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Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.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

    AI-generated summary

    Sybil Roberts · 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

    Sybil Roberts fell at her care home on 30 December 2013 and again on 1 February 2014, sustaining a fractured hip on each occasion before dying at Maelor Hospital Wrexham on 15 March 2014. The investigation identified that a further falls risk assessment had not been undertaken, and that her care plan and falls risk had not been reassessed and updated before her return from hospital, after which she sustained her second fracture two days later.

    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 reassess and update care plans and falls risks after hospital return

    Wider context from the report

    “During the course of the investigation it became apparent that although Mrs Roberts had been assessed upon her admission to the residential home, there had not been a referral to her GP (as would be normal practice at this home) for a further falls risk assessment. This is despite an acknowledgement that her condition was declining prior to the first fall. Furthermore her care plan and falls risk had not been reassessed and updated prior to her return to the home from hospital after the first fall and she sustained her second fracture only two days later. An inadequate assessment of the potential risks Mrs Roberts was made and I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”

    Source location

    Sybil Roberts · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Nottinghamshire

    AI-generated summary

    Beryl French · 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

    Beryl French was a resident at Landmere Nursing Home who developed respiratory difficulties while receiving personal care. Nursing staff did not initiate active interventions because they believed a completed DNACPR form was in place, but no such form existed. The concerns included staff understanding of DNACPR forms and insufficient end-of-life care planning.

    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

    Insufficient end-of-life care planning to guide nursing and care staff

    Wider context from the report

    “2. That End of Life Care planning was insufficient to guide nursing and care staff to help residents to die peacefully and with dignity in appropriate cases. ”

    Source location

    Beryl French · 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

    Use multidisciplinary meetings involving all relevant care bodies to inform comprehensive End of Life care plans where appropriate.

    Verbatim wording from the response

    “The first stage in End of Life care planning now is that there will be a Multi-Disciplinary Team meeting which will include all bodies involved in the care of a service user. These meetings used to be fragmented with different parties meeting together but now the meeting will include all bodies. At the conclusion of the meeting an informed judgment will be made and a comprehensive End of Life care plan will be drafted if appropriate. The End of Life care plan provides clarity and clear guidance to staff.”

    Source location

    2014-0198-Response-by-Life-Style-Care
    Page 3 · response
    Published 30 April 2014

    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

    Pilot the End of Life care plan in three homes.

    Verbatim wording from the response

    “The End of Life care plan has been piloted in 3 homes in different areas. In one home the pilot has been running for approximately 4 months and in the other 2 homes the pilot has been running for approximately 3 months. We have received regular positive feedback from the staff in the homes regarding the care plan. We have also received positive feedback from the CQC who had the view that the plan was clear and provided good guidance to staff.”

    Source location

    2014-0198-Response-by-Life-Style-Care
    Page 3 · response
    Published 30 April 2014

    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

    Complete Quality Assurance review and sign-off of the End of Life care plan.

    Verbatim wording from the response

    “The End of Life care plan is currently being considered by the Quality Assurance team and we anticipate this will be signed off by the end of September 2014. Once the care plan is signed off it will be implemented into the full portfolio of Life Style Care Plc homes with appropriate training for staff being provided.”

    Source location

    2014-0198-Response-by-Life-Style-Care
    Page 3 · response
    Published 30 April 2014

    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 the signed-off End of Life care plan across the full portfolio of homes and train staff to use it.

    Verbatim wording from the response

    “The End of Life care plan is currently being considered by the Quality Assurance team and we anticipate this will be signed off by the end of September 2014. Once the care plan is signed off it will be implemented into the full portfolio of Life Style Care Plc homes with appropriate training for staff being provided.”

    Source location

    2014-0198-Response-by-Life-Style-Care
    Page 3 · response
    Published 30 April 2014

    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 resuscitation protocol and End of Life care plan at least every three years and earlier when legislation or incidents require review.

    Verbatim wording from the response

    “Once implemented, both the protocol and care plan outlined above will be reviewed at least every 3 years as a minimum to identify whether any changes are required. The protocol and care plan will be reviewed before the end of the 3 year period if changes are required such as if new legislation is introduced or an incident occurs which triggers a review.”

    Source location

    2014-0198-Response-by-Life-Style-Care
    Page 3 · response
    Published 30 April 2014

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Herta Edith Maria WOODS · 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

    Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.

    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 create a care plan and provide assistance

    Wider context from the report

    “(4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her. This lady was very likely near the end of her life. However, from the evidence that I heard, it was clear that she would not have died when she did had she been given appropriate care and treatment. ”

    Source location

    Herta Edith Maria WOODS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South London

    AI-generated summary

    Simon William McAndrew · 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

    Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.

    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 formal written care plans with clear crisis-management guidance for distant residential homes

    Wider context from the report

    “Please will you also consider whether a formal, written care plan should be provided to the distant residential home with clear guidance as to what is to happen in defined circumstances of crisis. If the staff at Jordan Lodge had had the benefit of a care plan, they might have contacted the acute psychiatric team on 30th June 2011 to seek advice as how best to manage the immediate crisis. In the absence of a care plan, and with residential home staff who are not mental health professionals, the staff who were on duty on the day were left to deal with the crisis as best they could. Is that state of affairs capable of improvement? ”

    Source location

    Simon William McAndrew · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. West Sussex

    AI-generated summary

    Ryan Chapman · 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

    Ryan Chapman was admitted to a mental health ward and, while being accompanied to an activity, left the hospital and ran into the path of an articulated lorry. He died from his injuries on 22 May 2013. Concerns included staff misunderstanding and inconsistent application of the Trust’s leave policy, uncertainty about the role of peer support workers as escorts, delays in completing his risk assessment and care plan, limited information for his family, and inconsistent ward visitor security.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in completing health care plans

    Wider context from the report

    “4. Ryan’s Risk assessment and Health Care Plan was not completed within the required period. This plan was completed two days after it should have been. ”

    Source location

    Ryan Chapman · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Inner South London

    AI-generated summary

    Adrian Johnson · 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

    Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.

