Recurring concern

Failure to update risk assessments after material changes or safety events

First to latest report 12 Feb 2015 — 1 Jun 2026

Reports that mention this concern
28
Times this concern has been raised
30
Stated actions linked to this concern
63

What this concern includes

Includes failures to review or update a risk assessment after a material change, deviation from an agreed safety plan, significant deterioration, suspected overdose, intoxication, injury, incident or other safety event that should trigger reassessment, including failures to maintain a reliable process for timely updating.

What is not included
  • Excludes deficiencies limited to completing an initial risk assessment where no failure to update after a material change or safety event is identified.
  • Excludes failures in a separately named risk-assessment system or hazard when that named system supplies the more specific supported recurring concern.
  • Excludes generic care planning, documentation, training or staffing deficiencies unless they directly result in failure to update a risk assessment after a material change or safety event.
  • Excludes failures to implement risk-reduction actions after an otherwise current risk assessment unless updating the assessment is also deficient.

Reports and published responses 28 reports

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

  1. Manchester North

    AI-generated summary

    Mr Gary Leyland · 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

    Mr Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.

    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 conduct updated risk assessments

    Wider context from the report

    “4. The Court heard there was no updated risk assessment conducted as was envisaged following the email from the Probation Service. ”

    Source location

    Mr Gary Leyland · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Sussex

    AI-generated summary

    Saeid Hedayat · 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

    Saeid Hedayat lost control of his vehicle on the B2112 after encountering floodwater caused by a blocked drain, and the vehicle overturned, causing multiple injuries. He suffered a hypoxic brain injury and died. Concerns included risk assessments that did not account for recurring zone 1 drain blockages, were not regularly reviewed, and did not respond to relevant flooding reports, as well as the absence of warning signs despite recurring road flooding.

    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 review drain risk assessments at defined intervals and in response to relevant new information

    Wider context from the report

    “(1) West Sussex County Council’s risk assessment which was carried out to determine drain clearance frequency did not take any account of zone 1 blockages and I heard evidence that there is no time period set for reviewing the risk assessments. I heard evidence that the risk levels have not been reviewed since 2011 despite more recent data being available. (2) I also heard evidence that neither anomalous silt level reports nor reports from members of the public of road flooding would trigger a review of the risk assessments. (3) The highways authority representative at the inquest was not able to inform me of what plans West Sussex County Council has to reassess the drain risk levels in light of the increased severity of winter storms. ”

    Source location

    Saeid Hedayat · 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

    Operate and periodically optimise a countywide, risk-based gully-cleansing programme using silt, flooding and cleansing data.

    Verbatim wording from the response

    “At the start of our current Term Maintenance Contract (which commenced 1st July 2011) we worked with our contractor to develop an annual, county wide gully cleansing programme. To do this historical WSCC information regarding gully cleansing, silt levels and treatment intervals were assessed and an optimised cleansing programme developed. This approach involved looking at where flood events have occurred and, where silt levels in gullies have historically been high, arranging for these gullies to be cleaned more regularly than those in areas not prone to flooding and with historically low levels of silt.”

    Source location

    2019-0327-Response-by-West-Sussex-County-Council
    Page 1 · response
    Published 8 November 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Record Zone 1 blockages as obstructions before cleansing and include them in cleansing-data and defect reporting.

    Verbatim wording from the response

    “Moving forward, WSCC has now adopted the approach of recording Zone 1 blockages where the contractor is undertaking the cleansing programme. It will be logged as the asset being “obstructed prior to cleanse” and will be reported back with all other cleansing data and defects. This data, in addition to any recorded customer enquiries, will give enhanced data which will help identify areas where we might have ongoing zone 1 blockages and thus help address the Coroner’s concern.”

    Source location

    2019-0327-Response-by-West-Sussex-County-Council
    Page 2 · response
    Published 8 November 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the cleansing programme and reconsider risk levels for the new term maintenance contract.

    Verbatim wording from the response

    “As stated above, under our current Term Maintenance contract, we undertook a full review of the programme at the start of this year and a new optimised programme commenced on 1 April 2019. We are currently undertaking a procurement exercise for a new contract starting April 1st 2020 and there will be a review of the programme again and we will consider risk levels again. Award of the contract is likely to be made in December 2019 after which the specifications for drainage cleansing frequency within the new contract can be disclosed.”

