Recurring concern

Unreliable care-planning processes

First to latest report 1 Aug 2013 — 2 Jun 2026

Reports that mention this concern
120
Times this concern has been raised
141
Stated actions linked to this concern
200

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Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.

What is 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 and published responses 120 reports

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

  1. Inner North London

    AI-generated summary

    Dawn Patricia GILL · 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

    Dawn Patricia Gill, a long-term drug user, died from a methadone overdose after taking illicit drugs while in the Royal London Hospital alongside prescribed medication. Concerns included the absence of a nursing care plan addressing her drug use, the loss of her drug chart, failures to detect her in her room during searches, and confusion about when to alert hospital security after she was thought to be missing.

    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 nursing care planning for patients at increased risk from illicit drug use

    Wider context from the report

    “1. Ms Gill was a long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital. However, while she was in hospital, no nursing care plan was made to take this into account, for example by acknowledging the higher risk that it brought. One nursing sister was not even aware that staff suspected Ms Gill of going off the ward to take drugs. ”

    Source location

    Dawn Patricia GILL · 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 nursing teams to document suspected illicit drug use in care plans and include it in nursing handovers.

    Verbatim wording from the response

    “During her stay in hospital the wider nursing team and medical staff were aware of the suspicion of Ms Gill taking illicit drugs. She had been spoken to by the consultant and charge nurse and the senior nurse to advise this was not acceptable. However the nursing care plan could and should have been more explicit about this, and if it had been nursing staff would have been more aware of her behaviour and the attendant risks. All nursing teams in the hospital are being reminded of the importance of documenting the use of suspected use of illicit drugs in care plans, and of ensuring this information is part of the nursing handover.”

    Source location

    2018-0354-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 25 April 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Trust lacks the legal powers to prevent patients with capacity from leaving the ward voluntarily.

    Verbatim wording from the response

    “We were aware of her drug habit but we did not see her before her death so would have not have had chance to make any diagnosis or therefore suspected a drug overdose going forward all such patients we will suspect a potential for taking non prescribed drugs and treat accordingly but do not have the powers to stop such patients leaving the ward of their own free will.”

    Source location

    2018-0354-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 25 April 2019

    Open published response

  2. Wiltshire and Swindon

    AI-generated summary

    Terence Andrew Bennett · 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

    Terence Andrew Bennett, who had schizo-affective disorder and was severely mentally ill, suicidal and threatening harm to his mother, died by suicide after self-inflicting deep wounds to his neck and wrists on 26 October 2016. The inquest found that his death was contributed to by neglect. Concerns included inadequate care and risk-management plans, failures in record use and handover, insufficient family and multidisciplinary involvement, reliance on unqualified staff, and deficiencies in supervision, training and consultant working arrangements.

    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 sufficiently robust and informative care, risk and crisis management plans

    Wider context from the report

    “1. Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information. ”

    Source location

    Terence Andrew Bennett · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Henry James Heselton · 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

    Henry James Heselton died by hanging in a field off Down Lane, Guildford, on 28 September 2016. The report identified concerns about unclear electronic mental health records and poor communication between mental health teams and his general practitioner, which meant relevant information was not available to inform clinical judgement.

    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 relevant mental health history in care plans

    Wider context from the report

    “1. The electronic mental health records were unclear. Vital information about Mr Heselton’s mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information was not easy to extract for professionals needing to find information about a patient in a crisis. ”

    Source location

    Henry James Heselton · 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 collaborative My Safety & Crisis Plans with regular completion and update prompts, including after significant risk changes.

    Verbatim wording from the response

    “The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors; demographic, background, clinical history, psychological and psychosocial factors and current context. The clinical assessment of these factors leads to a management plan which will include a ‘My Safety & Crisis Plan’ (a collaborative approach to safety planning). This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen when there is a significant change in risk.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response

  4. County Durham and Darlington

    AI-generated summary

    Stanley Langdon · 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

    Stanley Langdon died at Dipton Manor Care Home on 21 May 2017 from complications arising from a periprosthetic left femoral fracture sustained while carers assisted him to climb onto a minibus. The report states that he would not have sustained the fracture if he had been transferred in a wheelchair using the available hydraulic lift. The principal concerns were that services began without an adequate care plan or needs assessment, and that care planning was not based on complete information or agreed with his family, creating a risk of similar accidents and deaths in future.

