-list management.

    Verbatim wording from the response

    “Brief interventions consist of up to ten one-to-one sessions per individual, alongside targeted group programmes. The target timeframe for initiating one-to-one brief interventions is four weeks. Following recent recruitment efforts and improved waiting list management, Dyfodol has successfully reduced the previous six-week waiting period. As of August 2025, the waiting list is compliant with the four-week target.”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 2 · response
    Published 31 July 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Expand group provision with weekly rolling programmes for people waiting for one-to-one brief interventions.

    Verbatim wording from the response

    “To ensure continued support, Dyfodol has expanded its group provision, enabling those on the waiting list to access weekly rolling programmes such as the Drug Education Programme, SMART Recovery, and the Nudge Course (a four-week psychosocial programme focused on managing substance use and mental health).”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 2 · response
    Published 31 July 2025

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    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

    Submit a proposal to HMPPS to enhance the clinical substance misuse service at HMP & YOI Parc.

    Verbatim wording from the response

    “These proposals will be shared with relevant stakeholders prior to submission to HMPPS for consideration. Additionally, following consultation with G4S, Public Health Wales, Welsh Government, and other stakeholders, the Prison Healthcare Directorate has submitted a proposal to HMPPS to enhance the clinical substance misuse service at HMP & YOI Parc. This includes:”

    Source location

    Cwn Taf Morgannwg University Health Board
    Page 3 · response
    Published 31 July 2025

    Open published response

  3. Cumbria

    AI-generated summary

    Gerald Goodwin · 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

    Gerald Goodwin, who had Alzheimer’s dementia and had consumed a significant amount of alcohol, was struck by a train while walking along a railway track on 10 November 2022; his death was confirmed at 00:17 on 11 November 2022. The principal concerns were that safeguarding and care-assessment referrals were rejected, closed, or not actioned, with multiple teams and systems failing to communicate effectively and potentially exposing other vulnerable adults to 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

    Case allocation and deallocation without action or explanatory recording

    Wider context from the report

    “(4) Thereafter Mr Goodwin's case was allocated and de-allocated to a social worker within the space of one day, without anything being done. It is said that there is no note or explanation for this. I am concerned that, once again, the ability of a case to be allocated and deallocated within a short period and without anything having been done may enable a case to 'fall through the cracks'. Indeed, the referral for the care assessment was not ultimately actioned until 25th November 2022, 2 weeks after Mr Goodwin died. ”

    Source location

    Gerald Goodwin · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Require recorded explanations for case deallocation and provide management oversight of all case closures.

    Verbatim wording from the response

    “Following completion of the witness statement a process was put in place and a directive was shared with Adult Social Care staff on 10th October 2023. This instructs staff that if a case is picked up to be allocated and is subsequently de-allocated this must be recorded as a case note on the electronic case recording system with a clear explanation of why the case is being closed, thus ensuring a clear audit trail is in place. We have also implemented a system where there is management oversight of all case closures to provide increased governance in this area.”

    Source location

    Response from Adult Social Services
    Page 4 · response
    Published 22 November 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct regular case-file audits of chronology and completed actions.

    Verbatim wording from the response

    “Regular case file audits are already in place which do look at the case chronology to ensure that appropriate actions have been taken.”

    Source location

    Response from Adult Social Services
    Page 4 · response
    Published 22 November 2023

    Open published response

  4. North East Kent

    AI-generated summary

    Hadley John Savory · 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

    Hadley John Savory was discharged from hospital on 25 September 2019 without evidence of a multi-agency planning meeting, and his care, support and treatment plan was unclear. His presentation later declined in the community, safeguarding referrals did not lead to multi-agency meetings, and he was found dead at home on 13 December 2019; toxicological evidence indicated that he had taken a lethal dose of methadone. The principal concerns related to hospital discharge planning, allocation of care responsibilities, meeting eligible care needs, safeguarding procedures for self-neglect or hoarding, and information sharing where mental capacity may fluctuate.

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    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 record attempts to escalate internal disagreements over team allocation

    Wider context from the report

    “(2) There was no recording (or available evidence of recording) of attempts to escalate internal disagreements as to which team Mr Savory should have been allocated to. Nor did the evidence establish how internal disagreements as to allocation of cases were recorded; ”

    Source location

    Hadley John Savory · Prevention of Future Deaths report
    Page 2 · concerns

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    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 recording arrangements for internal disagreements over case allocation

    Wider context from the report

    “(2) There was no recording (or available evidence of recording) of attempts to escalate internal disagreements as to which team Mr Savory should have been allocated to. Nor did the evidence establish how internal disagreements as to allocation of cases were recorded; ”

    Source location

    Hadley John Savory · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Worcestershire

    AI-generated summary

    Geoffrey Harrison HUTTON · 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

    Geoffrey Harrison Hutton died by suicide in his cell at HMP Long Lartin on 8 February 2019 after hanging himself with a ligature made from a laundry-bag drawstring. He had significant hearing impairment, longstanding mental health and substance misuse issues, and was subject to an ACCT document. The substantive concerns included failures relating to social-care referral and support for his hearing and communication needs, ineffective ACCT case-manager oversight, and insufficient ACCT training for some staff carrying out observations.

