Recurring concern

Unreliable care-planning processes

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First reported 1 Aug 2013•Latest report 2 Jun 2026

Definition

What this concern includes

Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.

Not included

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

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

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care14

Care Quality Commission9

Sussex Partnership NHS Foundation Trust9

Essex Partnership University NHS Foundation Trust7

NHS England7

Ministry of Justice5

Avon and Wiltshire Mental Health Partnership NHS Trust4

Barts Health NHS Trust4

Norfolk and Suffolk NHS Foundation Trust4

North East London NHS Foundation Trust4

Birmingham and Solihull Mental Health NHS Foundation Trust3

Central and North West London NHS Foundation Trust3

Hc-One Limited3

HM Prison and Probation Service3

Office of the Chief Coroner3

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

22 Dec2023
Surrey
Concerns raised1
1. Failure to produce a clear holistic care and crisis contingency plan
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Barbara Ann WOODMAN · 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

Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to produce a clear holistic care and crisis contingency plan
Wider context from the report
“c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted ████████’s very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern. ”
Source location
Barbara Ann WOODMAN · Prevention of Future Deaths report
Page 3 · concerns
Open source report
5 Oct2023
East London
Concerns raised1
1. Failure to complete falls care plans
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.

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

Iris Elaine Fordham · 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

Iris Elaine Fordham was admitted to hospital after an unwitnessed fall and concerns about her ability to keep herself safe due to Alzheimer’s disease. Failures to complete a falls risk assessment, falls care plan and enhanced care assessment led to the removal of 1:1 care, after which she sustained a fractured neck of femur in a further unwitnessed fall. She underwent surgical repair and died in a step-down care centre; concerns included poor clinical record-keeping, failures in falls-risk management and the absence of action through disciplinary or regulatory channels.

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 falls care plans
Wider context from the report
“3. The consequence of (2) was that no falls care plan was completed. ”
Source location
Iris Elaine Fordham · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Aug2023
Inner North London
Concerns raised2
1. Failure to update care plans and risk assessments in light of significant developments
2. Failure to review care plans at identifiable times
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.

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

Doris Irene URCH · 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

Doris Irene Urch, aged 90, fell at a care home on 6 February 2023 after support was not offered while she was ambulating. She sustained an acute left frontal intracranial haemorrhage and died on 28 February 2023. Concerns included inadequate fall-risk assessment and care planning, staff unfamiliarity with the care plan, failure to update it after an earlier fall, and inadequate preservation of historical 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 update care plans and risk assessments in light of significant developments
Wider context from the report
“(4) The care plan/risk assessment was not updated in light of a fall in November/December 2022. I was concerned that potentially significant developments might not be being taken into account in keeping the care plan under review. ”
Source location
Doris Irene URCH · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to review care plans at identifiable times
Wider context from the report
“(3) Staff seemed unfamiliar with the risk assessment/care plan, which I consider more of a systemic problem. It is unclear if/when care plans were reviewed by staff. ”
Source location
Doris Irene URCH · Prevention of Future Deaths report
Page 3 · concerns
Open source report
27 Jul2023
Essex
Concerns raised1
1. Failure to update community risk, care and security plans
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 1
1. Action
  Use MaST performance information in monthly management updates and supervision to identify and escalate overdue care plans, risk assessments and other care standards.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Johanne Blackwood · 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

Johanne Blackwood, known as Jo, died by suicide on 12 June 2021 after placing herself in the path of a train. The report identified concerns about unclear Care Coordinator handovers and responsibility for oversight after discharge, the absence of an allocated Care Coordinator for several weeks, failure to update her risk assessment, care plan and security plan, and inappropriate over-reliance on family members to keep her safe.

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 community risk, care and security plans
Wider context from the report
“4. The community Risk Assessment, Care Plan and Security Plan for Jo were not updated by a Care Coordinator between December 2020 and Jo’s death. ”
Source location
Johanne Blackwood · 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 MaST performance information in monthly management updates and supervision to identify and escalate overdue care plans, risk assessments and other care standards.

Verbatim wording from the response
“The team manager and team leads now receive monthly performance updates with regards to the various care standards compliance which include care plan and risk assessment which are then shared with the care coordinators for action. In addition, during supervision sessions with care coordinators, the supervisor will conduct a highlight review from MaST which provide clear options for care coordinators caseload for that particular supervisee.”