    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

    Care plans and needs assessments failing to incorporate complete available information

    Wider context from the report

    “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user. (5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users. (6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day) (7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day). ”

    Source location

    Stanley Langdon · 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

    Introduce a revised home-assessment document for completion before new placements.

    Verbatim wording from the response

    “A report was received, and ALL suggested improvements were made as the documents attached confirm ref SCAN20170623, this was in place prior to the inquest date.”

    Source location

    2018-0110-Response-by-Haven-Day-Centre
    Page 1 · response
    Published 17 June 2018

    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 existing and new placements to ensure suitable care plans address minibus access by steps or tail lift.

    Verbatim wording from the response

    “A report was received, and ALL suggested improvements were made as the documents attached confirm ref SCAN20170623, this was in place prior to the inquest date.”

    Source location

    2018-0110-Response-by-Haven-Day-Centre
    Page 1 · response
    Published 17 June 2018

    Open published response

  5. Sunderland

    AI-generated summary

    Patricia Ann Heslop · 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

    Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

    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

    Wider context from the report

    “4. There was evidence that care plans had not been updated, various documents not reviewed or read by others, as well as that records were incomplete or inaccurate. For example, the impression was given of Patricia being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs. ”

    Source location

    Patricia Ann Heslop · 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 evaluate the e.care electronic care-planning system, with organisation-wide rollout scheduled for October 2018.

    Verbatim wording from the response

    “2.3 Significant work has been undertaken by HC-One to introduce an electronic care planning system, e.care. The pilot has continued to be implemented, evaluated and refined in a number of homes and the measurable successes achieved to date have resulted in a date for roll out across the organisation in October 2018. The electronic system will remove the requirement for paper care plans to be kept in multiple files and enable all information and care plans to be stored in one place.”

    Source location

    2018-0102-Response-by-HC-One
    Page 4 · response
    Published 17 June 2018

    Open published response

  6. Nottinghamshire

    AI-generated summary

    George Goldby · 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

    George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and reviews.

    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 care plans and dietary requirements

    Wider context from the report

    “(3) There were three missed opportunities to re-refer Mr Goldby to SALT and to review his care plan and dietary requirements. ”

    Source location

    George Goldby · 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

    Introduce dining registers and quick-reference guides for managing specialist diets, with formal review and update governance.

    Verbatim wording from the response

    “7. Additional advice was sought from the company Hospitality specialist to establish if there were any further processes or mechanisms to help support the safe and effective management of people who require a specialist diet. As a result we have introduced a new system of dining registers with quick reference guides, which were put into place and help colleagues or any agency workers to reflect the handover documentation.”

    Source location

    2018-0104-Response-by-HC-One
    Page 2 · response
    Published 17 June 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement daily ‘Resident of the day’ care-plan reviews and report changing needs through the clinical risk register.

    Verbatim wording from the response

    “8. The manager and staff at the home have implemented a ‘Resident of the day’ approach to care plan reviews which means that a designated Resident has their care and support needs reviewed every day to ensure any changes are reflected in updated care plans and shared with colleagues who support them. Any changes in need are reported monthly through to the clinical risk register, which is monitored by the Senior Turnaround Manager working at the home and the Area quality management Team.”

    Source location

    2018-0104-Response-by-HC-One
    Page 2 · response
    Published 17 June 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a long-term diet-notification review process and incorporate it into HC-One’s choking-risk governance strategy.

    Verbatim wording from the response

    “The Catering Manager in the home has developed their own review process for long term updates of diet notifications where Residents care needs haven’t changed. The catering team have taken a proactive approach to the concerns raised. This process developed within Stoneyford will now form part of the governance strategy for managing the risk of choking across HC-One.”

    Source location

    2018-0104-Response-by-HC-One
    Page 3 · response
    Published 17 June 2018

    Open published response

  7. Gloucestershire

    AI-generated summary

    David Anthony Sketchley · 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

    David Anthony Sketchley, a resident of Ashley House Nursing Home, died after falling through a gap in a bariatric commode chair and sustaining a traumatic perianal injury. The report identified concerns about inadequate supervision, unclear care-plan requirements and definitions of supervision, and insufficient documented assessment of the commode’s suitability.