    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 ACCT Case Manager allocation and oversight system

    Wider context from the report

    “(2) There appears to be no effective system for allocating ACCT Case Managers at HMP Long Lartin. The officer (Officer A) who, when she opened the final ACCT document for Mr. Hutton, appointed herself as Case Manager for this ACCT, did so knowing that she would have no contact with him over the following two weeks. Officer A gave evidence that: (a) this was common practice at the prison; (b) officers were discouraged from not naming a Case Manager when they opened an ACCT, even if (as here ) it was opened at night; (c) she was hoping that another officer might “take it over” from her. As she predicted, she herself did indeed have no further contact with Mr. Hutton. Furthermore, this problem was not passed on or identified, and no other officer took over the Case Manager role. Therefore there was no effective oversight of an ACCT involving a potentially very vulnerable individual. Of particular concern is that another appears to have filled in Officer A’s details in the “name” and “signature” boxes at the foot of the ACCT Caremap, and dated them 7.2.19 (the day before Mr. Hutton’s death ), thereby giving the impression that Officer A had reviewed and satisfied herself that the actions identified in the Caremap had been dealt with. In fact, the most important action on the Caremap, which required a social care referral, had not been completed. This lack of effective oversight was not confined to Mr. Hutton’s final ACCT document. For his first ACCT document at HMP Long Lartin, only a month earlier, the named Case Manager had no involvement with it until the fourth ACCT Case Review, and made no entries on the Caremap ( which was signed off by a different officer ). I heard evidence from a member of the current Senior Management Team at the prison that: (a) there is currently no formal training for the allocation of, or fulfilment of the duties of the ACCT Case Manager role; (b) this will be reviewed, and training will be organised. The lack of an effective ACCT Case Manager, who is able to provide proper oversight of an ACCT, is an issue which was raised by me in a previous Report to Prevent Future Deaths which followed the death of another prisoner at HMP Long Lartin ( David KIRSCH – report dated 30.10.19 ) ”

    Source location

    Geoffrey Harrison HUTTON · 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 ACCT version 6 across the prison estate to support multidisciplinary, person-centred care for people at risk.

    Verbatim wording from the response

    “Your second concern relates to the system for allocating ACCT case managers. You may be aware that HMPPS has introduced a revised version of ACCT which went live across the prison estate in July 2021; ACCT version 6. The changes are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. The term Case Manager has been replaced with Case Coordinator to reflect the fact that everyone involved in the ACCT process is responsible for ensuring that good quality support is provided. Specific training for ACCT Case Coordinators is being provided and staff must undertake the relevant modules before taking up the role.”

    Source location

    2021-0191-Response-from-HMPPS_Published
    Page 2 · response
    Published 4 June 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

    Provide specific training and require relevant modules for ACCT Case Coordinators before they take up the role.

    Verbatim wording from the response

    “Your second concern relates to the system for allocating ACCT case managers. You may be aware that HMPPS has introduced a revised version of ACCT which went live across the prison estate in July 2021; ACCT version 6. The changes are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. The term Case Manager has been replaced with Case Coordinator to reflect the fact that everyone involved in the ACCT process is responsible for ensuring that good quality support is provided. Specific training for ACCT Case Coordinators is being provided and staff must undertake the relevant modules before taking up the role.”

    Source location

    2021-0191-Response-from-HMPPS_Published
    Page 2 · response
    Published 4 June 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 database to support allocation of ACCT Case Coordinators using staffing and caseload information.

    Verbatim wording from the response

    “At HMP Long Lartin a new database is being implemented to support the allocation of ACCT Case Coordinators. This contains information on staff rotas, periods of leave and how many open ACCTs each Case Coordinator currently has. This will facilitate effective allocation decisions and support a renewed focus on providing consistent and proper oversight and ownership of cases. In addition, the staffing resources within the safer custody team have been reviewed and an additional manager has been introduced, providing capacity to complete more assurance work around ACCT processes.”

    Source location

    2021-0191-Response-from-HMPPS_Published
    Page 2 · response
    Published 4 June 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

    Introduce an additional safer custody team manager to increase capacity for ACCT assurance work.

    Verbatim wording from the response

    “At HMP Long Lartin a new database is being implemented to support the allocation of ACCT Case Coordinators. This contains information on staff rotas, periods of leave and how many open ACCTs each Case Coordinator currently has. This will facilitate effective allocation decisions and support a renewed focus on providing consistent and proper oversight and ownership of cases. In addition, the staffing resources within the safer custody team have been reviewed and an additional manager has been introduced, providing capacity to complete more assurance work around ACCT processes.”

    Source location

    2021-0191-Response-from-HMPPS_Published
    Page 2 · response
    Published 4 June 2021

    Open published response

  6. Manchester South

    AI-generated summary

    Rachal Marie Murphy · 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

    Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.

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    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 allocation of cases within Early Help Services

    Wider context from the report

    “1. The Court heard that there was a significant delay in the allocation of cases within Early Help Services and from the evidence the Court was not satisfied that this had been resolved. ”

    Source location

    Rachal Marie Murphy · 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 Early Help caseloads and work allocation to identify and reduce allocation delays.

