Recurring concern

Unreliable timely provision of appropriate care packages

Get email alerts

Request correction

First reported 12 Mar 2014•Latest report 10 Feb 2026

Definition

What this concern includes

Includes deficiencies in the end-to-end assessment, arrangement, commissioning, implementation, availability, suitability or coordination of care packages when they result in delayed, absent or inappropriate support for the person or carer.

Not included

Excludes delays in unrelated statutory applications, safeguarding alerts, licensing processes or other administrative pathways.
Excludes generic workforce, funding or provider-capacity concerns unless the report directly ties them to failure to provide an appropriate care package.
Excludes failures concerning care-package oversight, communication or assessment when they are not presented as contributing to delayed, absent or inappropriate care-package provision.
Excludes hospital discharge or placement concerns that do not involve a required care package or equivalent community support arrangement.

Reports: 21
Individual concerns: 22
Date range: 2014–2026
Stated actions: 85

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 Care15

NHS England3

Betsi Cadwaladr University LHB2

Conwy County Borough Council2

Denbighshire County Council2

Flintshire County Council2

Gwynedd Council2

Isle of Anglesey County Council2

Kent County Council2

Medway Council2

NHS Kent and Medway Integrated Care Board2

Welsh Ambulance Services NHS Trust2

Wrexham County Borough Council2

Care Quality Commission1

Greater Manchester Health and Social Care Partnership1

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.

17 Apr2024
Wiltshire and Swindon
Concerns raised1
1. Lack of appropriate community care causing medically fit patients to remain on hospital wards
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Improve discharge processes and capacity modelling to support appropriate commissioned community care capacity.
  Stated by NHS EnglandStated in progress
2. Action
  Undertake programmes improving admissions avoidance and discharge flow to reduce patients remaining in acute medical beds without criteria to reside.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  Responsibility for responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Margaret Avril Burman · 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 Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.

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 appropriate community care causing medically fit patients to remain on hospital wards
Wider context from the report
“As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided. During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls. She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death. The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile. I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge. As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures. The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money. The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed. As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play. ”
Source location
Margaret Avril Burman · 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
Improve discharge processes and capacity modelling to support appropriate commissioned community care capacity.

Verbatim wording from the response
“Your Report also raises a concern around patients medically fit for discharge are remaining in hospital due to a lack of appropriate community care being available. This remains a challenge for the NHS and social care services across England. As a key part of NHS England’s Urgent & Emergency Care recovery, NHS England together with colleagues across the DHSC and the Department for Levelling up, Housing and Communities (DLUHC) are focussed on improving discharge processes and capacity modelling to ensure the right number of commissioned beds/non-bedded care.”

Source location
Response from NHS England
Page 2 · 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
Undertake programmes improving admissions avoidance and discharge flow to reduce patients remaining in acute medical beds without criteria to reside.

Verbatim wording from the response
“A range of programmes aimed at improving both admissions avoidance and discharge flow is being undertaken to support the reduction in the number of patients in acute medical beds with no criteria to reside. This work is a key priority for the NHS and is being driven through the published NHS Operational Planning Guidance and the Better Care Fund planning process and has associated improvement support available to regions and local systems.”

Source location
Response from NHS England
Page 2 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Responsibility for responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.

Verbatim wording from the response
“I am aware that that the National Medical Director is responding to your report on behalf of NHS England and as such I do not intend to duplicate the contents of his communication with you. However, I am assured that NHS England have reflected upon the concerns raised in your report in relation to Ms Burman’s care.”

