Recurring concern

Unreliable communication access for people requiring support

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First reported 10 Jan 2019•Latest report 10 Apr 2025

Definition

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.

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
13

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2019–2025

First to latest report issue date

Stated actions
23

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 Care2
Adferiad Recovery1
Avon and Wiltshire Mental Health Partnership NHS Trust1
Betsi Cadwaladr University LHB1
Cornwall Council1
Coventry and Warwickshire Partnership NHS Trust1
Department for Work and Pensions1
Home Office1
Kent County Council1
Metropolitan Police Service1
Ministry of Housing, Communities and Local Government1
NAViGO Health and Social Care CIC1
NHS Cornwall and the Isles of Scilly Integrated Care Board1
NHS Greater Manchester Integrated Care Board1
Oxford Health NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    Jonathan Mark George Hamer · 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

    Jonathan Mark George Hamer, who had bipolar affective disorder and was receiving community mental health care, died by suicide on 24 April 2024 after going onto railway tracks in front of a train. Concerns included communication failures during care-coordinator absences, the lack of systems to redirect or action unanswered communications, and the failure to prioritise and regularly review his case.

    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 provide service users and support networks with service-change information and current contact details

    Wider context from the report

    “1. There were communication difficulties experienced by Jonathan’s family and his supported housing with the community mental health trust responsible for his ongoing healthcare during the early part of 2024. Telephone calls and text messages were unanswered and there was no communication to confirm that in fact the care co-ordinator had a period of annual leave followed by an unplanned period of sick leave. It was unclear at inquest if service users and their support network had been provided with details of any service changes and current up to date contact details. This meant that important information was not being received by the community mental health team. ”

    Source location

    Jonathan Mark George Hamer · 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 alternative team and crisis contacts through staff email footers, shared communication channels, voicemail messages and the Trust website.

    Verbatim wording from the response

    “▪ We have asked community teams to add specifically created email footers to their personal NHS emails to advise recipients that the mailbox may not be monitored and to provide alternative team contact details and crisis service links.”

    Source location

    Response from South West London and St George’s Hospitals NHS Trust
    Page 2 · response
    Published 17 April 2025

    Open published response
  2. West Sussex, Brighton and Hove

    AI-generated summary

    Harry Benjamin SOUTHERN · 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

    Harry Southern had a history of mental illness, previous suicide attempt and traumatic events in the final year of his life. He died after tying a ligature around his neck with the intention of ending his life. The report raised concerns that young people and their families may not receive accessible, reliable information or timely contact with mental health and suicide-prevention services, and that funding reductions could further reduce available support.

    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 suicide prevention contact numbers to provide continuous access to someone able to speak with callers

    Wider context from the report

    “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

    Source location

    Harry Benjamin SOUTHERN · 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

    Recruit staff to improve Sussex Mental Health Line capacity.

    Verbatim wording from the response

    “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    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

    Change Sussex Mental Health Line working patterns to improve call accessibility.

    Verbatim wording from the response

    “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    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

    Improve Sussex Mental Health Line productivity to address demand and unanswered calls.

    Verbatim wording from the response

    “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    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

    A range of accessible community and crisis options, rather than improved helplines alone, is considered sufficient to provide local support 24/7.

    Verbatim wording from the response

    “All the aforementioned collaborative, partner working is part of the national strategy to improve community and crisis services to deliver more mental health crisis care in the community, close to people’s homes, through new models of care and support which is key to the long-term sustainability of the NHS. The aim being to improve accessibility of mental health support, not by focusing on improving helplines etc, but by having a range of accessible options which, collectively provide access to local support 24 hours a day, 7 days a week.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 3 · response
    Published 20 January 2025

    Open published response
  3. Coventry and Warwickshire

    AI-generated summary

    Darren Joseph Hope · 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

    Darren Joseph Hope died on 3 July 2023 after falling from the 10th-floor building where he lived while on unescorted Section 17 leave. The report identifies concerns about verifying leave conditions, ensuring people on leave can contact the facility, and the ability of the reporting system to identify and address patient-safety issues.

    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

    Lack of accessible and reliable means for service users on unescorted leave to contact the facility

    Wider context from the report

    “Concern 2: There may be a lack of accessible or reliable means for service users on unescorted leave to contact the facility if they encounter difficulties. This could impact their ability to seek support or assistance when needed. ”

    Source location

    Darren Joseph Hope · 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

    Implement a Section 17 leave contact card giving patients key numbers for NHS 111, 999, the Crisis Team and their ward.

