Recurring concern

Failure to reliably develop and review risk-reduction plans

First to latest report 21 Aug 2013 — 2 Jun 2026

Reports that mention this concern
48
Times this concern has been raised
50
Stated actions linked to this concern
80

What this concern includes

Includes failures of the risk-reduction or safety-planning process where a required plan is missing, not implemented, not assessed for appropriateness, or changed or ended without the risk review needed to maintain effective protection.

What is not included
  • Excludes generic risk-assessment failures where no risk-reduction or safety plan is involved.
  • Excludes failures to implement unrelated organisational action plans, audit recommendations or post-incident actions.
  • Excludes failures of a separately named hazard-specific or end-to-end safety system where risk planning is only an incidental component.
  • Excludes clinical or operational outcomes where no deficiency in developing, reviewing or maintaining a risk-reduction plan is identified.

Reports and published responses 48 reports

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

  1. Inner North London

    AI-generated summary

    Ian Gilmore HEGARTY · 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

    Ian Hegarty was admitted to hospital after a fall at home and later sustained an unwitnessed fall in hospital when the allocated staff member left the bay, causing a right femur fracture. His condition deteriorated and he died on 17 June 2024; the principal concern was that the care plan intended to reduce falls risk was not followed, with insufficient reassurance at the time of the inquest that the risk was being addressed.

    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 follow falls-risk care plans

    Wider context from the report

    “1) That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed. I heard evidence that an internal investigation into the matter has been commenced but is not yet concluded. As such, there was insufficient reassurance, at the time of the inquest, that the risk is being addressed. ”

    Source location

    Ian Gilmore HEGARTY · Prevention of Future Deaths report
    Page 2 · concerns

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    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 documentation audits, assurance meetings, metrics reviews and ward action planning across all six divisional wards.

    Verbatim wording from the response

    “3. | Weekly documentation audits & action plans”

    Source location

    Response from Barts Health NHS Trust
    Page 3 · response
    Published 1 November 2024

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    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 ward-based falls and enhanced-care risk-assessment training with senior-nurse oversight and refresher documentation sessions for staff.

    Verbatim wording from the response

    “4. | Training, Falls and Enhanced Care risk assessments”

    Source location

    Response from Barts Health NHS Trust
    Page 3 · response
    Published 1 November 2024

    Open published response

  2. Surrey

    AI-generated summary

    Sylvia Prichard · 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

    Sylvia Prichard, a resident of Moorlands Lodge Care Home, had an unwitnessed fall on 28 March 2024 after a delayed response to her call bell and later died in hospital from a traumatic acute subdural haemorrhage. The concerns included the absence of a falls minimisation plan, outdated and conflicting care-plan information, persistent delays in responding to call bells, and inadequate oversight and auditing of these issues.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide falls minimisation plans for residents at risk of falls

    Wider context from the report

    “- Mrs Prichard did not have a falls minimisation plan in place and the Manager of the care home was not aware that Avery Healthcare had a falls minimisation plan document which needed to be completed for residents at risk of falls. The Coroner is therefore concerned that other residents who are at risk of falls do not have falls minimisation plans in place. ”

    Source location

    Sylvia Prichard · Prevention of Future Deaths report
    Page 2 · concerns

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    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 falls risk assessments and multifactorial assessments and minimisation plans for residents identified as at risk.

    Verbatim wording from the response

    “• All residents have a falls risk assessment completed on admission. For those residents identified as having an increased risk of falls, a further multifactorial falls risk assessment is indicated and completed on the electronic care planning system.”

    Source location

    Response from Avery Healthcare Group
    Page 2 · response
    Published 31 October 2024

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    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

    Train the General Manager in the organisation’s falls-minimisation protocols and policies.

    Verbatim wording from the response

    “• The new General Manager has been trained in Avery Healthcare’s falls minimisation protocols and policies to ensure proper implementation, consistency and to continue to drive improvements.”

    Source location

    Response from Avery Healthcare Group
    Page 3 · response
    Published 31 October 2024

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    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

    Cascade further falls-risk training to strengthen staff knowledge and risk-management documentation.

    Verbatim wording from the response

    “• Further Falls risk training has been cascaded to specifically coach staff and develop their knowledge, understanding and reasoning in respect of their completion of entries in the care plans with a higher emphasis of the risk management to be embedded within all the care documentation.”