Source location
Response from DHSC
Page 1 · response
Published 29 April 2024
Open published response
10 Dec2023
West Sussex, Brighton and Hove
Concerns raised1
1. Inadequate community provision for the care and treatment of autistic people
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Develop commissioning standards to set clear expectations for good social care commissioning.
  Stated by Department of Health and Social CareStated planned
2. Action
  Invest in pilot training for senior local authority commissioners to improve care-market planning and data use.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Invest up to £700 million in workforce training, recognition and career progression to improve social care quality and outcomes.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Provide additional adult social care funding to increase workforce capacity and retention, reduce waiting times and support provider fee rates.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Run the next phase of the national Made with Care recruitment campaign.
  Stated by Department of Health and Social CareStated completed
3. Action
  Make care workers eligible for the Health and Care Worker Visa and add them to the Shortage Occupation List.
  Stated by Department of Health and Social CareStated completed
4. Action
  Provide £15 million to establish ethical international recruitment support and bolster the adult social care workforce.
  Stated by Department of Health and Social CareStated completed
5. Action
  Invest an additional £121 million to improve community support for autistic people and people with learning disabilities.
  Stated by Department of Health and Social CareStated in progress
6. Action
  Monitor implementation of the Building the Right Support Action Plan through the cross-system Delivery Board.
  Stated by Department of Health and Social CareStated in progress
7. Action
  Update Autism Act statutory guidance to improve outcomes and clarify local authority responsibilities for autistic adults’ social care.
  Stated by Department of Health and Social CareStated in progress
8. Action
  Publish the updated draft Autism Act statutory guidance for public consultation.
  Stated by Department of Health and Social CareStated planned
Respondent positions 1
1. Position
  Local authorities are responsible for planning and shaping local care markets because they are best placed to understand local population needs.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jessica Zoe EASTLAND-SEARES · 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

Jessie was pronounced deceased in hospital on 17 May 2022 after being found with a ligature around their neck, having been detained under the Mental Health Act and hospitalised since 4 March 2022. The report raises concerns about inadequate community provision for autistic people, including difficulties finding suitable support and the breakdown of temporary care arrangements before Jessie’s inpatient admission.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate community provision for the care and treatment of autistic people
Wider context from the report
“Sadly this case exposes the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions into inpatient mental health facilities and also A&E attendances. Despite a report from the Health and Social Care committee from 2021 this case showed that there does not seem to have been any real improvement and more lives are likely to be lost. Reading from this report, it says “The conclusion of this report was that Autistic people (and people with learning disabilities) have the right to live independent, free and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so.” The report identified that “the community support and provision for autistic people (and those with learning difficulties) and financial investment in those services is significantly below the level required to meet the needs of those individuals and to provide adequate support for them in the community. ” The Inquest heard that two years on there still remains an acute shortage of provision. Evidence was heard that East Sussex Council had tried over 30 providers to help put in place support for Jessie but they could not find a placement for her so the only provision that they were able to offer was supported housing with temporary care agency staff. This provision broke down which exacerbated Jessie’s mental health. This then led to a Hosptial mental inpatient admission. ”
Source location
Jessica Zoe EASTLAND-SEARES · 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
Develop commissioning standards to set clear expectations for good social care commissioning.

Verbatim wording from the response
“That is why, in Next steps to put people at the heart of care, we committed to developing commissioning standards: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their skills in future-proofing their care markets and ensuring they have the data they need to shape their markets well.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 19 December 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
Invest in pilot training for senior local authority commissioners to improve care-market planning and data use.

Verbatim wording from the response
“That is why, in Next steps to put people at the heart of care, we committed to developing commissioning standards: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their skills in future-proofing their care markets and ensuring they have the data they need to shape their markets well.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 19 December 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
Invest up to £700 million in workforce training, recognition and career progression to improve social care quality and outcomes.

Verbatim wording from the response
“social care workforce remains at the heart of our reform plans. We are supporting care workers to develop their skills and their careers, alongside a range of new funded training schemes. In December 2021, we set out our strategy for the social care workforce in our ‘People at The Heart of Care’ white paper and in 2023 we published ‘Next Steps to put People at the Heart of Care’ which set out more detail on the government’s plans for reform. It outlined our plans to invest in better workforce training, recognition, and career progression. The ‘Next Steps to put People at the Heart of Care’ also set out how we are investing up to £700 million over this financial year and next, building on £100 million already invested in 2022/23, to improve the quality of social care provision and care outcomes.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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
Provide additional adult social care funding to increase workforce capacity and retention, reduce waiting times and support provider fee rates.

Verbatim wording from the response
“The government has now made available up to £8.6 billion in additional funding over this financial year and next year to support adult social care and discharge. This includes £500m announced in January which has specifically been made available to support local authorities with the cost of social care in 2024/25.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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
Run the next phase of the national Made with Care recruitment campaign.

Verbatim wording from the response
“This is in addition to the Government’s support to Local Authorities in addressing workforce pressures, including:”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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
Make care workers eligible for the Health and Care Worker Visa and add them to the Shortage Occupation List.

