Recurring concern

Failure to reliably develop and review risk-reduction plans

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First reported 21 Aug 2013•Latest report 2 Jun 2026

Definition

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.

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
48

Distinct published reports

Individual concerns
50

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
80

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6
Essex Partnership University NHS Foundation Trust4
NHS England4
East London NHS Foundation Trust3
Tees, Esk and Wear Valleys NHS Foundation Trust3
Birmingham and Solihull Mental Health NHS Foundation Trust2
Surrey and Borders Partnership NHS Foundation Trust2
Sussex Partnership NHS Foundation Trust2
ADAPT, Bexley Locality Community Mental Health Team1
Adept Care Homes1
All family members1
Avery Healthcare Group1
Barts Health NHS Trust1
Beechwood Lodge1
Bexley ADAPT Service1

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.

  1. Birmingham and Solihull

    AI-generated summary

    Winston Harris · 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

    Winston Harris, a resident with dementia, left hospital on 17 March 2016 after previously attempting to leave the ward. He was found at a bus stop the following day, severely hypothermic with an acute kidney injury, and died on 22 March 2016; the inquest concluded that he died from dilated cardiomyopathy contributed to by hypothermia and acute kidney injury. Concerns included inadequate documentation of his absconding risk and pending deprivation of liberty application, failure to consider an emergency deprivation of liberty safeguard, and delays in processing the application.

    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 absconding risk and previous absconding behaviour in the care plan

    Wider context from the report

    “(1) The care plan for Mr Harris did not deal with his risk of absconding. As a result when he was transferred to City Hospital with his care plan there were no details of his previous absconding behaviour. ”

    Source location

    Winston Harris · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Birmingham and Solihull

    AI-generated summary

    Doreen England · 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

    Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.

    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 prepare care plans for patients at high risk of pressure sore formation

    Wider context from the report

    “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk. ”

    Source location

    Doreen England · 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

    Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.

    Verbatim wording from the response

    “It is also a significant concern that at the time of the inquest the organisation involved does not appear to have responded in correcting these issues. We are in communication with Birmingham Cross City CCG which has undertaken a significant amount of work in relation to this case already and who commission the service and will also ensure CQC are aware of the case.”

    Source location

    2015-0291-Responses
    Page 7 · response
    Published 23 July 2015

    Open published response

  3. London (East)

    AI-generated summary

    Michael Joseph Lyons · 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

    Michael Joseph Lyons had Parkinson’s disease with significant difficulties in balance, speech and swallowing. On 23 September 2014, while being cared for at home, he choked on cheese on toast after it was not cut into small pieces and he was left eating unsupervised, causing his death. Concerns included the absence of an adequate care plan addressing the known choking risk, including food preparation and supervision, and the failure to establish and implement the speech and language therapist’s recommendations.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Care plans failing to specify swallowing-risk management measures

    Wider context from the report

    “(1) The Care Agency were aware of the swallowing difficulties experienced by Mr Lyons and they had been informed of a SALT assessment having taken place in June 2014. (2) There was no evidence that the Care Agency had made any attempt to determine the outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the risk of choking. (3) Some carers were aware of the need for food to be cut into small pieces. The carer who attended on the 23 September confirmed that she was not aware that food needed to be cut up. (4) The care plan did not provide a management plan to protect Mr Lyons from the risk of choking. The care plan did not specify that food should be cut up and did not confirm that Mr Lyons should be supervised. (5) The care plan was dated 10 September 2014. The information from the SALT was available at that time and the author of the care plan should have taken steps to ensure that the care plan reflected the recommendations from the assessment. ”

    Source location

    Michael Joseph Lyons · 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 agency disputes being informed of the SALT assessment, choking risk, or recommendations requiring food preparation and meal supervision.

    Verbatim wording from the response

    “We were aware that Mr Lyons had difficulty with swallowing as a consequence of his sister ████████ informing us during our risk assessment. Our paperwork states that ‘no other health/social care professionals are involved in Mr Lyons’ care at this time. There is no information documented that we have been informed that a SALT assessment had taken place.”

    Source location

    2015-0067-Response-by-John-Stanley-Care-Agency
    Page 3 · response
    Published 20 February 2015

    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 agency says it could not supervise eating within the 30-minute visit while completing the existing personal-care tasks without additional allocated time.

