Recurring concern

Unreliable care-planning processes

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First reported 1 Aug 2013•Latest report 2 Jun 2026

Definition

What this concern includes

Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.

Not included

Excludes standalone procedural instructions, treatment steps, extubation plans and immediate deterioration-management plans unless the source explicitly identifies them as part of the person's formal care plan.
Excludes organisational improvement plans, staffing plans and operational contingency plans.
Excludes discharge planning, risk assessment, family involvement or generic records when that separate control is the concern and formal care-plan reliability is not directly asserted.

Reports: 120
Individual concerns: 141
Date range: 2013–2026
Stated actions: 200

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care14

Care Quality Commission9

Sussex Partnership NHS Foundation Trust9

Essex Partnership University NHS Foundation Trust7

NHS England7

Ministry of Justice5

Avon and Wiltshire Mental Health Partnership NHS Trust4

Barts Health NHS Trust4

Norfolk and Suffolk NHS Foundation Trust4

North East London NHS Foundation Trust4

Birmingham and Solihull Mental Health NHS Foundation Trust3

Central and North West London NHS Foundation Trust3

Hc-One Limited3

HM Prison and Probation Service3

Office of the Chief Coroner3

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.

22 Aug2022
Norfolk
Concerns raised1
1. Failure to maintain up-to-date Care Plans
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement the Dialog+ recovery-focused care plan with supporting staff training and individual support sessions.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
2. Action
  Strengthen care-plan completion and review through primary-nursing allocation, audit and Clinical Team Leader management supervision.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
AI-generated summary

Eliot HARRIS · 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

Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.

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 maintain up-to-date Care Plans
Wider context from the report
“4) Eliot’s Care Plan was not up to date at the time of his death. At the inquest evidence was heard that although audits show there has been an improvement in completion of Care Plans, there “is still some way to go” and staff still need to be prompted to complete these ”
Source location
Eliot HARRIS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Dialog+ recovery-focused care plan with supporting staff training and individual support sessions.

Verbatim wording from the response
“Care plans provide details of the agreed interventions between the patient, family and team to support an individual’s recovery. Alongside other clinical documents, they assist the staff in their communication of the assessed needs of the individual, and the actions being taken. In November 2021, the Trust started the process of implementing a new style of care plan referred to as Dialog +. This care plan is recovery focused and is designed to work with the patient to understand the areas of their life which are important to them which they wish to improve. As part of the implementation within the ward, a training session was held within the Safety Day and the team awayday which were further supported by individual sessions with staff when required.”

Source location
Response form Norfolk and Suffolk Foundation Trust
Page 3 · response
Published 3 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
Strengthen care-plan completion and review through primary-nursing allocation, audit and Clinical Team Leader management supervision.

Verbatim wording from the response
“As an individual’s care and treatment progresses, the ward employs a process to support the completion and revisions to of care plans as an individual’s care and treatment progresses. This includes strengthening the wards systems through the allocation of primary nursing responsibilities and the use of audit to monitor required improvements. The process provides feedback Clinical Team Leader leads the review of care plans and other clinical documentation as part of management supervision, all of which will enable further improvements. The care plans are used alongside the multi-disciplinary team meetings and handovers to support communication of care amongst the team”

Source location
Response form Norfolk and Suffolk Foundation Trust
Page 3 · response
Published 3 October 2022
Open published response
17 Aug2022
Manchester South
Concerns raised1
1. Failure to properly record care plans
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Share serious-incident learning with the Home Treatment Team and raise the importance of timely, accurate care-plan documentation.
  Stated by Pennine Care NHS Foundation TrustStated completed
2. Action
  Establish a substantive Consultant Psychiatrist post within the Home Treatment Team.
  Stated by Pennine Care NHS Foundation TrustStated completed
3. Action
  Adjust multidisciplinary meetings to ensure regular consultant attendance and improve communication and care planning.
  Stated by Pennine Care NHS Foundation TrustStated completed
AI-generated summary

Susan Mary Regan · 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

Susan Mary Regan, aged 61, experienced deteriorating mental and physical health, including malnutrition, dehydration, disturbed behaviour and possible self-harm, before being admitted to hospital and later discharged with support. On 25 July 2020, she took her own life at home. The principal concerns were that the Home Treatment Team did not consult her sons about possible hospitalisation and did not properly record or communicate a care plan with them.

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 properly record care plans
Wider context from the report
“1) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Mrs Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit. Admission to also be considered if Ms Regan would continue to show non-compliance on her medications. Such an enquiry was not undertaken. 2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons. ”
Source location
Susan Mary Regan · 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
Share serious-incident learning with the Home Treatment Team and raise the importance of timely, accurate care-plan documentation.

Verbatim wording from the response
“The death of Ms Regan and subsequent internal serious incident investigation and learning has been shared with the HTT. The importance of timely and accurate documentation within patient case notes including agreed care plans has been raised within all disciplines within the team.”