Verbatim wording from the response
“• Making care workers eligible for the Health and Care Worker Visa and adding them to the Shortage Occupation list (February 2022).”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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
Provide £15 million to establish ethical international recruitment support and bolster the adult social care workforce.

Verbatim wording from the response
“• Providing £15m for the 2023/24 financial year to help local areas establish support arrangements for ethical international recruitment and bolster workforce in adult social care.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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
Invest an additional £121 million to improve community support for autistic people and people with learning disabilities.

Verbatim wording from the response
“This financial year, we are investing an additional £121m to improve community support for autistic people and people with a learning disability, including funding for Children and Young People’s keyworkers. In addition, all Integrated Care Boards are expected to have an Executive Lead on learning disability and autism. This lead will support the board in planning to meet the needs of its local population of autistic people and people with a learning disability, and to have effective oversight of, and support improvements in, the quality of care for people in a mental health, learning disability and autism inpatient setting.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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
Monitor implementation of the Building the Right Support Action Plan through the cross-system Delivery Board.

Verbatim wording from the response
“We are determined to reduce the number of people with a learning disability and autistic people in mental health hospitals by supporting people to live well in their communities. The Building the Right Support Action Plan (published July 2022, alongside our response to the Health and Social Care Committee Report ‘The treatment of autistic people and people with learning disabilities’), brings together a wide range of actions we are taking across government and public services to help us drive progress on this. The cross-system Building the Right Support Delivery Board that I chair, monitors implementation of the commitments contained in the Action Plan.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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
Update Autism Act statutory guidance to improve outcomes and clarify local authority responsibilities for autistic adults’ social care.

Verbatim wording from the response
“We are currently prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people in line with the national Strategy. This will include setting out guidance on how local authorities can meet their responsibilities relating to social care provision for autistic adults. We expect to publish the updated draft Statutory Guidance for public consultation, this year.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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
Publish the updated draft Autism Act statutory guidance for public consultation.

Verbatim wording from the response
“We are currently prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people in line with the national Strategy. This will include setting out guidance on how local authorities can meet their responsibilities relating to social care provision for autistic adults. We expect to publish the updated draft Statutory Guidance for public consultation, this year.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 19 December 2023
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
Local authorities are responsible for planning and shaping local care markets because they are best placed to understand local population needs.

Verbatim wording from the response
“Under the Care Act (2014), local authorities have the duty to promote the efficient and effective operation of their care market, ensuring local care and support provision meets diverse local needs. They must have regard to current and future demand for care and support services and consider how providers will meet that demand. However, the Government recognises that shaping a care market is incredibly challenging. While local authorities are best placed to understand and plan for the care and support needs of their local population, there are elements of good market shaping practice that can be universally applied, such as involving those who draw upon care and their families in the commissioning process, supporting and investing in community services, and taking a prevention-based approach to shaping their market.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 19 December 2023
Open published response
23 Nov2023
Cornwall and Isles of Scilly
Concerns raised1
1. Lack of social care provision delaying discharge of medically fit patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide £1.6 billion over two years to support timely and effective hospital discharge.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

KENNETH HEARD · 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

Kenneth Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter demand.

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 social care provision delaying discharge of medically fit patients
Wider context from the report
“(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro. (8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows: 5,107 hours lost at Derriford Hospital, Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36 2,449 hours lost at Treliske Hospital, Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13 (9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below. Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes Time Lost in June 2023 Time Lost in July 2023 Time Lost in August 2023 Derriford Hospital 4714:17 3436:41 5107:36 Treliske Hospital 2833:15 2386:23 2449:47 (10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000. (11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST. The winter months are likely to see an increase in demand for ambulance services and for hospital beds. December 2022 was the most demanding month of last year and featured the longest delays in response and handover. December 2023 is likely to be the most demanding month of this year. (12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above. ”
Source location
KENNETH HEARD · Prevention of Future Deaths report
Page 5 · 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
Provide £1.6 billion over two years to support timely and effective hospital discharge.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 29 November 2023
Open published response
6 Jul2023
North Wales (East and Central)
Concerns raised1
1. Lack of adequate social care placements or community care for patients medically fit for hospital discharge
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.

