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Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.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

23 Dec2025
North Yorkshire and York
Concerns raised1
1. Failure to transport patients' care plans with them to hospital
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.
Respondent positions 1
1. Position
  The crew appropriately recorded and verbally handed over swallowing difficulty; it was historical background rather than an identified active or immediate choking risk.
  Stated by Yorkshire Ambulance Service NHS TrustDisputes the concern
AI-generated summary

Colin Richard BROWN · 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

Colin Richard Brown attended York Hospital Emergency Department on 28 March 2025 and choked on food provided by the hospital, leading to a cardiac arrest and transfer to intensive care. He died on 31 March 2025. The concerns were that his care plan was not transported to hospital and that information about his choking risk might not be reliably communicated or checked during the handover period.

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 transport patients' care plans with them to hospital
Wider context from the report
“During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital. There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown. Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers. It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves, as was the case here. ”
Source location
Colin Richard BROWN · 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
The crew appropriately recorded and verbally handed over swallowing difficulty; it was historical background rather than an identified active or immediate choking risk.

Verbatim wording from the response
““The information I have been provided shows the attending crew reported that Mr Brown did not disclose any requirement for a modified or soft diet to them, nor was any care plan or supporting documentation reported as existing or being provided, despite care notes within the bundle provided by HM Coroner stating Mr Brown required a modified diet. Furthermore, a collateral history was not obtainable as no carers or family members were at the scene. The ePR completed by the crew does include a past medical history entry noting previous swallowing difficulty. This reflects historical medical background obtained through them accessing the Summary Care Record for Mr Brown. This is part of routine history-taking and information gathering rather than identification of an active or clinically apparent risk at the time of ambulance assessment.”

Source location
Response from Yorkshire Ambulance Service NHS Trust
Page 3 · response
Published 24 December 2025
Open published response
27 Nov2025
Berkshire
Concerns raised2
1. Failure to correctly utilise care planning tools for malnutrition risks
2. Failure to follow dietician advice and care plans
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.
Actions described in response 3
1. Action
  Implement a weight-loss flag that triggers a multidisciplinary swarm huddle and individualised care planning, with compliance monitoring.
  Stated by Frimley Health NHS Foundation TrustStated planned
2. Action
  Deliver refresher training on nutritional risk assessment and Epic care planning through the Harm Free Care programme, with compliance monitoring.
  Stated by Frimley Health NHS Foundation TrustStated in progress
3. Action
  Escalate patients with significant weight loss to the Ward Matron for a documented multidisciplinary swarm review including dietitians.
  Stated by Frimley Health NHS Foundation TrustStated planned
AI-generated summary

June Violet FINDLAY · 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

June Violet Findlay fell at home on 23 October 2024, fracturing her hip and wrist, and later died at Thames Hospice on 11 December 2024 after her health deteriorated. Concerns included substantial weight loss and sub-optimal management, monitoring, recording, and auditing of the risk of malnutrition during her hospital admission.

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 correctly utilise care planning tools for malnutrition risks
Wider context from the report
“During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans. I am concerned that ward staff are not: 1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments; 2. Correctly utilising care planning tools to address the risks of malnutrition; 3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses. No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern: 4. The auditing of records does not seem to have identified the repeated failures to record required information. ”
Source location
June Violet FINDLAY · 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 follow dietician advice and care plans
Wider context from the report
“During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans. I am concerned that ward staff are not: 1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments; 2. Correctly utilising care planning tools to address the risks of malnutrition; 3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses. No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern: 4. The auditing of records does not seem to have identified the repeated failures to record required information. ”
Source location
June Violet FINDLAY · 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 a weight-loss flag that triggers a multidisciplinary swarm huddle and individualised care planning, with compliance monitoring.

Verbatim wording from the response
“1. Implement a new system to flag patients with a concerning weight loss which triggers a swarm huddle. A swarm huddle is designed to start as soon as possible after a patient safety incident occurs so in this case significant weight loss is identified. The purpose of the swarm-based huddle is to identify learning from patient safety incidents; this is in line with the National Patient Safety Framework (PSIRF). Immediately after an incident this identified the multidisciplinary staff ‘swarm’ to the ward to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. It will be expected that the swarm is attended by the Ward Matron and a member of the Patient Safety Team.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 3 · response
Published 3 December 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver refresher training on nutritional risk assessment and Epic care planning through the Harm Free Care programme, with compliance monitoring.

