Recurring concern

Unreliable communication access for people requiring support

First to latest report 10 Jan 2019 — 10 Apr 2025

Reports that mention this concern
13
Times this concern has been raised
13
Stated actions linked to this concern
23

What this concern includes

Includes failures in support-service arrangements for contacting or being contacted by people requiring support, including overly restricted care-planned communication options, unavailable telephone contact and failure to provide suitable alternative channels when the person's circumstances require them.

What is not included
  • Excludes generic communication, staffing or resource deficiencies unless they directly make support-service contact methods unavailable or unsuitable.
  • Excludes failures limited to appointment scheduling, referral processing or clinical treatment after communication has been established.
  • Excludes communication processes for unrelated recipients or settings where people requiring support are not the intended service users.
  • Excludes neutral descriptions of preferred communication methods without an identified safety deficiency.

Reports and published responses 13 reports

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

  1. East London

    AI-generated summary

    Chelsie Violet Greatorex · 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

    Chelsie Violet Greatorex took an overdose of prescribed medication on 10 March 2020 and died later that day despite emergency treatment. The report describes concerns about her anxiety as a complainant in a sexual assault case, delays in the investigation, the lack of specialist handling despite her being a child when the alleged assault occurred, and limited support after she contacted police.

    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 contacting complainants seeking support

    Wider context from the report

    “d. When Ms Greatorex sought support from the MPS, no contact was made for four days, even then, the extent of the support was an email with the contact details of a borough psychological support service. ”

    Source location

    Chelsie Violet Greatorex · 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

    Trial and roll out the THRIVE+ vulnerability assessment framework for assessing and reviewing victim and witness risk.

    Verbatim wording from the response

    “In order to provide additional support for victims and/or witnesses throughout the entire investigative process, the MPS has introduced a THRIVE+ vulnerability assessment which is currently being trialled and is anticipated to be rolled out across the MPS in April 2021. It is a set of principles and a framework to assess the type of policing response or investigation required for a particular set of circumstances. THRIVE covers: Threat – Harm – Risk – Investigation – Vulnerability – Engagement + Prevention/Intervention. The framework is a tool which aligns to and enhances the National Decision Model and includes the assessment and ongoing review of risk during investigations. It also provides a common language around risk to improve information sharing and decision-making.”

    Source location

    2021-0018-Response-from-MPS-Redaction
    Page 2 · response
    Published 27 January 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

    Carry out a cross-system review of the criminal justice response to rape and report a package of improvement actions.

    Verbatim wording from the response

    “That is why, along with the Ministry of Justice and the Attorney General’s Office, the Home Office is currently carrying out a review of the criminal justice response to rape. The scope of the review covers the length of the criminal justice process, from police report and investigation through to final outcome in court, so that we can take a comprehensive view of any issues that need to be addressed within the system and take action accordingly.”

    Source location

    2021-0018-Response-from-Home-Office-Redacted
    Page 1 · response
    Published 27 January 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

    Publish a restructured Victims’ Code establishing overarching rights to support during the criminal justice process.

    Verbatim wording from the response

    “The Regulation 28 Report raises specific concerns about the level of communication and information that Ms. Greatorex received from the police during the investigation and the support that was offered to her. The government wants to ensure that the rights of victims are recognised at every stage of the criminal justice system. For this reason, we recently published a new, restructured Victims’ Code which sets out 12 key overarching rights regarding the support that victims should receive from the police, courts and other criminal justice agencies. We will also be consulting on a new Victims’ Law that will guarantee that victims receive their rights under the Code and agencies are held to account for delivering them.”

    Source location

    2021-0018-Response-from-Home-Office-Redacted
    Page 2 · response
    Published 27 January 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

    Consult on a Victims’ Law to guarantee victims’ rights and hold agencies accountable for delivering them.

    Verbatim wording from the response

    “The Regulation 28 Report raises specific concerns about the level of communication and information that Ms. Greatorex received from the police during the investigation and the support that was offered to her. The government wants to ensure that the rights of victims are recognised at every stage of the criminal justice system. For this reason, we recently published a new, restructured Victims’ Code which sets out 12 key overarching rights regarding the support that victims should receive from the police, courts and other criminal justice agencies. We will also be consulting on a new Victims’ Law that will guarantee that victims receive their rights under the Code and agencies are held to account for delivering them.”