    Verbatim wording from the response

    “An improvement we have made is the development and implementation of a ‘contact card’ which will be given to each patient who is accessing leave. The ‘contact card’ has key phone numbers that a person can ring if they need help including NHS 111, 999, the Crisis Team phone number and the Ward telephone number.”

    Source location

    Response from Coventry and Warwickshire Partnership Trust
    Page 4 · response
    Published 5 November 2024

    Open published response
  4. Cornwall and Isles of Scilly

    AI-generated summary

    Sally Poynton · 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

    Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.

    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 adapt patient contact methods to known communication needs

    Wider context from the report

    “2) Community Mental Health Team i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain. I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly. ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice. iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances. iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge. I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above. ”

    Source location

    Sally Poynton · Prevention of Future Deaths report
    Page 4 · 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

    No further difficulties need to be overcome in the referral pathway into secondary mental health services.

    Verbatim wording from the response

    “• In terms of its function as a referral pathway I do not believe that there are any difficulties which need to be overcome.”

    Source location

    Response from Cornwall Council
    Page 2 · response
    Published 20 May 2024

    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 Integrated Care Board is expected to respond to concerns about the specific care provided.

    Verbatim wording from the response

    “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.”

    Source location

    2024-0267 Response from Department of Health and Social Care
    Page 1 · response
    Published 20 May 2024

    Open published response
  5. Manchester South

    AI-generated summary

    Tobias Ryse Mannering-Jones · 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

    Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.

    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 public service contact arrangements for people without a stable address

    Wider context from the report

    “3. Evidence was also heard that a person who has to rely on a homeless shelter can then become uncontactable to public service providers as they have no address for contact which means they then have even less chance of accessing support. ”

    Source location

    Tobias Ryse Mannering-Jones · 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

    Continue supporting night shelters through training resources, high-quality accommodation requirements and specialist outreach roles funded through the Rough Sleeping Initiative.

    Verbatim wording from the response

    “In DLUHC, I will continue to support the night shelter sector in line with the actions in the second matter of concern, including training resources on best practice for engagement; and will continue to ensure that areas in receipt of RSI funding have in place ending rough sleeping plans that include high quality off the street accommodation and specialist outreach roles that are designed to directly engage and support people on the streets. Shelters play a valuable role providing accommodation to those experiencing homelessness and lessons from matter of concern five are particularly pertinent in considering how this provision fits in and engages with other services.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 4 · response
    Published 20 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Support NICE guidance improving access to coordinated, multidisciplinary health and social care for people experiencing homelessness.

    Verbatim wording from the response

    “The Department recognises the importance of reducing barriers to services for those experiencing rough sleeping. This is why we supported the development of NICE guidance which provides recommendations on ways to improve access to, and engagement with, health and social care services for people experiencing homelessness. It also provides advice on how commissioners, planners, providers and practitioners across disciplines and agencies can work together as part of a multi-disciplinary team to support and improve outcomes for people experiencing homelessness.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 March 2024

    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

    Health-related concerns are led by DHSC, with DHSC and Manchester Integrated Care Board providing a separate, more detailed response.

    Verbatim wording from the response

    “My responses to the matters of concern are set out in turn below. I have worked closely with the other public bodies that have received the Report, including the Department of Health and Social Care (DHSC) and NHS England, in collaboration with Manchester Integrated Care Board. A separate response will be provided by DHSC and Manchester Integrated Care Board, which will respond in greater detail to the first, third and fifth matter of concern.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 2 · response
    Published 20 March 2024

    Open published response
  6. Rutland and North Leicestershire

    AI-generated summary

    Nazerine Frances Anderson · 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

    Nazerine Frances Anderson had a deterioration in her mental health following a Department for Work and Pensions performance review and took a paracetamol overdose on 17 May 2023. She later developed irreversible liver damage and died on 19 June 2023. The report raised concerns about missed opportunities to record her vulnerability, failures to direct communications through her daughter, and the training of DWP staff in supporting vulnerable individuals.

    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 act on requests to direct communication through a nominated person

    Wider context from the report

    “2. The failure to act upon a simple request for the DWP to direct communication through Naz’s daughter. This was a simple request and had been renewed by Naz during telephone calls and journal entries to the DWP. The request which had been made in writing by Naz’s daughter sat in another DWP computer system for a period of 4 months but even when uploaded to the main DWP computer system was not acted upon. In addition to the active requests of Naz and her daughter being overlooked, DWP staff did not proactively consider the need for communication to be directed to someone else to safeguard Naz, given her obvious vulnerability. ”

    Source location

    Nazerine Frances Anderson · 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

    Conduct an end-to-end review of the appointee process, including digital solutions, legislative changes, guidance, colleague capability and review timescales.