Verbatim wording from the response
“Harm Free Care - A trust campaign was launched in July 2025 to support a focus on 4 key areas relating to improving patient safety. This included improving nutritional care for patients to ensure they are assessed for nutritional status and risk of malnutrition using the malnutrition universal screening tool (MUST). If they are malnourished or at risk, interventions will be implemented to ensure that their status is improved as much as possible.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 3 · response
Published 3 December 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Escalate patients with significant weight loss to the Ward Matron for a documented multidisciplinary swarm review including dietitians.

Verbatim wording from the response
“3. All patients who are identified with significant weight loss in line with the SOP will be escalated to the Ward Matron who will ensure that a full swarm review including dieticians is undertaken and appropriate actions are taken and clearly documented.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 3 · response
Published 3 December 2025
Open published response
21 Nov2025
Worcestershire
Concerns raised1
1. Lack of guidance defining the component elements and required depth of s.117 plans
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
  Use a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing national guidance sufficiently addresses the required content and planning of Section 117 aftercare plans.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Timothy Thomas Reading · 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

Timothy Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of 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
Lack of guidance defining the component elements and required depth of s.117 plans
Wider context from the report
“(2) I was informed by the Representative of BSMHFT that there is no national guidance from the NHS or other source that explains what a s.117 plan should address. If so, this represents a lacuna which gives rise to concern that mental health providers are unclear as to the component elements for a s.117 plan and the degree or depth of planning required for individual patients. ”
Source location
Timothy Thomas Reading · 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 a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.

Verbatim wording from the response
“The Trust has now looked at the inpatient care and CMHT care around the s.117 plan on the back of your concerns. Section 117 of the Mental Health Act 1983 places a joint duty on the NHS Integrated Care Board and local authority to provide aftercare services for individuals detained under certain sections of the Act following discharge.”

Source location
Response from Birmingham and Solihull MH NHS Foundation Trust
Page 1 · response
Published 23 February 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing national guidance sufficiently addresses the required content and planning of Section 117 aftercare plans.

Verbatim wording from the response
“NHS England Mental Health colleagues have advised that there is clear guidance set out in the Mental Health Act Code of Practice on Section 117 aftercare which includes planning based on the person’s individual needs. It includes examples such as ensuring the person’s wider social, cultural and spiritual needs are met and specifies that after care should aim to support people in regaining or enhancing their skills, or learning new skills, in order to cope with life outside of hospital. Before deciding to discharge or grant more than a very short-term leave of absence to a patient, or to place a patient onto a Community Treatment Order (CTO), the responsible clinician should ensure that the patient’s needs for after-care have been fully assessed, discussed with the patient (and their carers, where appropriate) and addressed in their care plan.”

Source location
Response from NHS England
Page 1 · response
Published 23 February 2026
Open published response
7 Nov2025
Manchester South
Concerns raised1
1. Lack of clarity in wound care plans and wound management instructions
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.
Actions described in response 5
1. Action
  Require referrals to tissue-viability nurses or community teams within 24 hours, including photographs and current treatment-plan information.
  Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completed
2. Action
  Issue a Trust-wide alert requiring two Transfer of Care documentation copies for care-home discharges.
  Stated by Stockport NHS Foundation TrustStated completed
3. Action
  Audit five care-provider discharges per ward to verify Transfer of Care documentation is retained in patient records.
  Stated by Stockport NHS Foundation TrustStated planned
1. Action
  Establish a task and finish group to improve discharge checklist quality and information.
  Stated by Stockport NHS Foundation TrustStated completed
2. Action
  Improve the quality and information included in the discharge checklist through the task and finish group.
  Stated by Stockport NHS Foundation TrustStated planned
AI-generated summary

Richard Charles Worswick · 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

Richard Charles Worswick, who had Parkinson’s disease, frailty and complex health needs, developed an infected spinal wound and died from sepsis at Stepping Hill Hospital on 19 May 2025. The principal concerns were unclear communication and documentation of the wound-care plan between the hospital and care home, together with unclear escalation arrangements and limited documentation of concerns and escalation attempts.