    Source location

    2021-0018-Response-from-Home-Office-Redacted
    Page 2 · response
    Published 27 January 2021

    Open published response

  2. Buckinghamshire

    AI-generated summary

    Emma Felicity BUTLER · 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

    Emma Butler was an inpatient at Ruby Ward who died at Stoke Mandeville Hospital from blood loss after incised wounds inflicted outside the Whiteleaf Centre while she was on unescorted leave. The report raised concerns about access to means of self-harm on and outside the ward, hourly observations, urgent access to ward support, and planning for discharge.

    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

    Unavailability of immediate support or assistance through the specific ward number

    Wider context from the report

    “(4) Urgent or emergency access to the ward phone. The concern remains that a patient on unescorted leave outside the Centre who felt they were going to self- harm or who had self-harmed may not get immediate access to support or assistance by calling the specific ward number given to them. Whilst the evidence indicated the balance between positive risk taking, unescorted leave and taking responsibility for decisions and actions, the risk remains that the safety net is not sufficiently robust to ensure that if such a potentially fatal incident occurs, or is likely to occur, a patient can self-alert the ward and expect to receive an immediate response. ”

    Source location

    Emma Felicity BUTLER · 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 the leave documentation and welcome pack to clarify phone availability and emergency arrangements for patients on leave.

    Verbatim wording from the response

    “One action that was discussed was to make it explicit within the leave documentation and welcome pack that when patients are on leave it is possible that the ward phone may not be answered, due to staff attending to the needs of patients on the ward; and to suggest to patients going on leave that if they feel the need to speak to a member of staff, it is suggested that they return to the ward, and speak with their allocated nurse. It should also underline that the ward is not able to provide an immediate response to patients who are on leave and that if patients require an urgent response whilst away from the ward they should contact the emergency services.”

    Source location

    2019-0133-Response-by-Oxford-Health-NHS-Trust
    Page 4 · response
    Published 14 June 2019

    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 ward cannot guarantee an immediate phone response because staff must prioritise patients physically present on the ward.

    Verbatim wording from the response

    “I understand that our (then) Ruby ward Modern Matron confirmed in evidence that it is possible that the ward phone number given to patients will go unanswered at times, if a patient on leave (or a relative) attempts to make contact; and that it is right that the focus of ward staff on shift should be towards meeting the needs of patients who are physically present on the ward. Although ward staff have a role in attempting to ensure the safety of”

    Source location

    2019-0133-Response-by-Oxford-Health-NHS-Trust
    Page 3 · response
    Published 14 June 2019

    Open published response

  3. Avon

    AI-generated summary

    Christopher Michael SEAL · 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

    Christopher Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff processes.

    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

    Limited care-planned communication options for service-user contact

    Wider context from the report

    “9. Contact with service user – I was told that the preferred method is verbal contact and the only other means is a text message with this being care planned. In this changing world of communication should other care planned options be considered such as email or messaging? ”

    Source location

    Christopher Michael SEAL · 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

    Ensure staff understand individualised communication options and can discuss communication-method risks with service users.

    Verbatim wording from the response

    “AWP has local procedures for text access for people who are deaf or hard of hearing. It is recognised that some service users, regardless of disability, may prefer forms of communication other than phone calls. Where this is indicated an Individualised approach to communication with the service users will be considered and planned. However, e-mail or texting high risk information is not always suitable as information can be missed or there can be technical risks. The Trust has ensured that all staff are aware of the individualised communication options and that they are suitably able to have appropriate conversations with service users about the risks of various communication methods”

    Source location

    2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
    Page 4 · response
    Published 24 May 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing communication procedures address accessibility while restricting high-risk messaging and non-secure platforms because of safety and confidentiality risks.

    Verbatim wording from the response

    “AWP has local procedures for text access for people who are deaf or hard of hearing. It is recognised that some service users, regardless of disability, may prefer forms of communication other than phone calls. Where this is indicated an Individualised approach to communication with the service users will be considered and planned. However, e-mail or texting high risk information is not always suitable as information can be missed or there can be technical risks. The Trust has ensured that all staff are aware of the individualised communication options and that they are suitably able to have appropriate conversations with service users about the risks of various communication methods”

    Source location

    2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
    Page 4 · response
    Published 24 May 2019

    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