    Source location

    Response from Avery Healthcare Group
    Page 3 · response
    Published 31 October 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

    Disseminate updated falls-prevention policies and multifactorial falls-risk screening tools to managers for team implementation.

    Verbatim wording from the response

    “• The Falls Prevention Policy and Multi-Factorial Falls Risk Screening Tool was sent to all Home Managers and General Managers to read and familiarise themselves with the changes and to update their staff and teams.”

    Source location

    Response from Avery Healthcare Group
    Page 5 · response
    Published 31 October 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

    Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.

    Verbatim wording from the response

    “• Weekly Clinical Risk meetings are held within the Home, chaired by the General Manager and/or Deputy manager to analyse falls, accident and incidents, infections, admission, weight loss and medication reviews. Actions are agreed with timescales and ownership.”

    Source location

    Response from Avery Healthcare Group
    Page 5 · response
    Published 31 October 2024

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    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 an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.

    Verbatim wording from the response

    “• A new internal audit framework has been introduced, focusing on critical areas such as call bell response times and falls minimisation plans. All audit results will be shared transparently with staff to foster accountability.”

    Source location

    Response from Avery Healthcare Group
    Page 6 · response
    Published 31 October 2024

    Open published response

  3. Surrey

    AI-generated summary

    Locket Ure Williams · 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

    Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of My Safety Plans to clearly convey suicide risk

    Wider context from the report

    “Concern 3 I also heard that a child at risk of suicide may now be provided with a document, called “My Safety Plan”, one purpose of which is to help the child to communicate with others (including for example family members, teachers, and social workers) about their condition and risk. I was told that, if a child does not want to refer in the document to the risk of suicide, other terms such as “distress” may be used. To the extent that part of the purpose of the My Safety Plan is to enable the child to communicate their risk of suicide and thereby receive help to stay safe, I am concerned that by substituting the word “distress” for “suicide”, some plans may not refer to suicide and may not therefore ensure that the nature of the risk is clearly conveyed to those from whom the child may seek support, and to the responsible adults in their life. ”

    Source location

    Locket Ure Williams · Prevention of Future Deaths report
    Page 4 · concerns

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    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

    Formal risk documentation and information-sharing procedures are considered sufficient; My Safety Plan is not intended to record or share clinical suicide risk.

    Verbatim wording from the response

    “My Safety Plan is not a tool for assessing or recording risk of suicide. The document is not written in clinical terms, and it is not intended to be a means of sharing information about risk between organisations. Instead, formal documentation of clinical risk (including clear and correct clinical terminology around suicide) is recorded in the Risk Formulation and Care Plan documents which, along with My Safety Plan, form an interlinked suite of documents which are held within a person’s Electronic Patient Record.”

    Source location

    Response from Surrey and Borders Partnership NHS
    Page 2 · response
    Published 14 October 2024

    Open published response

  4. Gloucestershire

    AI-generated summary

    Lamarah Grace Scarlett · 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

    Lamarah Grace Scarlett, a 12-year-old girl with alternating hemiplegia of childhood, became distressed and experienced breathing difficulties while being transported home from school on 24 September 2021. Her head became hyperextended, obstructing her airway; she arrived home unresponsive and was pronounced deceased despite resuscitation efforts. Concerns included the regulation, training, safety-plan compliance, handovers, first-aid qualifications, assessment, and oversight of operators providing home-to-school transport for children with special educational needs.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of transport crew to read and understand patient safety plans

    Wider context from the report

    “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children? The following specific issues were identified: • The patient safety plans are not always read and understood by transport crew, • Home visits between passenger and transport crew often do not occur when contractually required, • The local authority are often not notified of personnel changes in the transport crew, • The need for proper handovers at drop off and pick up is not understood • There is no requirement for transport crew to be qualified first aiders, • The passenger assessment test requires further improvement, • There is no comprehensive schedule for inspection of transport operators, • There is no mandatory training or forums for operators to attend where information can be cascaded to them. • Operators have to approach multiple organisations which leads to confusion and inconsistency. ”

    Source location

    Lamarah Grace Scarlett · 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

    Publish statutory guidance strengthening local-authority arrangements for children’s home-to-school travel, including medical-needs risk assessment, suitable support and staff training.