    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 define required levels of resident supervision in care plans and guidance

    Wider context from the report

    “At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires. ”

    Source location

    David Anthony Sketchley · 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

    Revise care documentation, supporting guidance and resident-care policies to specify individualised supervision requirements and responsible staff for daily activities.

    Verbatim wording from the response

    “We now advocate the use of a two tier care documentation filing system which is a mandatory process and has been in use since 2017. The main care file is to be housed at the nurse’s station and is where the care plans sit. The second file, which is known as the supplementary file is to be housed at the point of care delivery i.e. in a resident’s bedroom. At the front of the supplementary file is a document named ‘My Day, My Life, and My Portrait’. This document is designed to give an overview of the care needs an individual requires and is available at the point of care delivery, allowing care staff immediate access to imperative information regarding a resident’s care needs. Therefore this document should be reviewed to incorporate an individual’s supervision requirement, including who carries out the supervision, during each activity of daily living requirement.”

    Source location

    2018-0069-Responses
    Page 2 · response
    Published 16 June 2018

    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

    Allocate resources for further investigation of the supervision, commode suitability and investigation deficiencies identified by the coroner, then discuss findings and agree actions and learning.

    Verbatim wording from the response

    “Bupa will allocate resource to undertake further investigations into the issues highlighted above under point 3 by the coroner, which were not covered in the original investigation. Any findings from the new investigation will be discussed at the BCS Clinical Governance Committee and actions and learning’s agreed.”

    Source location

    2018-0069-Responses
    Page 3 · response
    Published 16 June 2018

    Open published response

  8. Surrey

    AI-generated summary

    Ronald Arthur Farrington · 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

    Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.

    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 incorporate tissue viability advice into care plans

    Wider context from the report

    “1. Nuffield Care Centre: a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans. b.) Failed to keep accurate records. c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t. d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016. ”

    Source location

    Ronald Arthur Farrington · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Avon

    AI-generated summary

    Rebecca Jay ROMERO · 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

    Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric 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

    Failure of care plans to specify dates for meetings and task completion

    Wider context from the report

    “(2) Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so agreeing expectations are managed to everyone knows exactly what the plan is and when actions will occur. ”

    Source location

    Rebecca Jay ROMERO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Avon

    AI-generated summary

    Irene Winifred BAKER · 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

    Irene Winifred BAKER died following an operation for a fractured hip, which evidence suggested occurred at Rosewood Lodge Nursing Home, although the nursing home had no record of it. Concerns included failures to revise mobility care plans, undertake monthly mobility reviews, and contact a GP or call an ambulance when she was documented as unable to bear weight.

    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 revise the mobility care plan in response to documented deterioration in mobility

    Wider context from the report

    “1. No revision of the mobility care plan in response to monthly reviews documenting a deterioration in mobility in November and December 2016; ”

    Source location

    Irene Winifred BAKER · 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

    Overhaul and rewrite residents’ care plans.

    Verbatim wording from the response

    “• Care plans were completely overhauled and re-written by ████████ (this was evidenced at our North Somerset Council inspection on 14th September 2017)”

    Source location

    2017-0362-Response-by-Rosewood-Lodge
    Page 1 · response
    Published 11 February 2018

    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 care plans monthly or sooner after changes and update associated risk assessments.

    Verbatim wording from the response

    “• Care plans are reviewed on a monthly basis or before if there are any changes, risk assessments are updated accordingly and support from medical professionals is raised immediately to ensure we are able to meet their needs at all times.”

    Source location

    2017-0362-Response-by-Rosewood-Lodge
    Page 1 · response
    Published 11 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement computerised person-centred care-plan software for live updates and incident, accident, mobility and other needs reporting.

    Verbatim wording from the response

    “• From 31st January 2018, we have implemented a new computerised care plan software system, ‘Person Centred Software’ which allows care staff to update”

    Source location

    2017-0362-Response-by-Rosewood-Lodge
    Page 1 · response
    Published 11 February 2018

    Open published response

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

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Data last updated 7 September 2026