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 clarity in wound care plans and wound management instructions
Wider context from the report
“The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management. The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management. The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited. ”
Source location
Richard Charles Worswick · 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
Require referrals to tissue-viability nurses or community teams within 24 hours, including photographs and current treatment-plan information.

Verbatim wording from the response
“As a result of the Inquest findings and I can confirm that the following action has been taken to ensure proper adherence to the existing policies and procedures going forwards particularly with regard to the re-admission of residents to the Home from hospital and arrangements for monitoring of wound care and clinical observations:”

Source location
Response from Bamford Grange Care Home
Page 2 · response
Published 11 November 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Issue a Trust-wide alert requiring two Transfer of Care documentation copies for care-home discharges.

Verbatim wording from the response
“The Trust issued a Trust wide alert on 20 November 2025 in relation to Transfer of Care documentation and action required from all areas to ensure two copies of the documentation are printed; one to go with the patient to the care home and one to be placed in the patient’s records. Please find a copy of the Trust wide alert attached.”

Source location
Response from Stockport NHS Foundation Trust
Page 1 · response
Published 11 November 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit five care-provider discharges per ward to verify Transfer of Care documentation is retained in patient records.

Verbatim wording from the response
“In order to provide assurance that this practice is fully embedded across the Trust, a Trust wide audit will take place. Five patient discharges to other care providers will be audited per ward for discharges which have taken place in December. The audit will be carried out in the first two weeks of February 2026 and will check that there is a copy of the Transfer of Care documentation within the patient’s record.”

Source location
Response from Stockport NHS Foundation Trust
Page 1 · response
Published 11 November 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a task and finish group to improve discharge checklist quality and information.

Verbatim wording from the response
“During the course of this review, we have also identified that improvements are needed to the quality and information included in the discharge checklist. A task and finish group has been set up for this piece of work and will commence in January 2026.”

Source location
Response from Stockport NHS Foundation Trust
Page 2 · response
Published 11 November 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Improve the quality and information included in the discharge checklist through the task and finish group.

Verbatim wording from the response
“During the course of this review, we have also identified that improvements are needed to the quality and information included in the discharge checklist. A task and finish group has been set up for this piece of work and will commence in January 2026.”

Source location
Response from Stockport NHS Foundation Trust
Page 2 · response
Published 11 November 2025
Open published response
10 Oct2025
Essex
Concerns raised3
1. Failure to complete discharge care plans, risk assessment and procedures
2. Absence of a contact list in the integrated plan
3. Failure to review and update the s117 care plan
This report raised 10 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 5
1. Action
  Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Address the importance of recording information in care-plan sections through staff meetings, supervision and audit.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Discuss professional curiosity with teams, remind staff to review care-home paperwork and consult carers, and provide support sessions on asking appropriate questions.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
1. Action
  Review named-worker roles and responsibilities to strengthen accountability, and audit compliance.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Revise the Section 117 policy to improve care delivery and incorporate learning from the death.
  Stated by Essex County CouncilStated in progress
Respondent positions 1
1. Position
  Essex County Council is responsible for responding to concerns about placement appropriateness and updating the section 117 care plan.
  Stated by Essex Partnership University NHS Foundation TrustRedirects responsibility
AI-generated summary

Jillian Anne Steedman · 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

Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support 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 complete discharge care plans, risk assessment and procedures
Wider context from the report
“(4) The mental health Trust staff involved in the discharge and community care of Mrs Steedman were put on notice by a clinical lead on 16 March 2023 that the care plans, risk assessment and procedures relevant to the discharge had not been completed and were required in addition to the integrated plan that was attached to the email. These were never completed. ”
Source location
Jillian Anne Steedman · 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
Absence of a contact list in the integrated plan
Wider context from the report
“(13) There was no contact list provided as part of the integrated plan, and Mrs Steedman requested that her social worker be contacted when she was in crisis on 15 April, and she stated she wanted to die and would throw herself in front of a train. This led to the call being diverted to mental health crisis and not directly to the FIRST team in accordance with the plan. The appropriateness of the placement in the care home was not reviewed at that time or when the care home management expressed concerns about Mrs Steedman’s risks of diverting a taxi. ”
Source location
Jillian Anne Steedman · Prevention of Future Deaths report
Page 5 · 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 review and update the s117 care plan
Wider context from the report
“(5) Mrs Steedman was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs Steedman was not appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs Steedman due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022. ”
Source location
Jillian Anne Steedman · 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 structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.