Source location
Response from Pennine Care
Page 3 · response
Published 3 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
Establish a substantive Consultant Psychiatrist post within the Home Treatment Team.

Verbatim wording from the response
“It is also crucial to note that since the death of Ms Regan, the HTT now has a substantive Consultant Psychiatrist in place. This has brought a greater degree and consistency for both the team and patients using the service. The Multi-Disciplinary meetings (MDM’s) have been adjusted to ensure regular attendance of the consultant. This has allowed a better degree of communication and care planning with mutually agreed goals and actions.”

Source location
Response from Pennine Care
Page 3 · response
Published 3 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
Adjust multidisciplinary meetings to ensure regular consultant attendance and improve communication and care planning.

Verbatim wording from the response
“It is also crucial to note that since the death of Ms Regan, the HTT now has a substantive Consultant Psychiatrist in place. This has brought a greater degree and consistency for both the team and patients using the service. The Multi-Disciplinary meetings (MDM’s) have been adjusted to ensure regular attendance of the consultant. This has allowed a better degree of communication and care planning with mutually agreed goals and actions.”

Source location
Response from Pennine Care
Page 3 · response
Published 3 October 2022
Open published response
12 Aug2022
Dorset
Concerns raised1
1. Lack of written policy or guidance for reviewing care plans following incidents
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Disseminate the updated falls policy across the service and wider company, including requirements to update risk assessments and mobility care plans after falls.
  Stated by Tricuro LtdStated completed
AI-generated summary

Gerald Kenneth Tuck · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Gerald Kenneth Tuck, who had dementia and lived in a residential home, sustained repeated falls in December 2021 and January 2022. After the final fall, he was diagnosed with two acute subdural haematomas, his condition deteriorated, and he died on 2 March 2022. The concern was that the home had no written policy or guidance requiring care plans and falls risk assessments to be reviewed after incidents.

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 written policy or guidance for reviewing care plans following incidents
Wider context from the report
“i. There is no written policy or guidance in place at Sidney Gale House Residential Home around the review of care plans following an incident at the home and this could lead to a future death is necessary risk assessments are not undertaken following an incident occurring. ”
Source location
Gerald Kenneth Tuck · 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
Disseminate the updated falls policy across the service and wider company, including requirements to update risk assessments and mobility care plans after falls.

Verbatim wording from the response
“Our policy also reflects that staff are expected to update the falls risk assessments and mobility care plans after any fall to ensure that the care, support and risks are managed accordingly. We have ensured that all staff within the service and the wider company are very clear of the policy and that this must be followed.”

Source location
Response from Tricuro
Page 3 · response
Published 3 October 2022
Open published response
17 Jun2022
Manchester South
Concerns raised1
1. Failure to formulate individual plans for patients receiving repeat prescriptions of multiple analgesics
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Amanda Hesketh · 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

Amanda Hesketh, who had a complex health history and was prescribed multiple analgesic medicines, became unresponsive in the Emergency Department after presenting with diarrhoea and vomiting and could not be resuscitated. The report identified concerns about the lack of systematic reviews and individual plans for patients receiving multiple analgesics, limited specialist pain-clinic input, and inconsistent use of practice pharmacists.

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 formulate individual plans for patients receiving repeat prescriptions of multiple analgesics
Wider context from the report
“Notwithstanding the actions the practice has taken in response to Mrs Hesketh’s death, it is a matter of concern the partnership has yet to undertake or commission a systematic review of all patients receiving repeat prescriptions of multiple analgesics and formulate individual plans for each such patient; ”
Source location
Amanda Hesketh · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Feb2022
Norfolk
Concerns raised1
1. Failure to record specific review plans in care plans
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Use and build the SBAR tool in patient records during handovers and ward reviews to capture patient history, concerns and required escalation.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
AI-generated summary

Sheila Elizabeth Steggles · 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

Sheila Elizabeth Steggles, who had reduced mobility and several risk factors for thrombosis, collapsed on 5 November 2019 and died in an ambulance after suffering a cardiac arrest. The cause of death was recorded as acute pulmonary embolus arising from deep vein thrombosis. Concerns included the absence of a documented VTE risk assessment, insufficient consideration of reduced mobility and past DVT, inadequate staff training, and missed opportunities to provide prophylactic heparin.

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 record specific review plans in care plans
Wider context from the report
“If a patient is to be reviewed then a specific plan should be placed on to the care plan so that everyone knows what is needed to be done. ”
Source location
Sheila Elizabeth Steggles · 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
Use and build the SBAR tool in patient records during handovers and ward reviews to capture patient history, concerns and required escalation.