    Verbatim wording from the response

    “The increase for the morning call would have been required, as it is impossible to carry out all the personal care tasks already stipulated on the care plan and supervise Mr Lyons’ eating within the 30 minutes allocated by Social Services. We have no paperwork stipulating that Mr Lyons was at risk of choking and, therefore, needed to be supervised for all meals.”

    Source location

    2015-0067-Response-by-John-Stanley-Care-Agency
    Page 2 · response
    Published 20 February 2015

    Open published response

  4. Manchester South

    AI-generated summary

    Mark Hancock · 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

    Mark Hancock had a history of severe clinical depression and was receiving treatment at the Priory Hospital. On 12 February 2014, he was found at his parents’ house with serious self-inflicted wounds after concerns about his deteriorating presentation had been escalated but hospital admission did not occur because no bed was available. The report identified concerns about poor or absent records, the lack of a documented risk assessment, insufficient reassessment after concerns were escalated, and the absence of a procedure for admission when no bed was available.

    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 assess the appropriateness of risk management plans

    Wider context from the report

    “- Given there was no formal risk assessment there was no consideration as to whether the risk management plan was appropriate. ”

    Source location

    Mark Hancock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. North Wales (East and Central)

    AI-generated summary

    Sybil Roberts · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to reassess and update care plans and falls risks after hospital return

    Wider context from the report

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

    Source location

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

    Open source report

  6. Norfolk

    AI-generated summary

    KATHRYN LOUISE SAWYER · 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

    Kathryn Louise Sawyer, who had a significant history of mental health issues and was prescribed multiple medications including Methadone, was found collapsed and unresponsive at home on 14 August 2013 and died shortly after arriving at hospital. The medical cause of death was respiratory failure due to an overdose of Methadone in combination with therapeutic levels of other drugs. A principal concern was that, although her medication was reviewed in June 2013, there was no or no detailed record of the discussion and no plan for future medication, particularly any plan to decrease it.

    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 make a plan for future medication and dose reduction

    Wider context from the report

    “(1) Mrs Sawyer registered with the Roundwell Surgery in July 2012 at which time she was known to be addicted to Chloral Betaine (she was prescribed double the dosage recommended in the BNF) and was prescribed a number of different additional medications, including Methadone (prescribed by Trust Alcohol and Drug Service); (2) She attended the Surgery with a letter from her previous GP expressing Mrs Sawyers' concerns about her medication being decreased. It was felt sensible to allow her to feel comfortable with the Surgery before consideration was given to the medication and amounts she was being prescribed. This is accepted as reasonable. (3) During the course of the next 13 months Mrs Sawyer was seen by the Practice on a regular basis when her medication was varied and/or increased. She was admitted to Hospital in November 2012 as a result of an overdose. (4) Mrs Sawyer’s mental health condition stabilised in Spring 2013 when she attended the Surgery for physical problems only. (5) Her medication was not reviewed by the Surgery until June 2013. It was then reviewed by a Locum Doctor. There is no or no detailed record of the discussion relating to her medication and no plan made between patient and the surgery with regard to future medication and in particular any plan to decrease. ”

    Source location

    KATHRYN LOUISE SAWYER · 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

    Document the full clinical plan and management in records when starting patients on addictive medication.

    Verbatim wording from the response

    “2. For patients being put on addictive medication, the GP will ensure that the clinical plan / management is fully detailed in the patients’ medical records. Action – immediate”

    Source location

    2014-0177-Response-by-Roundwell-Medical-Centre
    Page 1 · response
    Published 16 April 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct six-monthly reviews for patients receiving long-term benzodiazepines or opiates and document the clinical plan and management discussed.

    Verbatim wording from the response

    “4. All patients on long term medication of Benzodiazepines and Opiates will have a six month medication review which will document the clinical plan/ management discussed with the patient. Action – immediate”

    Source location

    2014-0177-Response-by-Roundwell-Medical-Centre
    Page 1 · response
    Published 16 April 2014

    Open published response

  7. South Yorkshire (Western)

    AI-generated summary

    Mrs May Gibson · Prevention of Future Deaths report

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

    Report summary

    Mrs May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.

    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 develop risk reduction plans when mandated by risk assessments

    Wider context from the report

    “5) the failure to develop a risk reduction plan when mandated by the risk assessment, even as it was actually completed; ”

    Source location

    Mrs May Gibson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. West Sussex

    AI-generated summary

    Mr Walker · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to revisit and revise risk care plans

    Wider context from the report

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

    Source location

    Mr Walker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response
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Data last updated 7 September 2026