    Verbatim wording from the response

    “A thorough review has been undertaken of caseloads and allocation of work within the Early Help Service in part due to learning from cases such as this one and more recently our latest Ofsted inspection of children’s services. As a result, measures have been put in place which have led to a significant reduction of delay in the allocation of cases.”

    Source location

    2016-0401-Responses
    Page 1 · response
    Published 19 February 2017

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    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

    Allocate waiting-list families a worker within one month and have managers monitor families during the waiting period.

    Verbatim wording from the response

    “The table below provides quarterly data in relation to the number of families who have been entered onto a waiting list, having been identified as requiring a service from Early Help. The data gives a snapshot of the total number of families who were on the waiting list at the end of each quarter and gives clear evidence of the efforts that have been made to eradicate the use of a waiting list. The three cases that were on the waiting list at the end of the most recent quarter were allocated as soon as the holiday period came to an end and normal staffing levels were in place.”

    Source location

    2016-0401-Responses
    Page 1 · response
    Published 19 February 2017

    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

    Monitor Early Help allocations through a weekly Family Support Panel to support timely responses to children’s needs.

    Verbatim wording from the response

    “Managers within the Early Help Service continue to monitor this and are now vigilant in ensuring that the use of waiting lists is not common practice and that families receive a service at the point that need is identified.”

    Source location

    2016-0401-Responses
    Page 2 · response
    Published 19 February 2017

    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

    Submit six-monthly Early Help performance reports to the Safeguarding Children Board.

    Verbatim wording from the response

    “The future monitoring of this performance will be undertaken at a weekly Family Support Panel which will manage all allocations to Early Help and other services in order to maximise the timely response to children's needs. In addition, a report will be submitted to the Safeguarding Children Board on a six monthly basis to keep the Board updated on the progress of the Early Help Service and ensure a strong multi agency ownership.”

    Source location

    2016-0401-Responses
    Page 2 · response
    Published 19 February 2017

    Open published response

  7. Cornwall

    AI-generated summary

    Shannon Kimberley Gee · 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

    Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and records.

    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 resolving disputes over which organisation should treat a patient

    Wider context from the report

    “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations. The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify. ”

    Source location

    Shannon Kimberley Gee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Manchester West

    AI-generated summary

    Keith Samuel Peters · 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

    Keith Samuel Peters lived alone with Type II diabetes, chronic pancreatitis and alcohol dependence, and was admitted to hospital after his sister became concerned about his condition; he died on 12 September 2013. Concerns included delays and lack of prioritisation in assessing his social care needs, and the absence of a system to reallocate cases when an assessment could not be completed within the required period.

    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 allocate assessments to officers with sufficient availability for completion within the required period

    Wider context from the report

    “Brief circumstances of matters of concern (1) Mr Peters’ case was allocated to a Community Assessment Officer who was on annual leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters’ assessment within the required period. (2) During the periods when the Community Assessment Officer was available there is no evidence of Mr Peters’ case being prioritised, neither when the twenty eight day period allowed for the assessment to be completed was approaching expiry, nor when that period had expired. (3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight days required. ”

    Source location

    Keith Samuel Peters · 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

    Lack of a system for referring overdue assessments for reallocation to another officer

    Wider context from the report

    “Brief circumstances of matters of concern (1) Mr Peters’ case was allocated to a Community Assessment Officer who was on annual leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters’ assessment within the required period. (2) During the periods when the Community Assessment Officer was available there is no evidence of Mr Peters’ case being prioritised, neither when the twenty eight day period allowed for the assessment to be completed was approaching expiry, nor when that period had expired. (3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight days required. ”

    Source location

    Keith Samuel Peters · 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 six-weekly formal supervision and daily case discussions where required, supported by a systematic approach to reprioritisation or reallocation.

    Verbatim wording from the response

    “Action Staff to receive formal supervision on a 6 weekly basis and case discussions on a daily basis if required. The service does accept that a more systematic approach would be of benefit to managers and staff to enable reaching the 28 day period to enable reprioritisation/reallocation as necessary.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 3 · response
    Published 20 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop electronic monitoring and trigger functions to alert staff and managers to assessment timescales requiring prioritisation or reallocation.

    Verbatim wording from the response

    “The service will develop a monitoring and trigger function within the electronic system for staff and managers to be alerted to timescales for risk assessment prioritisation or reallocation as necessary.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 3 · response
    Published 20 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Communicate staff and manager responsibilities for alerting case managers when assessment timescales may not be met.

    Verbatim wording from the response

    “Action Staff to be reminded of personal responsibilities to alert their case manager to cases where timescales may not be met.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 2 · response
    Published 20 December 2013

    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 case did not appear urgent, and the allocated worker should have had sufficient time to complete the assessment.

    Verbatim wording from the response

    “Area of concern Mr P’s case was allocated to Community Assessment 1 who was on leave at the time, and whose future leave resulted in having limited time to complete Mr P’s assessment within the required period.”

    Source location

    2013-0378-Response-by-Bolton-Council
    Page 2 · response
    Published 20 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026