Verbatim wording from the response
“We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named”

Source location
Response from Essex Partnership University
Page 1 · response
Published 14 October 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Address the importance of recording information in care-plan sections through staff meetings, supervision and audit.

Verbatim wording from the response
“Response: Since Mrs Steedman’s death, the importance of recording information in the care-plan section has been addressed. This has included discussing in meetings with staff, supervision and audit.”

Source location
Response from Essex Partnership University
Page 2 · response
Published 14 October 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Discuss professional curiosity with teams, remind staff to review care-home paperwork and consult carers, and provide support sessions on asking appropriate questions.

Verbatim wording from the response
“Response: We refer to our reply above under concern 4 in respect of care plans and risk assessments. In addition, as part of team reflections in this matter, the importance of professional curiosity was discussed and the team were reminded that they should review care home paperwork (where access is possible) and also speak with carers within the home. Support sessions were provided on asking right questions using professional curiosity and how this would have given more opportunity to understand Mrs Steedman’s needs and risks, whilst acknowledging that the Care Home may in turn approach the Trust with regards to any information or support required.”

Source location
Response from Essex Partnership University
Page 3 · response
Published 14 October 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review named-worker roles and responsibilities to strengthen accountability, and audit compliance.

Verbatim wording from the response
“We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named”

Source location
Response from Essex Partnership University
Page 1 · response
Published 14 October 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Revise the Section 117 policy to improve care delivery and incorporate learning from the death.

Verbatim wording from the response
“We have also been working with system partners to improve the governance arrangements that support mental health care in our administrative area and are presently working on a revision to the Section 117 policy so that it supports the effective delivery of care in this important area and incorporates the learning from Mrs Steedman’s sad death. This work is ongoing, but we anticipate it will be completed within the next six months.”

Source location
Response from Essex County Council
Page 2 · response
Published 14 October 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Essex County Council is responsible for responding to concerns about placement appropriateness and updating the section 117 care plan.

Verbatim wording from the response
“Concern 5) Mrs Steedman was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs Steedman was not appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs Steedman due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022”

Source location
Response from Essex Partnership University
Page 2 · response
Published 14 October 2025
Open published response
11 Jun2025
Nottinghamshire
Concerns raised1
1. Failure to update care plans regularly and when circumstances require
This report raised 11 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
  Conduct weekly and monthly management audits of pressure-care records, actions, professional input, care plans and risk assessments.
  Stated by Red Oaks Care HomeStated completed
2. Action
  Provide a Clinical Lead role supporting care planning, evaluations, audits and resident care.
  Stated by Red Oaks Care HomeStated completed
Respondent positions 1
1. Position
  The strengthened systems and procedures for monitoring residents’ care arrangements are considered appropriate in all the circumstances.
  Stated by Red Oaks Care HomeExisting arrangements considered sufficient
AI-generated summary

Maureen POWELL · 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

Maureen Powell died from severe frailty after a prolonged period of ill health, hospitalisation and transfer to a nursing home. A serious pressure ulcer developed and worsened in the nursing home and contributed to her death. Concerns included inadequate recording and implementation of repositioning, failure to record skin inspections, delayed equipment and specialist referral, poor record-keeping, inaccurate reporting, and insufficient communication with her family.

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 regularly and when circumstances require
Wider context from the report
“3. Care plans were not updated regularly in line with good practice and were not always updated when the circumstances required; ”
Source location
Maureen POWELL · 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 weekly and monthly management audits of pressure-care records, actions, professional input, care plans and risk assessments.

Verbatim wording from the response
“• Weekly and monthly audits are conducted by management in relation to care records relating to residents’ pressure care and skin integrity, for the purpose of ensuring that all actions have been completed in a timely manner, any external professional input required has been sought accordingly, and that care plans and risk assessments have been reviewed and updated as appropriate.”

Source location
Response from Red Oaks Care Home
Page 2 · response
Published 19 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide a Clinical Lead role supporting care planning, evaluations, audits and resident care.