Verbatim wording from the response
“Handover between junior Doctors and other medical staff will be underpinned by the Situation Background Assessment Recommendation (SBAR) framework. This will ensure that patient history, emerging concerns and necessary action including escalation where necessary are known, recorded and acted on. Inpatient wards across the organisation utilise and upload the SBAR tool into patient records to assist with ward reviews and handovers. The SBAR document is built upon at each handover, therefore building up a comprehensive history of the patient.”

Source location
2022-0042-Response-from-Hellesdon-Hospital_Published
Page 2 · response
Published 14 February 2022
Open published response
8 Feb2022
Essex
Concerns raised1
1. Failure to formally update Care Plans and Risk Assessments thoroughly and timely
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John David Moore · 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 David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of concerns.

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 formally update Care Plans and Risk Assessments thoroughly and timely
Wider context from the report
“(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role: (i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death; (ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all; (iii) inadequate communication with other primary and secondary care providers; (iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients; (v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors. ”
Source location
John David Moore · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Sep2021
East London
Concerns raised1
1. Failure to update mobility care plans in response to changing care needs
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Eldine Loretta Lashley · 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

Eldine Loretta Lashley suffered an unwitnessed fall at a care home on 6 April 2021, sustaining a subdural haemorrhage, and died at home on 14 April 2021 despite medical intervention. Concerns were raised that her mobility care plan was not updated to reflect increased monitoring needs and that progress notes did not accurately record the frequency of checks carried out.

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 mobility care plans in response to changing care needs
Wider context from the report
“1. Mrs Lashley's mobility care plan was not updated in response to developments in her care needs – specifically she need to observe her more frequently than once per hour. 2. Progress notes created by nursing and care staff did not accurately reflect the frequency of checks carried out on Mrs Lashley. ”
Source location
Eldine Loretta Lashley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Jul2021
Warwickshire
Concerns raised1
1. Failure to record resident aggression incidents in care plans
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.
  Stated by Crosscrown LimitedStated completed
2. Action
  Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.
  Stated by Crosscrown LimitedStated completed
3. Action
  Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.
  Stated by Crosscrown LimitedStated completed
AI-generated summary

Dorothy Seekings · 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

Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.

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 record resident aggression incidents in care plans
Wider context from the report
“(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████. (2) the failure to raise a safeguarding alert with the local authority regarding the above incident. (3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident ”
Source location
Dorothy Seekings · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.

Verbatim wording from the response
“The two key changes are the acceleration of the implementation of a digital care management software system called CareDocs. This was being gradually introduced into the Homes run by Crosscrown during the Summer of 2019 but the events of August 8th accelerated the implementation of the new system and it is now in place in all Crosscrown Homes including Clifton Court and has been for some time. The digital CareDocs system allows Care Plans to be created that meet the specific requirements of individual service users and it allows the creation of a care plan reflective of the needs and preferences of the individual user.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 1 · response
Published 9 July 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
Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.

Verbatim wording from the response
“The Operations Team has implemented an enhanced agenda for the fortnightly staff meetings that are held at Clifton Court to include inter alia infection control – Covid, health and safety and accurate and systematic recording of behavioral issues.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 3 · response
Published 9 July 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
Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.

Verbatim wording from the response
“Under the new scheme such behaviour is recorded on the CareDocs system which prompts the completion of an Antecedent Behaviour Consequences form on the CareDocs system. The Care Home Manager at Clifton Court checks on a daily basis for amongst other things any ABC charts which may have been completed by members of staff. Should any safeguarding issues be recorded then the Manager will contact Adult Social Services and complete that process. The Operations Team are copied into all emails in relation to any safeguarding issues. In the last eighteen months Clifton Court has made eight referrals to the Adult Social Services Team at Warwickshire County Council all of which were closed down without an action by the Council. The issue of safeguarding is also now part of the Monthly Managers Report and is analysed by the Operations Team and evaluated for any patterns or learning issues.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 3 · response
Published 9 July 2021
Open published response
10 Feb2021
Black Country
Concerns raised2
1. Failure to update falls risk assessments and care plans after every fall
2. Failure to update falls risk assessments and care plans after every fall
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
  Stated by Care Quality CommissionStated completed
Respondent positions 1
1. Position
  CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
  Stated by Care Quality CommissionUnable to act
AI-generated summary

Eric Harold Bird · 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

Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.

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 falls risk assessments and care plans after every fall
Wider context from the report
“7. There was no evidence of any changes being made to Mr Birds falls care plan after the fall on 14/11/20 and no rationale recorded for not doing so; ”
Source location
Eric Harold Bird · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to update falls risk assessments and care plans after every fall
Wider context from the report
“6. There was no evidence that Mr Bird’s falls risk assessment and falls care plan had been updated after every fall; ”
Source location
Eric Harold Bird · 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
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.