    Verbatim wording from the response

    “Customers who require an appointee are naturally considered to be vulnerable, and whilst DWP has taken significant steps since 2018 to improve colleagues’ ability to understand the wide range of mental health issues that benefit customers may face, there is more work being undertaken.”

    Source location

    Response from Department for Work and Pensions
    Page 4 · response
    Published 21 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Add a Universal Credit account banner displaying recorded explicit consent and its currency.

    Verbatim wording from the response

    “In December 2023, the UC computer system was updated to include a banner which displays on a customer’s account when explicit consent is recorded. This immediately identifies that there is explicit consent given by a customer and allows colleagues to see what consent has been given and whether it is current. To support this, an explicit consent information campaign was launched on DWP’s intranet and broadcast to all colleagues working in UC. The campaign clearly explained what explicit consent is and how to record this consent on the UC system and was accompanied by training videos. Training events have been delivered to UC colleagues detailing how to record explicit consent actions to alert other colleagues dealing with the claim. As with all training, this has involved an assessment component to ensure that the training has been effective.”

    Source location

    Response from Department for Work and Pensions
    Page 5 · response
    Published 21 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver an explicit consent information campaign, including intranet dissemination, training videos, colleague training and effectiveness assessment.

    Verbatim wording from the response

    “In December 2023, the UC computer system was updated to include a banner which displays on a customer’s account when explicit consent is recorded. This immediately identifies that there is explicit consent given by a customer and allows colleagues to see what consent has been given and whether it is current. To support this, an explicit consent information campaign was launched on DWP’s intranet and broadcast to all colleagues working in UC. The campaign clearly explained what explicit consent is and how to record this consent on the UC system and was accompanied by training videos. Training events have been delivered to UC colleagues detailing how to record explicit consent actions to alert other colleagues dealing with the claim. As with all training, this has involved an assessment component to ensure that the training has been effective.”

    Source location

    Response from Department for Work and Pensions
    Page 5 · response
    Published 21 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update and disseminate consent and disclosure guidance to permit explicit-consent review periods of up to six months where appropriate.

    Verbatim wording from the response

    “The consent and disclosure guidance was most recently updated in January 2024 to allow UC colleagues to extend the review period on explicit consent up to six months where appropriate (for example, where someone is supporting a customer with an appeal which is expected to take longer than one month). Guidance previously advised colleagues to review explicit consent every month, but the department recognised this was not always the best approach and made the amendment. This change was cascaded through DWP communication channels.”

    Source location

    Response from Department for Work and Pensions
    Page 5 · response
    Published 21 February 2024

    Open published response
  7. South Yorkshire (Western)

    AI-generated summary

    Rachel Louise MORTIMER · 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

    Rachel Louise Mortimer took her own life on 25 June 2023 by hanging, following previous overdoses and a recent episode involving overdose and an attempt to hang herself. The report identified concerns that family and paramedics were not given advice about available support or emergency options, and that no alternative service was arranged after a planned risk-mitigation referral was unavailable.

    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 services that can be called to discuss a person's mental state

    Wider context from the report

    “1. Following concerned calls by family no advice was provided on what options were available to them if they were concerned for their family members safety and no provision of services that could be called to discuss her mental state. ”

    Source location

    Rachel Louise MORTIMER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  8. North Lincolnshire and Grimsby

    AI-generated summary

    Reece William NELSON · 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

    Reece Nelson was found hanging at his home address in Grimsby on 28 February 2022 and was pronounced dead by paramedics. His family had tried to contact his Care Coordinator because of concerns about his mental state, but they were not informed that the coordinator was on sick leave and no return call was made.

    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

    Lack of alternative contact arrangements during Care Coordinator absence

    Wider context from the report

    “On the morning of Reece Nelson's death his family attempted to contact his Care Coordinator due to concerns regarding his mental state. The Care Coordinator was on sick leave, however this information was not reported to the family and therefore no return call was made to them. Had the family been made aware that the Care Coordinator was on sick leave they would have tried alternative routes to contact the mental health services to seek assistance. There should be a system in place whereby alternative contact details are provided in the event of a staff member being absent ”

    Source location

    Reece William NELSON · 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

    Implement sickness-absence cover arrangements through the Revised Policy, including patient notification, alternate support, duty-worker escalation, home-visit cover and caseload allocation.