Verbatim wording from the response
“A Clinical Lead role has also separately been introduced to provide additional support with care planning, evaluations, audits and the provision of care to residents, amongst other matters.”

Source location
Response from Red Oaks Care Home
Page 3 · response
Published 19 June 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The strengthened systems and procedures for monitoring residents’ care arrangements are considered appropriate in all the circumstances.

Verbatim wording from the response
“Accordingly, significant steps have been taken by the Home to strengthen the systems and procedures in place to monitor the correct implementation of care arrangements for residents, which are considered to be appropriate in all the circumstances.”

Source location
Response from Red Oaks Care Home
Page 4 · response
Published 19 June 2025
Open published response
23 May2025
East London
Concerns raised1
1. Lack of a clear and documented care plan
This report raised 5 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 4
1. Action
  Use DIALOG assessments to co-produce and evaluate individualized care plans with service users.
  Stated by North East London NHS Foundation TrustStated in progress
2. Action
  Deliver care-planning workshops to strengthen staff skills in co-producing individualized, recovery-focused care plans.
  Stated by North East London NHS Foundation TrustStated in progress
3. Action
  Use the MaST electronic system in Havering to monitor caseloads, documentation, engagement, risk and care-planning reviews.
  Stated by North East London NHS Foundation TrustStated completed
1. Action
  Implement the NICE-based risk-formulation approach through co-produced training, updated recording systems and team support.
  Stated by North East London NHS Foundation TrustStated in progress
AI-generated summary

George Kenneth Fraser · 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 Kenneth Fraser, aged 37, was found deceased at his home after mental health services had been unable to contact him and his family had last contacted him several weeks earlier. The cause and date of death were uncertain. Concerns included the absence of a clear care plan and robust risk assessment, and inadequate action and communication following failed contact and concerns raised by a friend and family.

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 a clear and documented care plan
Wider context from the report
“(1) There was no clear and documented care plan in place whilst Mr Fraser was under the care of the Mental Health and Wellness Team. There was a lack of structure to the care provided to Mr Fraser by the Mental Health and Wellness Team. ”
Source location
George Kenneth Fraser · 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 DIALOG assessments to co-produce and evaluate individualized care plans with service users.

Verbatim wording from the response
“Since 2024, we have been undertaking significant improvement work in relation to care planning. This has been driven by identified quality improvements, including those raised by patients and carers. In doing so, we have worked in close collaboration with patients and carers.”

Source location
Response from North East London Foundation Trust
Page 2 · response
Published 29 May 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver care-planning workshops to strengthen staff skills in co-producing individualized, recovery-focused care plans.

Verbatim wording from the response
“We are monitoring the use of this approach, and the number of plans being developed in this way is increasing as implementation progresses. Additionally, care planning workshops have been held throughout 2025 and are scheduled to continue. These workshops aim to support staff to use their skills to co-create individualised care plans with service users and their support networks. The workshops emphasise the importance of involving service users in the care planning process, focusing on their preferences and goals.”

Source location
Response from North East London Foundation Trust
Page 2 · response
Published 29 May 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use the MaST electronic system in Havering to monitor caseloads, documentation, engagement, risk and care-planning reviews.

Verbatim wording from the response
“Mental Health and Wellness Teams in Havering have also started using an electronic system, the Management and Supervision Tool (MaST). This enables clinicians and managers to manage caseloads and to monitor the quality of documentation, levels of engagement, and how documentation reflects risk and the complexity of a patient’s needs. This also enables monitoring of DIALOG and care planning, allowing staff to clearly identify, where review of the patient is required.”

Source location
Response from North East London Foundation Trust
Page 3 · response
Published 29 May 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the NICE-based risk-formulation approach through co-produced training, updated recording systems and team support.

