Recurring concern

Unreliable inter-agency information sharing for coordinated care

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First reported 29 May 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures of the inter-agency care information-sharing system, including inadequate arrangements, communication channels, shared records or contact mechanisms when these prevent timely access to relevant care, needs or risk information between agencies.

Not included

Excludes information-sharing failures unrelated to coordination between agencies supporting a person.
Excludes failures confined to a single organisation's records, assessment, documentation or communication process unless the report directly links them to inter-agency information sharing.
Excludes generic staffing, confidentiality, policy or technology deficiencies that are not specifically tied to the unsafe inter-agency information-sharing condition.
Excludes hazards involving public access to harmful information or physical communication and rescue equipment.

Reports: 212
Individual concerns: 235
Date range: 2013–2026
Stated actions: 492

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 Care57

NHS England39

Ministry of Justice14

Home Office11

Greater Manchester Health and Social Care Partnership9

HM Prison and Probation Service8

NHS Greater Manchester Integrated Care Board8

Care Quality Commission7

Greater Manchester Mental Health NHS Foundation Trust7

Birmingham and Solihull Mental Health NHS Foundation Trust6

Metropolitan Police Service6

College of Policing5

Greater Manchester Police5

Midlands Partnership University NHS Foundation Trust5

Pennine Care NHS Foundation Trust5

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 Jun2015
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group
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

Andrew John Nickolls · 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

Andrew John Nickolls was discharged from Torbay Hospital on 12 September 2013 and was later found by police officers in his flat after concerns were raised. The report identified concerns about information sharing and continuity of primary care for a vulnerable adult who may have been neglecting himself; the medical cause of death was unascertained and the inquest conclusion was open.

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 ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group
Wider context from the report
“The principal learning point is to be that there is an advantage in a patient being looked after by a primary carer (i.e. a GP) within the Clinical Commissioning Group. If this is not the case, then it is imperative that there is clear information sharing, particularly where there is a vulnerable adult and there is a possibility they are neglecting themselves. ”
Source location
Andrew John Nickolls · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Jun2015
Cumbria
Concerns raised1
1. Failure to communicate significant risk information to ambulance and psychiatric staff
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

Alice Anne McMeekin · 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

Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental 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
Failure to communicate significant risk information to ambulance and psychiatric staff
Wider context from the report
“1.The Police The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called. The officers had not spoken to the original caller, who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”. “Common sense” told the officers that the person was one and the same and they did a welfare check on his mother. At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentiality they did not pass those remarks onto the Ambulance Team. This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement. It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with. ”
Source location
Alice Anne McMeekin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 May2015
Inner North London
Concerns raised1
1. Failure to make potentially important CANDI service information accessible to other services within the Trust
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
  Maintain a protocol for checking new referrals against IAPTUS and recording relevant current or recent ICope contacts on RiO.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Train designated acute-assessment staff across liaison, crisis-resolution and bed-management teams to check IAPTUS records and access clinical notes.
  Stated by North London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Entering all ICope patient data in both systems is impractical and would provide little benefit because of the service’s referral volume.
  Stated by North London NHS Foundation TrustUnable to act
AI-generated summary

Keith Gallimore · 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

Keith Gallimore, who had discussed plans to commit suicide with a clinical psychologist, was found deceased at home on 4 December 2014. The medical cause of death was the combined toxic effects of heroin and cocaine, and suicidal or accidental intent could not be established to the required standard. Concern was raised that potentially important iCope information was not accessible to other services within the same Trust without a proactive request, including in out-of-hours settings.

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 potentially important CANDI service information accessible to other services within the Trust
Wider context from the report
“(1) I am concerned that potentially important information, documented by a service provided by CANDI, is not accessible by other services within the same Trust, without a proactive request being made. It was not clear why this restriction is in place, nor what steps could be taken if information were required in an ‘out-of-hours’ setting, at which time the iCope service would not be available to copy notes to Rio. Although there was no evidence that, had the iCope notes been available to the Crisis Team, the outcome of Mr Gallimore's case would have been different, I am concerned that future deaths could result because of this issue. ”
Source location
Keith Gallimore · 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
Maintain a protocol for checking new referrals against IAPTUS and recording relevant current or recent ICope contacts on RiO.