    Source location

    2019-0327-Response-by-West-Sussex-County-Council
    Page 2 · response
    Published 8 November 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Consider climate-change impacts and future-proof the highway network, including adapting drain risk levels to more severe winter storms.

    Verbatim wording from the response

    “As Highway Authority we will be considering the climate change impacts and how to future proof our network. This will include understanding and reacting to drain risk levels in light of any increased severity of winter storms.”

    Source location

    2019-0327-Response-by-West-Sussex-County-Council
    Page 3 · response
    Published 8 November 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

    Regular cleansing-cycle reviews and annual programme optimisation are considered sufficient to reassess drain risk and adjust cleansing frequencies.

    Verbatim wording from the response

    “The treatment intervals for each gully were reviewed on a regular basis to ensure that the most appropriate level of service is delivered. At the end of a two-year cleansing cycle, an optimised cleansing regime was agreed and this took into account any changes in silt levels and priority based on levels of risk determined by the assessment of need.”

    Source location

    2019-0327-Response-by-West-Sussex-County-Council
    Page 2 · response
    Published 8 November 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

    Officer assessment of flooding reports, ad hoc cleansing, and use of recorded data are considered sufficient to address drainage risks and inform future optimisation.

    Verbatim wording from the response

    “Flooding incidents are not necessarily caused by blocked gullies. When we receive a report of a flooding incident where water is slow to drain, then an officer will attend site and assess the likely cause. There may not be any evidence of an issue and in this case the contractor may not be asked to attend. For example, where there has been an exceptional severe weather event and the gully and drainage system did not have the capacity to cope with the deluge. If an officer visits the site and the gully is silted they will arrange for our contractor to attend site and undertake an ad hoc cleanse. Whenever our contractor attends site for cleansing or jetting outside of the cleansing programme (i.e. when data is recorded as ‘Ad-Hoc’) if the level of silt recorded is above 50% then this would factor into the optimisation of the frequency of cleansing going forward.”

    Source location

    2019-0327-Response-by-West-Sussex-County-Council
    Page 3 · response
    Published 8 November 2019

    Open published response

  3. Oxfordshire

    AI-generated summary

    Daniel Davey · 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

    Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.

    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 review in-possession medication risk assessments when risk changes

    Wider context from the report

    “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy. In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away. A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary. This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this. ”

    Source location

    Daniel Davey · 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

    Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.

    Verbatim wording from the response

    “Response: As was stated at the inquest, our prescriber’s always record on the prescription form whether the medication they are prescribing should be held in possession. We have reminded our staff to ensure when they are reviewing any medication that they, where necessary, include an update of the ‘Medication In possession risk assessment’ which goes onto SystmOne, which in turn will feed into the ACCT. This ensures that both dispensing staff and prison staff are aware of any changes and respond accordingly, this will include the removal of any medicines currently being held.”

    Source location

    2019-0267-Response-by-Midlands-NHS-Trust
    Page 2 · response
    Published 17 October 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with Care UK, Pharmacy and Safer Custody on medication reviews and stop checks under the ACCT procedure.

    Verbatim wording from the response

    “As part of the ACCT LOP we are committed to working with colleagues in Care UK, Pharmacy and Safer Custody regarding medication reviews and “stop checks”.”

    Source location

    2019-0267-Response-by-Midlands-NHS-Trust
    Page 2 · response
    Published 17 October 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review in-possession medication risk assessments after specified incidents, changed circumstances, ACCT openings, or other identified safety concerns.

    Verbatim wording from the response

    “HMP Bullingdon also adheres to the Care UK “In possession policy for Prisons” which reviews ‘in possession’ status:”

    Source location

    2019-0267-Response-by-Care-UK
    Page 2 · response
    Published 17 October 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Issue guidance requiring ACCT case managers to discuss in-possession medication routinely and complete risk assessments with healthcare input.

    Verbatim wording from the response

    “Your second concern relates to reviews of in possession medication risk assessments. I understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point. At Bullingdon, if the ACCT case manager is concerned about the immediate welfare of an individual they are required to conduct a review immediately, and to ensure that there is healthcare input to that review. The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until they can confirm that it is safe for the prisoner to continue to have it in their own possession.”