    Verbatim wording from the response

    “The Department for Education publishes statutory guidance to assist local authorities in meeting their home-to-school transport duty. The latest version of the guidance was published in 2023 and includes much more comprehensive guidance about meeting a child’s needs than the version that was available at the time of Lamarah’s death. It is available here: www.gov.uk/government/publications/home-to-school-travel-and-transport-guidance. I believe it goes a long way to addressing the concerns you have raised in this case. In particular, it recommends that drivers and passenger assistants are trained in basic life support skills. It expects local authorities to conduct risk assessments, to consider how a child’s medical needs might affect them during their journey, and to put in place proportionate arrangements to manage those needs.”

    Source location

    Response from Department for Education
    Page 2 · response
    Published 9 August 2024

    Open published response

  5. East London

    AI-generated summary

    Zara Natasha Aleena · 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

    Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.

    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 conduct timely risk assessments with complementary risk management plans

    Wider context from the report

    “(3) The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence. ”

    Source location

    Zara Natasha Aleena · Prevention of Future Deaths report
    Page 3 · concerns

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    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 revised risk-assessment training to new practitioners and introduce new training for experienced staff.

    Verbatim wording from the response

    “3.3. As set out in our response to His Majesty’s Inspectorate of Probation Serious Further Offence Review, the RoSH Guidance is based on the right evidence, including learning from Serious Further Offence Reviews and Domestic Homicide Reviews, but there are ongoing organisational challenges in its implementation. We are taking steps to address the barriers to its effectiveness, but we know there is more to do, and we will publish a new HMPPS Public Protection Strategy by the end of March 2025. We have already made changes to the suite of risk training which all new learners on the Probation qualification route and new Probation Service Officers complete.”

    Source location

    Response from HMPPS and MoJ
    Page 4 · response
    Published 2 August 2024

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    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 further risk-assessment training events for practitioners responsible for managing people in the community.

    Verbatim wording from the response

    “3.4. The structured process of risk assessment as set out in the RoSH Guidance, if followed, supports staff to think about an individual’s behaviour holistically, not just the index offence; and make reflective, logical, and informed decisions about risk. The section on risk management provides a structure to produce risk management plans that address the identified risks and set actions to protect people at risk.”

    Source location

    Response from HMPPS and MoJ
    Page 4 · response
    Published 2 August 2024

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    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, pilot and launch the Continuing Professional Development risk-learning product for experienced practitioners.

    Verbatim wording from the response

    “4.4. Experienced Probation Practitioners are required to revisit and complete their training in relation to Child Safeguarding and Domestic Abuse on a three-year cycle. Knowledge and understanding of risk assessment and management are further developed through experience of the work and its supervision. However, historically there has not been a requirement to attend further formal training on risk assessment and management. Having recognised that risk practice is not consistently at a sufficient standard, in December 2023 a new Continuing Professional Development risk learning product was commissioned to address this gap. This is intended to enable experienced practitioners to explore in-depth concepts related to risk assessment and to ensure their practice knowledge is up to date.”

    Source location

    Response from HMPPS and MoJ
    Page 5 · response
    Published 2 August 2024

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    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 and roll out the ARNS digital assessment and sentence-planning service with supporting staff learning.

    Verbatim wording from the response

    “7.4. More broadly, we are investing in the Assessing Risks, Needs and Strengths (ARNS) project, the replacement for OASys to be used in prisons and by the Probation Service. The project aims to deliver a transformational change in how we assess offenders, using the latest international evidence, including that on criminal desistance. In addition to a new enabling digital service for assessment and sentence planning, there is a comprehensive new learning and development offer to support staff to adapt and enhance their practice. The roll-out of ARNS is scheduled to begin in the third quarter of 2025 and be in place fully by the third quarter of 2026.”