Source location
Response from Essex Partnership University NHS Fondation Trust
Page 3 · response
Published 28 July 2023
Open published response
14 Jul2023
Blackpool and the Fylde
Concerns raised1
1. Failure to maintain care plans with accurate nutritional requirements
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Mr Terence Burns · 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 Terence Burns, a resident of Highgrove Rest Home, was transferred to hospital on 28 October 2022 after his physical condition deteriorated. His blended-diet requirement was not communicated to ambulance services or the hospital, and he was later found unresponsive with food residue in his throat and died. Concerns included inaccurate care-plan information about his nutritional needs and failure to check the documents handed over during transfer.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain care plans with accurate nutritional requirements
Wider context from the report
“The written care plan that was in place at Highgrove Rest Home did not contain the information that Mr Burns required a blended diet. Having heard the oral evidence from the two carers who attended the inquest to give evidence, I accepted that Mr Burns was being fed a blended diet in advance of his attendance at hospital on 28 October 2022. I found that the monthly reviews of the care plan, that were carried out on 4 September and 8 October 2022, did not amend the care plan to include the need for a blended diet, and accordingly the written care plan did not accurately define the nutritional needs of Mr Burns. This missing information from the care plan was a concern for me as the documentary evidence relating to the nutritional requirements of Mr Burns was not correct. ”
Source location
Mr Terence Burns · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Apr2023
West Sussex, Brighton and Hove
Concerns raised2
1. Failure to update the family responsibilities section of the care and safety plan
2. Lack of an overnight care plan
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
  Develop a co-produced culture of care improvement programme strengthening family and carer involvement in patient care, suicide and self-harm risk management, and safety planning.
  Stated by NHS EnglandStated in progress
2. Action
  Conduct a Trust-wide qualitative audit of inpatient records to assess care-plan completion and meaningful family or carer engagement, then present and monitor findings through the Effectiveness Committee.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
3. Action
  Audit monthly whether families participate in ward reviews or receive follow-up contact about the care plan when unable to attend.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
1. Action
  Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.
  Stated by Sussex Partnership NHS Foundation TrustStated planned
2. Action
  Conduct monthly spot checks on Amberley ward to confirm overnight care plans are completed and uploaded for patients taking overnight leave.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
AI-generated summary

Caroline Victoria Forte · 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

Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to update the family responsibilities section of the care and safety plan
Wider context from the report
“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”
Source location
Caroline Victoria Forte · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of an overnight care plan
Wider context from the report
“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”
Source location
Caroline Victoria Forte · 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
Develop a co-produced culture of care improvement programme strengthening family and carer involvement in patient care, suicide and self-harm risk management, and safety planning.

Verbatim wording from the response
“Your concern at the lack of national guidance regarding help and support for families in similar situations to that experienced by Caroline’s family has also been raised with NHS England’s national Mental Health Team. In 2022, NHS England committed £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. The Mental Health team have advised that these improvements will include developing a culture of care improvement programme which, importantly, is being co-produced with patients, carers, and families with lived experience of mental health illness. The programme, which should come to completion in 2025, addresses the concerns you raise, identifying opportunities to strengthen family/carer voice in patient care, including the risk management of suicide and self-harm and safety planning.”

Source location
Response from NHS England
Page 1 · response
Published 5 May 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct a Trust-wide qualitative audit of inpatient records to assess care-plan completion and meaningful family or carer engagement, then present and monitor findings through the Effectiveness Committee.

Verbatim wording from the response
“As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-”

Source location
Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 5 May 2023
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 monthly whether families participate in ward reviews or receive follow-up contact about the care plan when unable to attend.

Verbatim wording from the response
“As indicated above, safety planning ought to be a collaborative process and I was truly saddened to hear that Caroline's family were left without strategies to support them to minimise Caroline's risks. Amberley ward have, of course, reflected, at length, on the sequence of events that led to Caroline's death. The Matron is overseeing monthly audits to check that family have either participated in ward”

Source location
Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 5 May 2023
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
Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.

Verbatim wording from the response
“During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.”

Source location
Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 5 May 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct monthly spot checks on Amberley ward to confirm overnight care plans are completed and uploaded for patients taking overnight leave.

Verbatim wording from the response
“As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-”

Source location
Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 5 May 2023
Open published response
13 Mar2023
Cornwall and Isles of Scilly
Concerns raised1
1. Delays in reviewing new residents’ Care Plans
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Update the Care Plan Policy to define the expected timeframe for reviewing new residents’ care plans after admission.
  Stated by Bowden Derra Park LimitedStated completed
AI-generated summary

Lugh Baker · Prevention of Future Deaths report

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

Report summary

Lugh Baker, a 24-year-old man with Angelman’s syndrome, epilepsy and difficulty swallowing, was found unresponsive at Rosewood House on 21 April 2021 after receiving medication in a chocolate milkshake. CPR was unsuccessful, and the cause of death was recorded as unascertained with an Open Conclusion. Concerns included gaps in monitoring, delays in reviewing new residents’ care plans, and insufficient arrangements for staff unfamiliar with a resident’s unusual presentation.