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

Emlyn Victor 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

Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.

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 adequate social care placements or community care for patients medically fit for hospital discharge
Wider context from the report
“Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable. It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community). I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions. ”
Source location
Emlyn Victor Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jun2023
North Wales (East and Central)
Concerns raised1
1. Inadequate social care placements or community care for patients medically fit for discharge
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.

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

Leonard Charles Harmsworth · 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

Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate social care placements or community care for patients medically fit for discharge
Wider context from the report
“Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff. Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community). I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals. I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. ”
Source location
Leonard Charles Harmsworth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Sep2020
Manchester South
Concerns raised1
1. Delays in putting care packages in place for medically optimised patients
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 4
1. Action
  Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.
  Stated by Department of Health and Social CareStated completed
2. Action
  Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
3. Action
  Create additional community discharge capacity, including reablement support, domiciliary care and community beds.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
1. Action
  Review community-based capacity to ensure discharge pathways have the correct types of capacity.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
Respondent positions 1
1. Position
  NHS providers and local partners, including social services, are responsible for timely discharge planning and post-discharge care.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Joseph Michael Cheetham · 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

Joseph Michael Cheetham suffered an unwitnessed accidental fall, underwent surgery for a dislocated prosthetic hip, and later died in hospital on 22 January 2020 after pneumonia, dysphagia and respiratory deterioration. Concerns included prolonged waiting in the Emergency Department because of bed shortages and discharge home before a care package was in place, while he was frail and vulnerable and had lost weight in hospital.

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 putting care packages in place for medically optimised patients
Wider context from the report
“2. The inquest heard that he was medically optimised, and he had lost weight in hospital whilst awaiting a care package to be put in place. One was still not in place by 24th December and it was likely to be at least another 2-3 weeks before one was in place. To avoid further deconditioning and weight loss in an acute setting whilst awaiting a care package his family took on caring for him at home to facilitate a discharge. ”
Source location
Joseph Michael Cheetham · 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
Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.

Verbatim wording from the response
“This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3.6billion funding for winter, an extra £588million was confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.”

Source location
2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 23 November 2020
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
Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.

Verbatim wording from the response
“As part of the initial COVID 19 response, Greater Manchester localities worked to rapidly develop updated Discharge to Assess Pathway Guidance, which were formally approved in late April and have now been adopted across all localities within Greater Manchester. The purpose of the guidance is to improve the flow of all patients being discharged from acute care and to help ensure patients’ needs are assessed in the home or usual place of residence – not in the hospital. If it is not”

Source location
2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Page 2 · response
Published 23 November 2020
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
Create additional community discharge capacity, including reablement support, domiciliary care and community beds.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. The additional capacity includes: reablement support, domiciliary care and community beds. Further work is underway to review community-based capacity to support discharges to ensure the correct types of capacity. There has since been a significant reduction in delayed transfers of care across GM from approximately 5% to less than 1%.”

Source location
2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Page 3 · response
Published 23 November 2020
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 community-based capacity to ensure discharge pathways have the correct types of capacity.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. The additional capacity includes: reablement support, domiciliary care and community beds. Further work is underway to review community-based capacity to support discharges to ensure the correct types of capacity. There has since been a significant reduction in delayed transfers of care across GM from approximately 5% to less than 1%.”

Source location
2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Page 3 · response
Published 23 November 2020
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
NHS providers and local partners, including social services, are responsible for timely discharge planning and post-discharge care.

Verbatim wording from the response
“It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. NHS providers are expected to begin planning for a person’s discharge at the point of admission, which should include practical arrangements, care requirements and where the person is being discharged to. The hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.”

Source location
2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 23 November 2020
Open published response
27 Apr2020
Manchester South
Concerns raised1
1. Delays in arranging suitable community care packages for discharge
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 3
1. Action
  Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.
  Stated by Department of Health and Social CareStated completed
2. Action
  Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
  Stated by Manchester University NHS Foundation TrustStated completed
3. Action
  Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
  Stated by Manchester University NHS Foundation TrustStated completed
Respondent positions 3
1. Position
  NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.
  Stated by Manchester University NHS Foundation TrustRedirects responsibility
2. Position
  The Trust’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.
  Stated by Manchester University NHS Foundation TrustUnable to act
AI-generated summary

Evelyn Ross · 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

Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.