Verbatim wording from the response
“Since the publication of NICE Guidance NG225 on self-harm was published, focusing on assessment, management, and preventing recurrence, we have been working to change Trust practice in relation to the assessment and management of risk. In November 2023, NELFT's senior clinical leadership established a working group to plan for the full implementation of this”

Source location
Response from North East London Foundation Trust
Page 3 · response
Published 29 May 2025
Open published response
17 Mar2025
Essex
Concerns raised1
1. Failure to appropriately update and document 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 5
1. Action
  Discuss care plans at weekly multidisciplinary team meetings and after incidents or changes.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Circulate a Trust communication reminding staff to review care plans regularly.
  Stated by Essex Partnership University NHS Foundation TrustStated planned
3. Action
  Audit care-plan quality through ward, Practice Nurse Educator and person-centred audits, and share or escalate findings through governance and supervision.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
1. Action
  Pilot individualised care-plan templates informed by patient focus groups and evaluate them through patient workshops.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Provide each ward with an aligned Practice Nurse Educator to support staff skills and care-plan quality.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

DARREN NEIL TURNER · Prevention of Future Deaths report

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

Report summary

Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge 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
Failure to appropriately update and document care plans
Wider context from the report
“(a) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Darren’s Care Plan consistent with Trust policy. The last up-date to his Care Plan was 12 days prior to discharge. ”
Source location
DARREN NEIL TURNER · 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
Discuss care plans at weekly multidisciplinary team meetings and after incidents or changes.

Verbatim wording from the response
“We can provide assurance that there is an expectation that care plans are reviewed as a minimum weekly or following any incidents or change. To further support this changes are being made to ensure care plans are discussed at weekly MDTs.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 17 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Circulate a Trust communication reminding staff to review care plans regularly.

Verbatim wording from the response
“To support staff in meeting this expectation a further Trust communication will be circulated reminding staff of the importance of regular review of the care plan.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 17 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit care-plan quality through ward, Practice Nurse Educator and person-centred audits, and share or escalate findings through governance and supervision.

Verbatim wording from the response
“The Ward manager undertakes weekly oversight of all care plans for inpatients through auditing (via the Trust Tendable system) and the quality of care planning is discussed at supervision. The outcome of such audits is shared via the Care Unit Local Quality and Safety Group and is visible via the Trust Tendable dashboard and through to the Care Unit Accountability Meeting and Trust Quality Committee.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 17 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Pilot individualised care-plan templates informed by patient focus groups and evaluate them through patient workshops.

Verbatim wording from the response
“A Quality Improvement Project has been undertaken on Gosfield Ward with support from the Trust QI Hub. The aim has been to review care plans to ensure they are individualised, of value to our patients and in a supportive template for continual review. The project has included focus groups with patients to understand what must be included in their care plans. Patient feedback has been recorded, and this has informed the content of the care plan templates being piloted on Gosfield Ward.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 17 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide each ward with an aligned Practice Nurse Educator to support staff skills and care-plan quality.

Verbatim wording from the response
“Wards now have a Practice Nurse Educator (PNE) aligned to the ward, to help guide and support ward staff. This includes ongoing skills development including in relation to quality of care plans.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 17 March 2025
Open published response
20 Dec2024
Worcestershire
Concerns raised1
1. Ambiguity in care plans about required staffing and gender for personal care
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 2
1. Action
  Audit all Chandler Court care plans to remove ambiguous instructions about residents’ moving, handling and personal-care needs.
  Stated by Care UKStated in progress
2. Action
  Update the care-plan audit checklist to identify and correct inaccurate language, using the incident as a specific example.
  Stated by Care UKStated completed
AI-generated summary

Edith Theresa PYE · 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

Edith Theresa PYE sustained a fracture after rolling from her bed at Chandler Court Care Home on 29 March 2024 while receiving personal care from one carer instead of the required two. She underwent an above-knee amputation, developed a chest infection and pulmonary emboli, and died at the care home on 28 April 2024. Concerns included ambiguous care-plan and handover information, inadequate staff awareness and compliance, lack of auditing, and weaknesses in the internal investigation.

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
Ambiguity in care plans about required staffing and gender for personal care
Wider context from the report
“1) At the inquest, the care home manager gave evidence that the care home recognized that Mrs. Pye was a high risk of falling or rolling from her bed, and also had a history of making unsubstantiated accusations against staff. The care home therefore required: (a) that Mrs. Pye’s personal care should always be provided by no less than two carers; and (b) that personal care should be provided, where possible, by two female carers, and if not possible, one female carer should always be present. These requirements should have been reflected in Mrs. Pye’s care plan, but the care plan was ambiguous – for example, it stated: “Edith may require the support of 2 carers with personal hygiene needs” and “Edith prefers to receive care from female carers – if this is not possible with the allocated staff for the shift, assistance should be sought from another suite”; ”
Source location
Edith Theresa PYE · 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
Audit all Chandler Court care plans to remove ambiguous instructions about residents’ moving, handling and personal-care needs.