    Source location

    2019-0267-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 17 October 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 monthly audits, policy reviews and spot checks are considered sufficient to manage in-possession medication risks.

    Verbatim wording from the response

    “I can confirm that HMP Bullingdon is fully compliant with Care UK’s mandatory monthly audit in ensuring all prisoners have an ‘in possession status’ recorded on their medical notes from reception.”

    Source location

    2019-0267-Response-by-Care-UK
    Page 2 · response
    Published 17 October 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

    Care UK and Midlands Partnership NHS Foundation Trust are responsible for replying about in-possession medication risk-assessment reviews.

    Verbatim wording from the response

    “Your second concern relates to reviews of in possession medication risk assessments. I understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point. At Bullingdon, if the ACCT case manager is concerned about the immediate welfare of an individual they are required to conduct a review immediately, and to ensure that there is healthcare input to that review. The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until they can confirm that it is safe for the prisoner to continue to have it in their own possession.”

    Source location

    2019-0267-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 17 October 2019

    Open published response

  4. West Yorkshire (West)

    AI-generated summary

    Pauline Taylor · 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

    Pauline Taylor, who was bedbound and living alone, died in her home after a fire developed around her bed on 30 May 2015. The report identified concerns about the fire risks of low-paraffin emollient creams, limited warnings and awareness of those risks, the contribution of the airflow mattress, and the absence of a further risk assessment after her circumstances changed.

    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 undertake a further risk assessment after a significant change in circumstances

    Wider context from the report

    “(8) Following a significant change in Mrs Taylor's circumstances in March 2015 a further risk assessment had not been undertaken by Locala. ”

    Source location

    Pauline Taylor · Prevention of Future Deaths report
    Page 4 · 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

    Complete further risk assessments when relevant patients experience changes in health, circumstances or environment.

    Verbatim wording from the response

    “The first two points on the action plan seek to address the issue you have raised concerning further risk assessment: the action Locala will seek to achieve is that further risk assessments will be completed on all patients who smoke and/or have emollients in use with or without air products, at any stage where there is a change in their physical, physiological or mental health condition or circumstances, and a change in their environment or as a result. In addition, a flowchart is being designed to enable staff to identify patients that are frail or living with changing circumstances and documentation and training is being worked up to implement this throughout the organisation.”

    Source location

    2017-0330-Response-by-Locala_Redacted
    Page 2 · response
    Published 21 July 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

    Design a frailty and changing-circumstances flowchart and develop documentation and training for organisation-wide implementation.

    Verbatim wording from the response

    “The first two points on the action plan seek to address the issue you have raised concerning further risk assessment: the action Locala will seek to achieve is that further risk assessments will be completed on all patients who smoke and/or have emollients in use with or without air products, at any stage where there is a change in their physical, physiological or mental health condition or circumstances, and a change in their environment or as a result. In addition, a flowchart is being designed to enable staff to identify patients that are frail or living with changing circumstances and documentation and training is being worked up to implement this throughout the organisation.”

    Source location

    2017-0330-Response-by-Locala_Redacted
    Page 2 · response
    Published 21 July 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

    Audit records for missed further risk assessments and manage findings through community nursing team leaders.

    Verbatim wording from the response

    “In relation to undertaking further risk assessments records are being audited to see that this happening, and situations are not being missed, and this is being managed through the community nursing team leaders group. They are responsible within their teams for ensuring staff understand the need for further risk assessment when circumstances change.”

    Source location

    2017-0330-Response-by-Locala_Redacted
    Page 3 · response
    Published 21 July 2017

    Open published response

  5. South Yorkshire (Eastern)

    AI-generated summary

    John Atkinson · 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

    John Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team services.

    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 updated risk assessments after key events or significant deterioration in presentation

    Wider context from the report

    “(1) Lack of updated Risk Assessments when key events occurred or there was a significant deterioration in presentation. ”

    Source location

    John Atkinson · 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

    Commission tailored STORM risk-management training for Intensive Community Therapies Team staff.