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 arranging suitable community care packages for discharge
Wider context from the report
“2. The inquest was told that whilst Mrs Ross was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community. ”
Source location
Evelyn Ross · 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
Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.

Verbatim wording from the response
“During the COVID-19 pandemic, we are supporting health and care organisations to ensure we have the capacity to meet the needs of people affected by the virus. The COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to reduce the friction surrounding funding decisions and assessments and focus on getting people out of hospital with the right support as soon as they are medically fit. We have made £1.3 billion funding available via the NHS to help patients who no longer need urgent treatment to get home from hospital safely and quickly. This funding will cover the follow-on care costs for adults in social care, and people in need of additional support, when they are out of hospital and back in their homes, community or care settings, during the pandemic.”

Source location
2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 5 June 2020
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
Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.

Verbatim wording from the response
“In respect of adult patients such as Mrs Ross, the Trust adheres to a comprehensive local ‘Discharge Policy for Adult Inpatients (excluding Children and Maternity)’, implemented May 2019, a copy of which is enclosed (Appendix 1). At the Trust’s WTWA site this policy is overseen by the Integrated Discharge team. The policy is applicable to all Trust staff who are involved in the assessment, planning and monitoring of patient discharges. It also applies to staff from other health/social care organisations involved in the discharge”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 3 · response
Published 5 June 2020
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 Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.

Verbatim wording from the response
“As stated above, a Patient Flow Coordinator role has been developed and successfully appointed to Ward 6 at Trafford General Hospital. In addition, the Hospital Discharge Service is available and responsible for supporting wards in the discharge process of patients, and their input is routinely sought for instance in respect of patients who require special considerations or who may have complex support needs on discharge. The discharge service will assist the ward staff to plan and identify the supporting needs of the patient for discharge.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 4 · response
Published 5 June 2020
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
NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.

Verbatim wording from the response
“It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. Discharge arrangements from hospital should start before a patient is ready for discharge and the hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.”

Source location
2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 5 June 2020
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
Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.

Verbatim wording from the response
“In line with usual practice in secondary care, patient discharges from hospital are in some cases dependent upon In-reach Psychiatric Liaison Services such as RAID, and/or actions by other bodies such as Local Authorities; for instance assessments in respect of any ongoing package of care required in the community, as well as other bodies in the Social Care sector. It is the Trust’s responsibility to undertake such liaison where applicable to ensure arrangements are in place so that the Trust can effect a safe patient discharge to the community. Given the Trust’s dependence on other parties in respect of this, delays can occur, and this is unfortunately an NHS-wide issue not unique to our Trust. Safe discharge requires teamwork across many people and organisations.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 3 · response
Published 5 June 2020
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 Trust’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.

Verbatim wording from the response
“centre placement was declined by the Local Authority; in order for the clinical team to progress her discharge, as I am sure you will appreciate, there was a limitation on further actions the Trust was able to take to address this issue, due to its dependence on actions by In-reach, Social Care and other bodies.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 5 · response
Published 5 June 2020
Open published response
20 Oct2016
Leicester City and South Leicestershire
Concerns raised1
1. Unavailability of community support for patients with challenging presentations
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 4
1. Action
  Develop an integrated clinical pathway and care model for people with personality disorders, including a proposed bespoke enhanced community service.
  Stated by Leicestershire Partnership NHS TrustStated in progress
2. Action
  Continue negotiating commissioner contracts for provision of the proposed personality-disorder services.
  Stated by Leicestershire Partnership NHS TrustStated in progress
3. Action
  Implement comprehensive community-based mental health pathways so people access care at the right time and place.
  Stated by Department of Health and Social CareStated planned
1. Action
  Provide £400 million of additional investment through 2020/21 to improve community mental health provision.
  Stated by Department of Health and Social CareStated completed
Respondent positions 2
1. Position
  Providing an enhanced community service for people with severe and complex personality disorder is outside the Trust’s current commissioning remit.
  Stated by Leicestershire Partnership NHS TrustOutside remit
1. Position
  Commissioners are responsible for developing and commissioning the proposed enhanced severe and complex personality disorder community service.
  Stated by Leicestershire Partnership NHS TrustRedirects responsibility
AI-generated summary

Victoria Georgia Halliday · 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

Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.

