Recurring concern

Unreliable timely provision of appropriate care packages

First to latest report 12 Mar 2014 — 10 Feb 2026

Reports that mention this concern
21
Times this concern has been raised
22
Stated actions linked to this concern
85

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.

What is 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 and published responses 21 reports

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

  1. Wiltshire and Swindon

    AI-generated summary

    Wendy Bernadine BROWN · Prevention of Future Deaths report

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

    Report summary

    Wendy Bernadine BROWN had suffered from depression and had been the full-time carer of her severely disabled granddaughter. After a period of approximately 18 months without support or respite, Wendy died by hanging at her home during the late evening of 27 August into the morning of 28 August 2013. The concerns included delays and gaps in adult social care support, the adequacy of signposting and funding information, the timeliness of processing care applications, and the availability of appeal routes.

    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 processing applications and implementing care packages causing gaps in carer support

    Wider context from the report

    “a) During the course of the Inquest I heard how Swindon Borough Council outsourced their Adult Care to an organisation called SEQOL and that that organisation commenced effective operation in November 2011 with relevant social workers transferring under the Transfer Undertaking Regulations to the new organisation. I heard evidence from the Interim Company Secretary at SEQOL and in relation to the delay as regards the implementation of care packages and I was concerned to learn that some 18 months effectively elapsed where Wendy was effectively solely responsible for the care of ████ her severely disabled granddaughter, without respite care or care support. I am concerned as regards the adequacy of the measures taken by the commissioners to ensure that relevant Adult Care Public Services are effectively signposted so that the public are aware of available services and more importantly that the funding routes are also highlighted. The system of social adult care is a complicated maze and I have tried to keep this concern as simple as possible. I would be grateful if you could please review the matter having regard to this particular case with a view to establishing whether or not there are any lessons to be learned following the death of Wendy. I understand that no review has been undertaken to date and I am concerned that such delay could place another carer under similar strain and that that scenario could directly contribute to another person’s death if they were then to take their own life whilst packages were being arranged. ”

    Source location

    Wendy Bernadine BROWN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in processing applications and implementing care packages causing gaps in carer support

    Wider context from the report

    “b) I am also concerned and would be grateful if you could please review the timeliness within which applications both from the funding perspective and service nature are processed under your administration. It concerns me that whilst applications are being processed or even assessments themselves are being undertaken (as I understand it even as part of transition arrangements some organisations will not assess the individual until they are 18) that there is inevitably going to be a gap in support for carers whilst the application is being determined until the care package if approved is implemented. This concerns me in a case where you have an individual such as ███████ who quite clearly requires an extensive support and care package. I appreciate that instances such as ████ are in the extreme but I am concerned that Wendy and █████ situation is unlikely to be unique. ”

    Source location

    Wendy Bernadine BROWN · 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 commissioner-led pre-verification coaching to Learning Disability staff on presenting required information for timely funding decisions.

    Verbatim wording from the response

    “consideration by exceptions panel, but overtime the numbers have significantly decreased allowing the Exceptions panel to focus on the most complex of cases. Particular reference is made to the timeliness within which applications both from the funding perspective and service nature were processed. Prior to, and continuing after, the death of WB support was provided by SBC commissioners to the Learning Disability team, not exclusively to, but including the Transitions workers. The purpose of this support was to provide a focus on compliance with the Adult Services assessment requirements so that applications from the Learning Disability team could be dealt with efficiently without repeated queries and clarifications being necessary before public funds could be allocated.”

    Source location

    2014-0113-Response-by-Swindon-Borough-Council
    Page 3 · response
    Published 12 March 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

    Allow indicative budgets to be agreed pending additional information when services above the indicative budget are requested, enabling timely service provision.

    Verbatim wording from the response

    “An immediate action taken is that, were services over and above the indicative budget are requested, the indicative budget can be agreed pending any additional information required to ensure that some services are in place in a timely manner. As detailed above, services were agreed for ███ in September 2011 however her grandmother did not feel that the services available in Swindon could meet her granddaughter’s needs. Direct Payments were available to WB from November 2011, she had originally identified a group of personal assistants that she wanted to provide services to ████████. These Personal Assistants subsequently did not take up the offer from Wendy and during this time Direct Payments continued to be accumulated within her designated account whilst she sought alternative services.”

    Source location

    2014-0113-Response-by-Swindon-Borough-Council
    Page 4 · response
    Published 12 March 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

    Finalise and relaunch the revised Transitions Protocol to reflect the extended statutory transition age.

    Verbatim wording from the response

    “████████ case was managed through the Transitions process. Swindon Borough Council along with partner organisations had, and continues to have a Transitions Protocol in place. This involves the Adult Transitions team (a SEQOL Team) in the planning of young people in transitions from year 9 (14 years) onwards. Changes to legislation formally extending the transitions process for young people to age 25 has required the Transitions protocol to be revisited and re-launched. Work is in progression finalising the new protocol, whilst transitions is not uniquely the preserve of Learning Disabilities the majority of young people in transition have a learning disability with the management of the Transitions and transitions workers resting in SEQOLs Learning Disabilities Team. Transition therefore forms an important part of the Learning Disability Workstreams referred to above.”

    Source location

    2014-0113-Response-by-Swindon-Borough-Council
    Page 3 · response
    Published 12 March 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing contractual, audit, verification and improvement arrangements are considered sufficient to address delays and complexity in adult social care decision-making.

    Verbatim wording from the response

    “The Verification process is supported by a contracts team and dedicated brokers and placement officers who access the services that are identified in support plans. The contracts team are involved in the establishing of service arrangements and the monitoring of such contracts. There are many commissioning challenges for Adult Social Care reported nationally, and Swindon is not immune to such challenges. We believe that the structure allows for these challenges to be addressed and the commitment to the workstreams in the Learning disability area demonstrates our commitment to improve in this area. In addition we have recognised that further development of the local service offer is required and a Market Position Statement is in draft form and due to be published in the coming months.”

    Source location

    2014-0113-Response-by-Swindon-Borough-Council
    Page 3 · response
    Published 12 March 2014

    Open published response

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

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Data last updated 7 September 2026