    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

    Inadequate caremap planning

    Wider context from the report

    “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”

    Source location

    Adrian Johnson · 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

    Reinforce CAREMAP reviews at each case review and record responsibility for actions and feedback at the next review.

    Verbatim wording from the response

    “Colleagues at Belmarsh have confirmed that ACCT case managers will be reminded during the ongoing ACCT refresher training and in the updated local policy of the requirement to review the CAREMAP at each case review and record the manager who is responsible for each action and who is required to feed back at the next case review.”

    Source location

    2013-0364-Response-by-NOMS
    Page 3 · response
    Published 20 December 2013

    Open published response

  7. Manchester North

    AI-generated summary

    Jack William PARTINGTON · 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

    Jack Partington was born by planned caesarean section on 25 November 2011 and developed breathing difficulties requiring neonatal ventilation. After developing a pneumothorax, he was treated with intubation and ventilation but deteriorated and died on 26 November 2011. Concerns included gaps in neonatal handover and care planning, treatment decisions made without multidisciplinary consultation, lack of routine use of exhaled carbon dioxide detectors, absence of national guidance on paralysing agents and neonatal ventilation, and inadequate monitoring of ventilatory pressure after intubation.

    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 individualised neonatal nursing care plans

    Wider context from the report

    “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions. ”

    Source location

    Jack William PARTINGTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.

    Verbatim wording from the response

    “I note that you have sent a Regulation 28 report to the local NHS Trust for its response. I believe that the issues concerning staffing, staff training, governance and clinical issues are local issues that should properly be addressed by the Trust.”

    Source location

    2013-0308-Response-by-Department-of-Health
    Page 2 · response
    Published 21 February 2014

    Open published response

  8. West Somerset

    AI-generated summary

    Kevin Paul SUTTON · 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

    Kevin Paul SUTTON, who had Huntington’s disease and continuing depression, was discharged to Halcon House and took his own life on 3 September 2012. During the inquest, evidence indicated that no care plan had been prepared, so Halcon House staff were not made aware of the suicidal risk; the stated concern was the Trust’s failure to provide care plans.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide care plans

    Wider context from the report

    “Failure by the Trust to provide care plans. ”

    Source location

    Kevin Paul SUTTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. West Sussex

    AI-generated summary

    Mr Walker · 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 Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

    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 revisit and revise risk care plans

    Wider context from the report

    “(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”

    Source location

    Mr Walker · 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

    Insufficient scope and depth of risk care planning

    Wider context from the report

    “(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”

    Source location

    Mr Walker · 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 clinical risk-care-planning documents to reduce repetition and support succinct recording of relevant issues.

    Verbatim wording from the response

    “The point I think you are making is that the identified risks should also have been included in subsequent documents, such as the Risk Care Plan. We completely agree. As I say, the Risk Care Plan for Mr Walker was poor. In recognition of the importance of documentation and to ensure continued learning and improvement, we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”

    Source location

    2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 21 August 2013

    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

    Complete regular audits of risk-care-planning documentation to ensure required standards are met.

    Verbatim wording from the response

    “The point I think you are making is that the identified risks should also have been included in subsequent documents, such as the Risk Care Plan. We completely agree. As I say, the Risk Care Plan for Mr Walker was poor. In recognition of the importance of documentation and to ensure continued learning and improvement, we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”

    Source location

    2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 21 August 2013

    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

    Clinicians understood the patient’s risks despite deficiencies in some risk-care documentation.

    Verbatim wording from the response

    “1. Risk care planning It is difficult to respond definitively to your conclusion that the consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient. We do acknowledge that some documentation was not of the standard we would expect. In particular, the Risk Care Plan and the Formulation section of the MDT Clinical Review was poor and so taking this in isolation could imply ████████ risk care planning. However, I think it is important to reinforce the evidence of Consultant Psychiatrist. She explained that the staff caring for Mr Walker did have a good understanding of his risks and that these risks were documented in the Acute Care Risk Assessment, Acute Care Screening and the daily MDT Evaluation and Progress Notes.”

    Source location

    2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
    Page 1 · response
    Published 21 August 2013

    Open published response

  10. West Yorkshire (East)

    AI-generated summary

    Annie Rose GIBSON · 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

    Annie Rose Gibson, an 84-year-old woman living alone, was found unresponsive at home after a fall the previous day and was pronounced dead on 13 October 2012. The post-mortem cause of death was recorded as hypothermia, immobility, and fractured pelvis with haemorrhage. The principal concern was that emergency medical assistance was not obtained despite the fall and injury, and that hospital treatment might have prevented the development of hypothermia and the death.

    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 training protocols and Care Plans to ensure emergency-service calls and ambulance attendance despite client wishes

    Wider context from the report

    “My recommendations are that you should address situations such as this in your training protocols and Care Plans to ensure that your carers would always, notwithstanding the wishes of your client, call the Emergency Services and ensure ambulance attendance. I also recommend that the wishes of the client would have to be overridden in such a situation, in particular when relatives cannot be contacted. ”

    Source location

    Annie Rose GIBSON · Prevention of Future Deaths report
    Page 2 · 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