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 reviewing new residents’ Care Plans
Wider context from the report
“ii) Concern was raised that Care Plans for new residents were not reviewed sufficiently promptly. I asked to see a policy document setting out the expectation for healthcare professionals for how long it should take for a new resident’s Care Plan to be reviewed after admission. ”
Source location
Lugh Baker · 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
Update the Care Plan Policy to define the expected timeframe for reviewing new residents’ care plans after admission.

Verbatim wording from the response
“ii. Concern was raised that Care Plans for new residents were not reviewed sufficiently promptly. I asked to see a policy document setting out the expectation for healthcare professionals for how long it should take for a new resident's Care Plan to be reviewed after admission.”

Source location
Response from Bowden Derra Park ltd
Page 1 · response
Published 22 March 2023
Open published response
1 Dec2022
East London
Concerns raised1
1. Failure to incorporate ways of supporting patients to engage in their recovery into holistic care plans
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.

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

Mary Ebere Nwanyonyiri · 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

Mary Ebere Nwanyonyiri was admitted to Goodmayes Hospital after deterioration in her mental state and was found unresponsive on 19 April 2021; post-mortem investigations found that she died from Covid-19 infection. The report raised concerns about the absence of a written care plan and completed risk assessment, the lack of clear assessment of her capacity to refuse physical observations, and failures to recognise and respond urgently to the severity of her condition.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to incorporate ways of supporting patients to engage in their recovery into holistic care plans
Wider context from the report
“1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved. The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery. Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations. ”
Source location
Mary Ebere Nwanyonyiri · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Nov2022
Norfolk
Concerns raised1
1. Inaccuracies in care plans
This report raised 12 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
  Complete new-resident risk assessments within 24 hours and care plans within seven days, prioritising high-risk assessments within six hours and reviewing plans with families and when needs change.
  Stated by Runwood Homes PLCStated planned
2. Action
  Audit care plans regularly through senior-team reviews and the monthly Resident of the Day process to check accuracy, person-centred content and individualisation.
  Stated by Runwood Homes PLCStated in progress
AI-generated summary

Janice HOPPER · 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

Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

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
Inaccuracies in care plans
Wider context from the report
“3. The Care Plan contained several inaccuracies such as referring to Mrs Hopper as a "man" and saying she enjoyed taking her meals in the communal dining room, when she was confined to her room due to Covid 19 isolation. ”
Source location
Janice HOPPER · 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
Complete new-resident risk assessments within 24 hours and care plans within seven days, prioritising high-risk assessments within six hours and reviewing plans with families and when needs change.

Verbatim wording from the response
“New residents’ risk assessments will be completed in co-ordination within 24 hours and care plans within 7 days, although priority will be given within the first 6 hours to the highest risks to residents, e.g. choking, falls, pressure ulcers, evacuation during a fire, nutrition/hydration and any other specific ones such as pain, epilepsy, diabetes, moving and handling, absconding. This will allow staff to be able to assess the resident and gain further knowledge of their needs. All families will be invited to attend after 6 weeks to review these and then sign, these will be followed up monthly during the “Resident Of The Day” process and a full review will be undertaken at 6 months of the resident’s care plan and risk assessments, or if needs change they will be reviewed sooner.”

Source location
Response from Runwood Homes
Page 1 · response
Published 1 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit care plans regularly through senior-team reviews and the monthly Resident of the Day process to check accuracy, person-centred content and individualisation.

Verbatim wording from the response
“All care staff have now completed further training on the electronic care plan system, all care staff are fully trained in making sure care plans are developed for the individual and nothing is to be copied and pasted from others’ care plans. This is being regularly reviewed by the senior team through auditing, and reviewed again monthly during the resident of the day process.”

Source location
Response from Runwood Homes
Page 1 · response
Published 1 December 2022
Open published response
21 Oct2022
Inner South London
Concerns raised1
1. Failure to formulate Care and Treatment plans identifying core treatment needs
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 5
1. Action
  Increase qualified ward staffing to support formulation and negotiation of Care and Treatment Plans.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Introduce Advanced Clinical Practitioners to support care planning, risk management and identification of Care and Treatment Plan deficiencies.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Provide a dedicated Safeguarding Adult and Mental Capacity Lead Practitioner to support capacity-assessment training and Care and Treatment Plan completion.
  Stated by Central and North West London NHS Foundation TrustStated completed
1. Action
  Develop Quick Reference Guides supporting staff use of the electronic clinical record system and care-planning templates.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Establish a statutory duty for clinicians to create care and treatment plans for patients detained under the Mental Health Act.
  Stated by Department of Health and Social CareStated planned
Respondent positions 1
1. Position
  Existing care-plan formulation, monitoring and review processes, including multiple checks and balances, are considered robust and sufficient.
  Stated by Central and North West London NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Daniel John O’Sullivan · Prevention of Future Deaths report