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
Unavailability of community support for patients with challenging presentations
Wider context from the report
“3) The “community support” referred to by the in-patient clinicians does not exist in reality for patients with this challenging presentation, leaving discharged patients and their families without adequate support. ”
Source location
Victoria Georgia Halliday · 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 an integrated clinical pathway and care model for people with personality disorders, including a proposed bespoke enhanced community service.

Verbatim wording from the response
“However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 20 October 2016
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
Continue negotiating commissioner contracts for provision of the proposed personality-disorder services.

Verbatim wording from the response
“Further to our response to concern 3, LPT is not commissioned to provide an “enhanced service” to provide support and treatment for people with a severe and complex personality disorder (SCPD) in the community. A group of our senior clinical and operational leaders, with support from Commissioners, are working together to develop an integrated clinical pathway and model for care for people with Personality Disorders. As part of this proposal a dedicated team to provide this enhanced service is proposed, the purpose of which is to provide an intensive community based treatment support for both patients in treatment, and in crisis. The aim is to link the pathway together with supporting services in primary care, social care, and Police. We continue to work with our commissioners to negotiate our 2017/2018 contracts for provision of services, of which this remains an ambition to provide.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 4 · response
Published 20 October 2016
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 comprehensive community-based mental health pathways so people access care at the right time and place.

Verbatim wording from the response
“We want to eliminate unnecessary out of area placements for adult acute mental health care by 2020/21 and reduce significantly delayed transfers of care so that people can move from hospital to care in the community, ensuring that beds are available for those most in need. We appreciate that this will not happen overnight but we are committed to delivering change. Also, through the Five Year Forward View, we will implement a comprehensive set of community-based mental health pathways of care so that people have access to care at the right time in the right place.”

Source location
2016-0370-Response-by-Department-of-Health
Page 2 · response
Published 20 October 2016
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 £400 million of additional investment through 2020/21 to improve community mental health provision.

Verbatim wording from the response
“The Government announced an additional £400m investment up to 2020/21 to improve the quality of community mental health provision as an effective and safe alternative to hospital admission. This builds on the successful National Mental Health Crisis Care Concordat which has seen every local area develop a crisis care action plan to ensure that no-one in crisis is turned away.”

Source location
2016-0370-Response-by-Department-of-Health
Page 2 · response
Published 20 October 2016
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
Providing an enhanced community service for people with severe and complex personality disorder is outside the Trust’s current commissioning remit.

Verbatim wording from the response
“However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 20 October 2016
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
Commissioners are responsible for developing and commissioning the proposed enhanced severe and complex personality disorder community service.

Verbatim wording from the response
“However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.”

Source location
Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 20 October 2016
Open published response
1 Feb2016
Norfolk
Concerns raised1
1. Lack of a system for following up implementation of agreed care packages
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Provide staff cover and daily duty-system backup so agreed actions and urgent requests are followed up during absences and outside planned arrangements.
  Stated by Norfolk County CouncilStated completed
2. Action
  Instruct the Care Arranging Service to source longer-term care, share assessment information with providers, identify start dates and record actions on CareFirst.
  Stated by Norfolk County CouncilStated completed
3. Action
  Maintain communication and an unmet-need log when required care and support cannot be sourced.
  Stated by Norfolk County CouncilStated completed
1. Action
  Review discharged people’s care packages at four weeks and at regular intervals to ensure continuing suitability.
  Stated by Norfolk County CouncilStated completed
Respondent positions 1
1. Position
  The dedicated Hospital Discharge Social Care team and Care Arranging Service ensure agreed care requests are followed up and actioned.
  Stated by Norfolk County CouncilExisting arrangements considered sufficient
AI-generated summary

LORRAINE SHEILA YOUNGS · 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

Lorraine Sheila Youngs was a detained patient at Hellesdon Hospital who was found unresponsive after wrapping a telephone cord around her neck and died two days later in hospital. The report raised concern that an agreed community care package had not been implemented or followed up, and that there appeared to be no system for monitoring implementation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system for following up implementation of agreed care packages
Wider context from the report
“The inquest heard evidence regarding Lorraine Young's care in the community. Evidence was given from Lorraine's social worker that a care package had been agreed in principle at a visit on 12 February 2015. At the time of her death, this had not been implemented. The evidence given was that this had not been followed up. Whilst it could not be said in the context of Lorraine's death whether the delay affected the outcome, I was concerned that a delay in following up implementation of an agreed care package could, in different circumstances, affect the outcome for a vulnerable Service User. The evidence before the inquest was that there appeared to be no system for following up implementation of an agreed care package. ”
Source location
LORRAINE SHEILA YOUNGS · 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
Provide staff cover and daily duty-system backup so agreed actions and urgent requests are followed up during absences and outside planned arrangements.