    Verbatim wording from the response

    “In the event a Care Coordinator rings in sick or any other sickness absence period, the Team Leader will go through staff diaries and task admin to phone each patient to let them know their worker is off sick, the Team Leader will also determine whether alternate support is required in the absence of their Care Coordinator. In the event other support is required the Team Leader is to liaise with the duty person to arrange this. The team are to be made aware and relevant duties allocated in the morning huddle by the Team Leader. All patients will be made aware that they can contact our duty worker for support at any time during office hours Monday to Friday 9am to 5pm. The duty worker is able to conduct a home visit where needed.”

    Source location

    Response from Navigo
    Page 2 · response
    Published 8 January 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue operating the Revised Policy and maintain audited processes for informing new and existing staff about sickness-absence cover arrangements.

    Verbatim wording from the response

    “5 Navigo will continue to operate in accordance with the Revised Policy and will ensure processes to inform both new and existing staff members of the cover arrangements remain in place and are audited.”

    Source location

    Response from Navigo
    Page 3 · response
    Published 8 January 2024

    Open published response
  9. North Wales (East and Central)

    AI-generated summary

    Emily Corfield · 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

    Emily Corfield, aged 41, was found deceased at home on 19 September 2021 after a history of alcohol misuse and two hospital admissions for coffee ground vomiting and alcohol withdrawal. The principal concern was the lack of evidence that the alcohol liaison team provided inpatient or outpatient support or that referrals to external organisations were made.

    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 telephone communication for people requiring support

    Wider context from the report

    “Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad. Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only. It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and / or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes. Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support / service users (in writing only) and the waiting time for support sessions / counselling is long. This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner. ”

    Source location

    Emily Corfield · 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

    Seek updated automated communication routes for the service, such as text appointment reminders.

    Verbatim wording from the response

    “Adferiad is, however, currently in the process of seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, continue to have regard to your concern. However, we are unable to guarantee that patients will act on appointments; and/or respond to our telephone calls, messages, visits, or other forms of communication.”

    Source location

    Response from Adferiad
    Page 4 · response
    Published 21 July 2023

    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

    Routine telephone calls were not undertaken because administrators lacked therapeutic skills and using therapists would increase service pressure and waiting times.

    Verbatim wording from the response

    “At the material time, our administrators were responsible for sending out the abovementioned letters to patients. They did not, however, make routine calls to patients as this would require a different skill set given that in our experience, when patients are spoken to on the telephone, they often seek therapeutic engagement. Our administrators are not therapists and using our therapists to make routine telephone calls would add pressure to the service in the context of current resources and consequently, add to service waiting times.”

    Source location

    Response from Adferiad
    Page 4 · response
    Published 21 July 2023

    Open published response
  10. Inner North London

    AI-generated summary

    Max TURBUTT · 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

    Max Turbutt had experienced mental ill health for several years and had been supported by Kent County Council services as a care leaver. The report states that he died by suicide, with the medical cause of death recorded as hanging. Concerns were raised that attempts by Max and his father to contact his personal adviser were unsuccessful, with no phone redirect or email out-of-office message, and that a crisis number led only to an answerphone.

    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 provide an accessible alternative contact when a personal advisor or social worker is unavailable

    Wider context from the report

    “Max’s father told me at inquest that in March and April 2022, Max tried to contact his personal advisor at the 18+ Service at Thistley Hill in Dover on several occasions over a number of weeks, but found her phone always to be switched off. There was no redirect and no out of office on her email. Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick. A crisis number was given and Mr Turbutt called it, but it was simply an answerphone. This arrangement does not seem adequate for a vulnerable person in need. ”

    Source location

    Max TURBUTT · 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

    Advise young adults immediately when their allocated Personal Advisor is off long-term sick, providing the Team Manager’s name and Duty contact number.

    Verbatim wording from the response

    “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

    Source location

    Response from Kent County Council
    Page 3 · response
    Published 20 October 2022

    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

    Require the relevant staff member to add a mobile-phone voice message identifying whom to contact during their absence.

    Verbatim wording from the response

    “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

    Source location

    Response from Kent County Council
    Page 3 · response
    Published 20 October 2022

    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

    Ensure an out-of-office email reply is added when a staff member is absent on a long-term basis.

    Verbatim wording from the response

    “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

    Source location

    Response from Kent County Council
    Page 3 · response
    Published 20 October 2022

    Open published response
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Data last updated 7 September 2026