    Source location

    Response from HMPPS and MoJ
    Page 7 · response
    Published 2 August 2024

    Open published response

  6. Inner North London

    AI-generated summary

    Anna Vivien Elliott · 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

    Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety 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 conduct an adequate risk assessment before ending a safety plan

    Wider context from the report

    “Concern 5 A safety plan had been agreed with Anna and put in place in the afternoon of 24 November 2021. This worked well and was a good example of staff thinking about Anna’s safety and the best strategy in the context of least restrictive practice. However, during the night shift, that safety plan was ended without a formal (or any adequate) risk assessment taking place. In accordance with the Trust’s policy, safe and supportive observation levels cannot be decreased without the input of a doctor. I remain unclear whether the same applies to other measures contained in safety plans and the PFD witness was unable to confirm the position. ”

    Source location

    Anna Vivien Elliott · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver monthly Tower Hamlets training on Dialog+ care planning, safety plans and risk formulations using group scenarios.

    Verbatim wording from the response

    “25. In Tower Hamlets the Trust has introduced Dialog+ Plus and Safety Planning training facilitated by Trust Matrons. We have a monthly schedule where inpatient staff in Tower Hamlets must attend Training covering Dialog+ care planning, safety plans and risk formulations. Staff have an opportunity to practice using scenarios in groups.”

    Source location

    Response from ELFT
    Page 9 · response
    Published 31 July 2024

    Open published response

  7. Norfolk

    AI-generated summary

    Edith Jane ALDEN · 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 Jane Alden, a resident assessed at very high risk of falls, left a communal area unnoticed and unsupervised on 13 September 2021, fell in the garden and suffered severe head injuries. She died on 25 September 2021. Concerns included unclear and inconsistent care plans and risk assessments, insufficient supervision and staffing, and the use of unlocked communal-area access for residents at very high risk of falls.

    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 consistent and clear fall-risk mitigation requirements in care plans and risk assessments

    Wider context from the report

    “1. Care Plans and Risk Assessments were not consistent and clear as to what steps were required to mitigate the risks of Mrs Alden falling. ”

    Source location

    Edith Jane ALDEN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise care plans and risk assessments to provide person-focused, consistent falls-risk management guidance.

    Verbatim wording from the response

    “Care plans and risk assessments were fully reviewed and revised. Working with an external consultancy for guidance and advice we changed the structure and wording of our care plans to better reflect a person focused approach with a higher emphasise of risk management embedded within these documents.”

    Source location

    2024-0196 Response from The Limes Care Home
    Page 4 · response
    Published 29 April 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

    Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.

    Verbatim wording from the response

    “Policies and procedure reviews Policies and procedures are continuously reviewed as part of our development as a company. Special emphasis has been given to any of our policies linked to falls, including environmental factors, individual risks, actions to be taken to improve staff guidance around understanding and interventions required to mitigate risks where possible.”

    Source location

    2024-0196 Response from The Limes Care Home
    Page 3 · response
    Published 29 April 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

    Implement monthly care-plan and risk-assessment audits covering at least 10% of the home.

    Verbatim wording from the response

    “Auditing care plans and risk assessments continue to be reviewed on a monthly basis as a minimum or when there is a significant change. Care plan audits have been completed with regional management support, and is now set as 10% of the home each month, being completed by the management team. This includes all aspects of the care plan including risk assessments, Mental Capacity assessments, front page, planned care, photo etc.”

    Source location

    2024-0196 Response from The Limes Care Home
    Page 5 · response
    Published 29 April 2024

    Open published response

  8. Bedfordshire and Luton

    AI-generated summary

    Joy EBANKS · 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

    Joy Ebanks lived alone and was found unresponsive at home on 24 May 2023 after taking prescribed oxycodone and pregabalin for pain; she was pronounced deceased at the scene. The medical cause of death was oxycodone toxicity enhanced by pregabalin intake. The report raised concerns about very prolonged prescribing of two dependency-forming drugs, without evidence of a plan to reduce the dosages, and about the limited evidence for their long-term use in chronic pain.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans

    Wider context from the report

    “[1] There was evidence of very prolonged prescribing of two dependency forming drugs with no evidence to suggest that a discussion had been had or plan had been formulated to reduce the dosages. ”

    Source location

    Joy EBANKS · 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

    Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.

    Verbatim wording from the response

    “Our Clinical Lead Pharmacist identified, and risk scored all patients on opioid medications and also those on gabapentinoid medications to determine and recall individuals for a face-to-face structured medication review within a 28-day time period. These patients were then sent letters to inform them that their medication would be undergoing an upcoming review with a specialist prescribing pharmacist.”