    Verbatim wording from the response

    “The policy clearly describes the expectation to review risk following any significant event or clinical change in a patient’s presentation. In Mr Atkinson’s case this did not occur as expected and therefore the Trust has taken measures in relation to the care coordinator’s performance to address this. Furthermore the Trust recognises that staff in the Intensive Community Therapies Team (ICT) require a strengthened approach to risk management given the complexities of their patient group. The Trust has therefore commissioned some tailored STORM training (Skills based Training on Risk Management) due to be delivered during February and March 2017. Furthermore each member of staff in the ICT team will have completed two TED educational sessions during January 2017 (Kevin Briggs- “The Bridge between suicide and life”, and “Overcoming hopelessness”).”

    Source location

    2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 3 · response
    Published 12 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

    Conduct weekly risk-review audits and supervision snapshot audits, incorporating them into the 2017 Clinical Audit Programme.

    Verbatim wording from the response

    “The Trust’s internal trainer has assured me that the STORM training package includes the key issues of accelerating risk and risk profiling in order that staff clearly understand the expectation to update risk assessments regularly when there is a change in presentation. In order to understand the impact of these additional measures the Trust is undertaking weekly audits of risk reviews and snap-shot audits via staff supervision. This is also incorporated in the RDaSH Clinical Audit Programme 2017. As an additional measure the Trust has scheduled a Quality Review of the ICT Team during January 2017 (conducted by RDaSH staff who work outside of the ICT Team) to independently monitor the rapid improvement plan.”

    Source location

    2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 3 · response
    Published 12 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

    Review risk assessments and risk management during Intensive Community Therapies Team staff supervision.

    Verbatim wording from the response

    “The issues of effective risk management are being addressed throughout the ICT team as described earlier in my response. The team manager, as part of their role, reviews risk assessments and risk management during staff supervision and this is part of the ICT action plan put in place to address any systemic issues.”

    Source location

    2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 4 · response
    Published 12 February 2017

    Open published response

  6. West London

    AI-generated summary

    Ian David Morley · 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

    Ian David Morley, a wheelchair-bound resident in supported accommodation with multiple sclerosis, died after being found alight in his wheelchair, apparently after a cigarette fell onto a towel covering the seat. Concerns included the absence of a fresh risk assessment after his condition deteriorated and inadequate fire risk management at Greenrod Place.

    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 conduct a fresh risk assessment following deterioration in condition

    Wider context from the report

    “1. The multiple sclerosis nurse who had been working with the deceased noted that his condition had deteriorated shortly before his death. This should have prompted a fresh risk assessment but it was not evident that it did, in fact, do so. ”

    Source location

    Ian David Morley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Manchester West

    AI-generated summary

    Emmeline Hampson · 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

    Emmeline Hampson died in hospital on 6 November 2014 after a fall at her nursing home caused a subdural haematoma and intracerebral bleeding. The concerns included repeated falls without review of her falls risk assessment or referral back to the Falls Service, inadequate procedures and record keeping, shortcomings in alarm audibility and differentiation, and insufficient training of agency staff.

    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 review falls risk assessments and refer recurrent falls back to the Falls Service

    Wider context from the report

    “ii. From the 4th October 2014 there were five falls including the fall on the 4th October 2014 and culminating in the fall on the 29th October 2014. There was no review of the falls risk assessment and no referral back to the Falls Service following any one of the falls between the 4th October 2014 and the 29th October 2014 even though Mrs Hampson’s condition had changed and there were recurrent falls. ”

    Source location

    Emmeline Hampson · Prevention of Future Deaths report
    Page 3 · 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 procedures for reviewing risk assessments after falls or significant changes in residents’ condition

    Wider context from the report

    “iii. There were no procedures in place at the Nursing Home in relation to the review of risk assessments after a fall or after an obvious and significant change in a resident’s condition. ”

    Source location

    Emmeline Hampson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. Northamptonshire

    AI-generated summary

    Jane Marie Clark and Isobel Griffin · 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

    Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature 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

    Failure to update risk assessments with emerging risks

    Wider context from the report

    “Re Jane Marie Clark 1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented. 2. She did not place any boundaries on the leave for example providing a time by which Jane was to return. 3. Risk assessment documentation generally was poor and appeared perfunctory. Re Isobel Griffin 1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th. 2. The risk assessment was not updated with the events of the 7th. 3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature. 4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family. 5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment. 6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances. 7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk. ”

    Source location

    Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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