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

Report summary

Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to formulate Care and Treatment plans identifying core treatment needs
Wider context from the report
“1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects: a) A failure to update a suicide self-harm risk assessment. b) A failure to formulate a Care and Treatment plan identifying core treatment needs. A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced. However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up. The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness. As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs. The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs. The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use. I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct. The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation. My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019. The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue. ”
Source location
Daniel John O’Sullivan · 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
Increase qualified ward staffing to support formulation and negotiation of Care and Treatment Plans.

Verbatim wording from the response
“Approximately 18 months ago St Charles Mental Health Unit saw an increase in qualified staff for each ward at the Unit. This has provided additional opportunity for staff to spend one to one time formulating and negotiating Care and Treatment plans, aimed at reducing any identified risks and promoting patient recovery.”

Source location
Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 25 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce Advanced Clinical Practitioners to support care planning, risk management and identification of Care and Treatment Plan deficiencies.

Verbatim wording from the response
“In addition, St Charles Mental Health Unit has recruited and trained Advanced Clinical Practitioners (ACPs). One of the roles of the ACP is to support the MDT and in particular the nursing team with specific interventions, care planning and risk management. This includes reviewing the Care and Treatment Plan and highlighting any deficiencies.”

Source location
Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 25 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide a dedicated Safeguarding Adult and Mental Capacity Lead Practitioner to support capacity-assessment training and Care and Treatment Plan completion.

Verbatim wording from the response
“The St Charles Mental Health Unit site also has a Safeguarding Adult & Mental Capacity Lead Practitioner who provides dedicated support to the unit with training for the assessment of capacity which informs care plans and a part of training will remind staff how this should feed into the Care and Treatment Plan and dynamic plans.”

Source location
Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 25 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop Quick Reference Guides supporting staff use of the electronic clinical record system and care-planning templates.

Verbatim wording from the response
“A number of changes have occurred within the Trust and more locally at St Charles Mental Health Unit since the incident in March 2019. The Trust began using SystmOne as its electronic clinical system in February 2019. As staff transitioned to the new electronic clinical record system they were learning about the operation and functionality of the system, and this also involved use of templates within the system and recording of information. It is fair to say that in March 2019 St Charles Mental Health Unit was at the start of the process of using SystmOne. Three and a half years later staff are now proficient in its use. This has been assisted by the use of Quick Reference Guides (QRG) developed to support staff.”

Source location
Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 25 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a statutory duty for clinicians to create care and treatment plans for patients detained under the Mental Health Act.

Verbatim wording from the response
“We are aware through the independent review of the Mental Health Act and subsequent White Paper consultation, and according to the Care Quality Commission, that care planning is sometimes not to the high standards required by the Code of Practice. This is why the draft Mental Health Bill, which was published on 27 June 2022, proposes a statutory duty on clinicians to create a care and treatment plan for all relevant patients detained under the Mental Health Act (including, but not limited to, section 2 and section 3 patients), to help ensure that greater respect and attention is given to care and treatment planning.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 25 October 2022
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 care-plan formulation, monitoring and review processes, including multiple checks and balances, are considered robust and sufficient.

Verbatim wording from the response
“We are satisfied that the process now regarding formulation, monitoring and review of the Care and Treatment Plan is a robust one with appropriate checks and balances to promote the support and interventions our vulnerable patients require. As with all aspects of care and treatment of our patients, our processes are constantly under review, and we will continue to drive towards excellence and to achieve the best possible outcomes for our patients.”

Source location
Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 25 October 2022
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to produce a clear holistic care and crisis contingency plan

Concerns raised1

Failure to complete falls care plans

Concerns raised2

Failure to update care plans and risk assessments in light of significant developments

Failure to review care plans at identifiable times

Concerns raised1

Failure to update community risk, care and security plans

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

Concerns raised1

Failure to maintain care plans with accurate nutritional requirements

Concerns raised2

Failure to update the family responsibilities section of the care and safety plan

Lack of an overnight 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

Concerns raised1

Delays in reviewing new residents’ Care Plans

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

Concerns raised1

Failure to incorporate ways of supporting patients to engage in their recovery into holistic care plans

Concerns raised1

Inaccuracies in care plans

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

Concerns raised1

Failure to formulate Care and Treatment plans identifying core treatment needs

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

Actions described in response 1

Actions described in response 5

Actions described in response 1

Actions described in response 2

Actions described in response 5

Respondent positions 1