    Source location

    Response from Kirby Road Surgery
    Page 2 · response
    Published 8 January 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

    Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.

    Verbatim wording from the response

    “The Partners and Management Team sourced and recruited a specialist prescribing pharmacist (who has extensive experience of working in a pain clinic) to undertake the face-to-face structured medication reviews. Three of our inhouse clinical pharmacists are also undergoing training with our specialist prescribing pharmacist to enhance their skills and knowledge in this area to perform these reviews in the future.”

    Source location

    Response from Kirby Road Surgery
    Page 2 · response
    Published 8 January 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

    Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.

    Verbatim wording from the response

    “The Partners and Management Team sourced and recruited a specialist prescribing pharmacist (who has extensive experience of working in a pain clinic) to undertake the face-to-face structured medication reviews. Three of our inhouse clinical pharmacists are also undergoing training with our specialist prescribing pharmacist to enhance their skills and knowledge in this area to perform these reviews in the future.”

    Source location

    Response from Kirby Road Surgery
    Page 2 · response
    Published 8 January 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, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.

    Verbatim wording from the response

    “Our Opioid Prescribing Policy and our Gabapentinoid Prescribing Policy underwent updating and review by the Quality Assurance Manager to ensure all information was up to date. This was further reviewed by BLMK Medicines Management Matthew Davies to ensure compliance. Once recommended actions were implemented into policy, this was then signed off and ratified by”

    Source location

    Response from Kirby Road Surgery
    Page 2 · response
    Published 8 January 2024

    Open published response

  9. Essex

    AI-generated summary

    Nadia Wyatt · 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

    Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.

    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 include risk management and contingency planning in care plans

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”

    Source location

    Nadia Wyatt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. County Durham and Darlington

    AI-generated summary

    Margaret AUSTIN · 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

    Margaret Austin died at Stanley Park Care Home on 17 September 2023, following an unwitnessed fall from her bed on 1 July 2023 that caused a pubic rami fracture and contributed to her overall decline. Concerns included incomplete and discrepant documentation about managing her high falls risk, lack of evidence that the risk management plan was reviewed as her risks changed or after falls, and outstanding falls-risk training for most care-home staff at the date of the inquest.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to review risk management plans when risks change or after falls

    Wider context from the report

    “2. There was no evidence that the risk management plan was reviewed as the deceased's risks changed nor in the aftermath of documented falls. ”

    Source location

    Margaret AUSTIN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review risk management plans and clarify documentation, review, updating and clinical-rationale expectations for staff.

    Verbatim wording from the response

    “Stanley Park has taken a number of steps to improve documentation around assessment and management of falls, including documentation to reflect the rationale sitting behind clinical decision making. The steps taken are as follows:”

    Source location

    Response from Care UK
    Page 1 · response
    Published 14 February 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

    Remind staff of reassessment triggers, including after hospital discharge and return to the home.

    Verbatim wording from the response

    “As part of the review and discussions outlined in respect of point (1) above, during these same processes the Home Manager has ensured that staff are appropriately recognising when falls/risks assessments and management plans need to be reviewed and updated and that the reviews are being carried out in a timely manner. The specific actions in relation to this point are as follows:”

    Source location

    Response from Care UK
    Page 2 · response
    Published 14 February 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

    Review accident and incident reports to identify required responses and further falls-mitigation measures.

    Verbatim wording from the response

    “b. The management team are reviewing all accident and incident reports to ensure that appropriate actions in response have been identified, including any further mitigation steps such as sensory equipment, roll mats and requests to the GP for a secondary care falls referral.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 14 February 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

    Discuss accidents and incidents in weekly clinical reviews and assign actions to update assessments and management plans.

    Verbatim wording from the response

    “c. Accidents and incidents are being discussed during the weekly clinical review meetings, with specific actions being assigned to staff members around ensuring that the individual's assessment and management plan is updated.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 14 February 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

    Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.

    Verbatim wording from the response

    “d. Assessments and plans are being reviewed by the Deputy Manager to ensure triangulation of care and to confirm that actions set in the clinical review meetings have been fully completed.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 14 February 2024

    Open published response

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

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Data last updated 7 September 2026