Verbatim wording from the response
“Our response: All care plans at Chandler Court care home are being audited to ensure that there are no ambiguous instructions in relation to residents’ care needs. This review includes moving and handling, and personal care needs. Currently 20 care plans have been audited and we expect to complete the remainder by close of business tomorrow; 14 February 2025.”

Source location
2024-0706 - Response from Care UK Ltd
Page 2 · response
Published 27 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update the care-plan audit checklist to identify and correct inaccurate language, using the incident as a specific example.

Verbatim wording from the response
“Additionally, it is Care UK policy that care plans are audited on a monthly basis within the home. The Home Manager is responsible for reviewing and signing-off the audit. As a consequence of this Inquest we have updated the audit checklist to emphasise that the language used must be accurate. The checklist now provides this incident as a specific example, such that in the future if a care plan states that a resident may be assisted by two carers instead of must be assisted by two carers it can more easily be identified and corrected.”

Source location
2024-0706 - Response from Care UK Ltd
Page 2 · response
Published 27 December 2024
Open published response
10 Dec2024
Manchester West
Concerns raised1
1. Conflicting and undefined terminology in care plans and guidance
This report raised 4 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
  Revise support plans to define supervision and monitoring terms used alongside SALT guidance.
  Stated by Bolton CaresStated in progress
Respondent positions 1
1. Position
  SALT professionals within Bolton Council are responsible for amending guideline terminology; support plans will reflect the amended terms.
  Stated by Bolton CaresRedirects responsibility
AI-generated summary

Craig Brendon SPIBY · 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

Craig Brendon SPIBY, who had a condition that made him susceptible to choking, died on 13 July 2024 after choking on a sandwich while eating lunch unsupervised at an assisted living facility. The principal concerns were inconsistent understanding and use of monitoring and supervision requirements, inadequate clarity in care-plan terminology, insufficient professional curiosity when he was believed to be asleep, limited confidence in choking-related first aid, and a lack of training addressing confirmation bias.

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
Conflicting and undefined terminology in care plans and guidance
Wider context from the report
“The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018. The Care and Support plan made clear that at mealtimes in particular, the deceased ought to be ‘monitored’. The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’. Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times. Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time. Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial. It follows that the following matters of specific concern arise: 1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user. 2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used. 3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe. 4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case. 5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events. ”
Source location
Craig Brendon SPIBY · 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 support plans to define supervision and monitoring terms used alongside SALT guidance.

Verbatim wording from the response
“Once these amended guidelines are in place, we will ensure that the terms of use are reflected in our support plans.”

Source location
Response from Bolton Cares
Page 4 · response
Published 27 December 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
SALT professionals within Bolton Council are responsible for amending guideline terminology; support plans will reflect the amended terms.

Verbatim wording from the response
“SALT (Speech and Language Therapy) guidelines and Eating and Drinking Guidance are provided by the Speech and Language Team from Bolton Community Learning Disability Team, Bolton Council. They do use the terms ‘supervise/monitor’ and these terms are then reflected in our own Provider Support Plans. Following receipt of the Coroner’s report we have worked with Bolton Council and the relevant health colleagues and adult social care teams to address these issues.”

Source location
Response from Bolton Cares
Page 3 · response
Published 27 December 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to transport patients' care plans with them to hospital

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 correctly utilise care planning tools for malnutrition risks

Failure to follow dietician advice and 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 guidance defining the component elements and required depth of s.117 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

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

Concerns raised1

Lack of clarity in wound care plans and wound management instructions

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.5

Concerns raised3

Failure to complete discharge care plans, risk assessment and procedures

Absence of a contact list in the integrated plan

Failure to review and update the s117 care plan

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.5

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

Concerns raised1

Failure to update care plans regularly and when circumstances require

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

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

Respondent positions 1

Actions described in response 3

Actions described in response 1

Respondent positions 1

Actions described in response 5

Actions described in response 5

Respondent positions 1

Actions described in response 2

Respondent positions 1