Verbatim wording from the response
“The Hospital Discharge Social Care staff cover for one another during any period of absence to ensure that agreed actions are followed up. There is also the back-up of the North locality mental health team duty system, whereby there is a member of staff available every day during office hours to respond to urgent and unplanned requests.”

Source location
Lorraine-Youngs-Response
Page 2 · response
Published 1 February 2016
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
Instruct the Care Arranging Service to source longer-term care, share assessment information with providers, identify start dates and record actions on CareFirst.

Verbatim wording from the response
“This service can be arranged at short notice and can support hospital discharge. If the assessment by the hospital discharge social worker indicates longer term needs, the worker instructs the NCC Care Arranging Service to source care services. The Care Arranging Service (CAS) shares the relevant assessment information with the potential care provider to ensure that they are able to meet the person’s assessed care and support needs and identifies the date the care package is needed to start. The actions of the Care Arranging Service are recorded on CareFirst, the NCC electronic client based information system.”

Source location
Lorraine-Youngs-Response
Page 2 · response
Published 1 February 2016
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
Maintain communication and an unmet-need log when required care and support cannot be sourced.

Verbatim wording from the response
“Having this dedicated team ensures that the care requests are followed up and actioned. CAS keep the social worker informed of their actions and the care they have arranged. If CAS are unable to source the care and support required they inform the social worker and keep an unmet need log.”

Source location
Lorraine-Youngs-Response
Page 2 · response
Published 1 February 2016
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 discharged people’s care packages at four weeks and at regular intervals to ensure continuing suitability.

Verbatim wording from the response
“Once the person is discharged from hospital, the locality social work team becomes responsible for ensuring that the care package continues to meet the needs of the person by carrying out an initial review at four weeks and then at regular intervals.”

Source location
Lorraine-Youngs-Response
Page 2 · response
Published 1 February 2016
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 dedicated Hospital Discharge Social Care team and Care Arranging Service ensure agreed care requests are followed up and actioned.

Verbatim wording from the response
“Three experienced mental health social worker/approved Mental Health Professionals based in this team link with the acute wards to ensure early signposting, timely and proportionate needs assessments, multi-disciplinary decision making and discharge planning. This facilitates much closer working arrangements which ensure that patients who are admitted to the ward can be assessed as soon as they are well enough, and arrangements made for their discharge. This means that delays and last minute arrangements are avoided.”

Source location
Lorraine-Youngs-Response
Page 2 · response
Published 1 February 2016
Open published response
7 Aug2015
Plymouth, Torbay and South Devon
Concerns raised1
1. Inappropriate care package
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Gordon Eric Atkinson · 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

Gordon Eric Atkinson lived alone in a poor-condition caravan and had numerous falls, including an unwitnessed fall that caused burns. He was later admitted to a care home, nursing home and hospital, where he died on 6 February 2015. The concerns included unsuitable accommodation, self-neglect, and an inappropriate care package.

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
Inappropriate care package
Wider context from the report
“(3) It appeared from the evidence at the Inquest that his care package was inappropriate ”
Source location
Gordon Eric Atkinson · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of appropriate community care causing medically fit patients to remain on hospital wards

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

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

Concerns raised1

Inadequate community provision for the care and treatment of autistic people

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.11

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

Concerns raised1

Lack of social care provision delaying discharge of medically fit patients

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

Lack of adequate social care placements or community care for patients medically fit for hospital discharge

Concerns raised1

Inadequate social care placements or community care for patients medically fit for discharge

Concerns raised1

Delays in putting care packages in place for medically optimised patients

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.4

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 2

Respondent positions 1

Actions described in response 11

Respondent positions 1

Actions described in response 1

Actions described in response 4

Respondent positions 1