Verbatim wording from the response
“The matters of concern which arose from the preventing future deaths report have prompted the CQC to take action. In direct response, we held a management review meeting on 17 February 2021. Following the management review meeting, we reviewed the evidence we held about Castlehill Specialist Care Centre, the information held following the specific incident review related to Mr Bird’s death and information following the inspection completed in January 2021.”

Source location
2021-0122-Response-from-Care-Quality-Commission-Redacted
Page 2 · response
Published 4 May 2021
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
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.

Verbatim wording from the response
“• As a result of these findings, CQC held a management review meeting on 18 March 2021 to discuss the findings under our specific incident guidance. In order to open a formal criminal investigation, we have to be able to evidence a Registered Person (either a Registered Provider or Registered Manager) failed to provide safe care and treatment to Mr Bird in relation to this incident and can prove beyond reasonable doubt this incident was avoidable. We did not feel that this threshold was met and therefore will not progress the case.”

Source location
2021-0122-Response-from-Care-Quality-Commission-Redacted
Page 3 · response
Published 4 May 2021
Open published response
10 Feb2021
Oxfordshire
Concerns raised2
1. Failure to update care plans and risk assessments with material overdose information and information from clinical reviews and contacts
2. Lack of a clear care plan following emergency review
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Maintain current risk assessments and care plans for Care Programme Approach patients and share them with patients and families as appropriate.
  Stated by OHFTStated completed
2. Action
  Review electronic care-record processes for recording and reviewing risk formulations and assessments, including family views and best-practice family involvement.
  Stated by OHFTStated completed
3. Action
  Embed multidisciplinary team care-plan reviews for patients at risk of suicide.
  Stated by OHFTStated completed
1. Action
  Have the Quality Improvement team consider family involvement, enhanced risk formulation and suicide-risk assessment within thematic improvement work.
  Stated by OHFTStated in progress
2. Action
  Include risk-assessment and care-plan quality in Trust audits during the coming year.
  Stated by OHFTStated planned
AI-generated summary

LISA MARIE THOMPSON · 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

Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.

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 care plans and risk assessments with material overdose information and information from clinical reviews and contacts
Wider context from the report
“Evidence was heard that: (1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020 (2) The care plans and risk assessments at the mental health Trust were not updated: (a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication. (b) the two most recent overdoses were not recorded (c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out. (d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist (e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator ”
Source location
LISA MARIE THOMPSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a clear care plan following emergency review
Wider context from the report
“Evidence was heard that: (1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020 (2) The care plans and risk assessments at the mental health Trust were not updated: (a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication. (b) the two most recent overdoses were not recorded (c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out. (d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist (e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator ”
Source location
LISA MARIE THOMPSON · 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
Maintain current risk assessments and care plans for Care Programme Approach patients and share them with patients and families as appropriate.

Verbatim wording from the response
“The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:”

Source location
2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 27 May 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
Review electronic care-record processes for recording and reviewing risk formulations and assessments, including family views and best-practice family involvement.

Verbatim wording from the response
“The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:”

Source location
2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 27 May 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
Embed multidisciplinary team care-plan reviews for patients at risk of suicide.

Verbatim wording from the response
“The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:”

Source location
2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 27 May 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
Have the Quality Improvement team consider family involvement, enhanced risk formulation and suicide-risk assessment within thematic improvement work.

Verbatim wording from the response
“To that end, the Trust has a Quality Improvement team² who are dedicated to working with our local teams to continually improve the quality of our services. Our Chief Nurse has asked the Quality Improvement team to ensure areas of improvement relating to this tragic serious incident are considered alongside other themes identified from the thematic review, in particular:”

Source location
2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 3 · response
Published 27 May 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
Include risk-assessment and care-plan quality in Trust audits during the coming year.

Verbatim wording from the response
“Please be assured that this work is a high priority for the Trust. Trust audits in the coming year will include looking at the quality of risk assessments and care plans. We have also included safety planning questions into our CPA and Essential Standards audits. I also hope it will help to inform you about work being carried out if I attach the Trust’s Action Plan record (“C”).”

Source location
2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 3 · response
Published 27 May 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to maintain up-to-date Care Plans

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to properly record care plans

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Lack of written policy or guidance for reviewing care plans following incidents

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to formulate individual plans for patients receiving repeat prescriptions of multiple analgesics

Concerns raised1

Failure to record specific review plans in care plans

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to formally update Care Plans and Risk Assessments thoroughly and timely

Concerns raised1

Failure to update mobility care plans in response to changing care needs

Concerns raised1

Failure to record resident aggression incidents in care plans

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Failure to update falls risk assessments and care plans after every fall

Failure to update falls risk assessments and care plans after every fall

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to update care plans and risk assessments with material overdose information and information from clinical reviews and contacts

Actions described in response 2

Actions described in response 3

Actions described in response 1

Actions described in response 1

Actions described in response 3

Actions described in response 1

Respondent positions 1