Verbatim wording from the response
“I agree that there is a gap in information sharing between ICope and rest of the Trust, this is because of the use of different electronic patient record systems. ICope is obliged to use electronic patient records system called IAPTUS because of national data reporting requirements, whilst all other services in the Trust use electronic patient records system called RIO. ICope has an established protocol for checking all new referrals against the RIO system and for making entries on RIO where patients have either current or recent contact with the service.”

Source location
2015-0184-Response-by-Camden-and-Islington-NHS-Trust
Page 1 · response
Published 11 May 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Train designated acute-assessment staff across liaison, crisis-resolution and bed-management teams to check IAPTUS records and access clinical notes.

Verbatim wording from the response
“One possible solution would be for all ICope staff to enter all their patient data on RIO as well as IAPTUS. Given the number of referrals to the service (some 17,000 in the last year) this is impractical and would mostly be of little benefit. Following discussion between leads in our Acute Division and ICope it was agreed that the most effective solution would be to provide IAPTUS training to a small number of front-line staff (who provide services 7 days a week/ 24 hours a day) in the Acute Division. This means that staff working in the acute assessment teams will be able to make routine checks on all new patients against the IAPTUS system and have immediate access to the full clinical notes. All IAPT staff are already trained on the use of RiO electronic system and have access to RiO.”

Source location
2015-0184-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 11 May 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
Entering all ICope patient data in both systems is impractical and would provide little benefit because of the service’s referral volume.

Verbatim wording from the response
“One possible solution would be for all ICope staff to enter all their patient data on RIO as well as IAPTUS. Given the number of referrals to the service (some 17,000 in the last year) this is impractical and would mostly be of little benefit. Following discussion between leads in our Acute Division and ICope it was agreed that the most effective solution would be to provide IAPTUS training to a small number of front-line staff (who provide services 7 days a week/ 24 hours a day) in the Acute Division. This means that staff working in the acute assessment teams will be able to make routine checks on all new patients against the IAPTUS system and have immediate access to the full clinical notes. All IAPT staff are already trained on the use of RiO electronic system and have access to RiO.”

Source location
2015-0184-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 11 May 2015
Open published response
16 Apr2015
Manchester South
Concerns raised1
1. Failure to provide Appropriate Adults with relevant custody risk information
This report raised 27 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

Kesia Lena Mary Leatherbarrow · 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

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide Appropriate Adults with relevant custody risk information
Wider context from the report
“She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS, nor that she had threatened to jump off a bridge on her release. ”
Source location
Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Page 7 · concerns
Open source report
9 Mar2015
Manchester City
Concerns raised1
1. Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
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.

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

Craig Douglas Bell · 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

Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.

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 share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
Wider context from the report
“2. I am concerned that the appropriate sharing of information relating to risk and suicidal or self harming behaviour did not take place between the clinical team and HMPS staff. For example, the direct threat of suicide made at the review on the 27 November 2012 was not disclosed to HMPS staff. Appropriate, timely mutual information exchange had not taken place and there is a concern that this may be vital but may be overlooked if steps are not taken to make this a matter of routine. It means that clinical staff have to be able to review the clinical record appropriately and share information with their HMPS colleagues. ”
Source location
Craig Douglas Bell · Prevention of Future Deaths report
Page 5 · concerns
Open source report
20 Feb2015
Wiltshire and Swindon
Concerns raised1
1. Failure to share patient information accurately with other agencies involved in care
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 6
1. Action
  Implement the College of Emergency Medicine mental health risk assessment tool for ED suicide and self-harm risk assessment and urgency documentation.
  Stated by Salisbury NHS Foundation TrustStated completed
2. Action
  Implement a mental health referral proforma to record risk, assessment timeframe, accepting practitioner and agreed actions for out-of-hours referrals.
  Stated by Salisbury NHS Foundation TrustStated planned
3. Action
  Incorporate the mental health referral proforma into the upgraded ED electronic system for electronic transfer and storage by the end of 2015.
  Stated by Salisbury NHS Foundation TrustStated planned
1. Action
  Update JSP 950 Leaflet 2-7-2 with guidance on care transfers, responsibility, NHS coordination, information sharing and access to Defence Medical Services advice.
  Stated by Ministry of DefenceStated in progress
2. Action
  Continue discussions with the Ministry of Defence and NHS England to address concerns about information sharing and care responsibility for armed forces personnel.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Conduct a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated planned
Respondent positions 4
1. Position
  Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.
  Stated by Public Health EnglandUnable to act
1. Position
  The Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.
  Stated by Public Health EnglandRedirects responsibility
2. Position
  The mental health providers named in the report are expected to comment on the particular case and address concerns locally.
  Stated by Public Health EnglandRedirects responsibility
3. Position
  Local mental health providers are expected to address the specific case and concerns from their local perspective.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Richard Jeffrey Jones · 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

Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share patient information accurately with other agencies involved in care
Wider context from the report
“I am concerned in particular as to the following matters : a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment. b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency. c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care. ”
Source location
Richard Jeffrey Jones · 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
Implement the College of Emergency Medicine mental health risk assessment tool for ED suicide and self-harm risk assessment and urgency documentation.

Verbatim wording from the response
“Since the death of Mr Jones, and following review of the case in collaboration with AWP, an immediate action taken by SFT Emergency Department was to implement a new mental health risk assessment tool as recommended by the College of Emergency Medicine. This tool provides a more accurate assessment of the risk of suicide or self harm than the SADPERSON score we were previously using. It enables clinical staff to risk assess patients and document their findings prior to referring the patient to the mental health team with an indication of the appropriate urgency for their response. (Mr Jones fell within the low risk category using the old and new tools). The tool is”

Source location
2015-0068-Response-by-Salisbury-NHS-Trust
Page 1 · response
Published 20 February 2015
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 a mental health referral proforma to record risk, assessment timeframe, accepting practitioner and agreed actions for out-of-hours referrals.

Verbatim wording from the response
“To ensure robust recording of information to the out-of-hours AWP service a proforma will be generated for clinician use. This will include information such as the assessed level of risk as per the mental health risk assessment tool, the agreed timeframe for assessment, the name of the accepting mental health practitioner, and any other agreed actions from the telephone referral conversation. The proforma will safeguard against any misunderstandings between an ED clinician to an AWP”

Source location
2015-0068-Response-by-Salisbury-NHS-Trust
Page 2 · response
Published 20 February 2015
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
Incorporate the mental health referral proforma into the upgraded ED electronic system for electronic transfer and storage by the end of 2015.

Verbatim wording from the response
“mental health worker and vice versa. Once completed, the information will then be faxed or emailed to an agreed secure number or address for AWP to place with the AWP patient record, and the original will be held within the ED patient record at SFT. This will be incorporated within the ED upgraded electronic system by the end of the year so that it can be transferred and stored electronically.”

Source location
2015-0068-Response-by-Salisbury-NHS-Trust
Page 3 · response
Published 20 February 2015
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 JSP 950 Leaflet 2-7-2 with guidance on care transfers, responsibility, NHS coordination, information sharing and access to Defence Medical Services advice.

Verbatim wording from the response
“I can confirm that we are now updating leaflet 2-7-2 of the Department’s medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”

Source location
2015-0068-Response-by-Ministry-of-Defence
Page 2 · response
Published 20 February 2015
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 discussions with the Ministry of Defence and NHS England to address concerns about information sharing and care responsibility for armed forces personnel.

Verbatim wording from the response
“At a national level, the Department of Health (DH) works closely with the MoD and with NHS England to ensure that service personnel receive the right health services. Medical notes relating to an individual patient must pass readily from the MoD to the NHS and back again as appropriate. This will become increasingly important as the number of Armed Forces reservists is increased, as these personnel will access health services from the MoD when mobilised, and from the NHS at other times.”

Source location
2015-0068-Response-by-Department-of-Health2
Page 2 · response
Published 20 February 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.

Verbatim wording from the response
“Your report was considered by our Critical Incident Review Group, which is chaired by my Medical Director, ████████ on 2 March 2015. It was decided that to best explore the issues you have raised, we should conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces. This will enable staff from the different agencies to collaborate and identify the best solutions to the problems you have raised concerns about, to include a review of any relevant policies and procedures.”

Source location
2015-0068-Response-by-Avon-Wiltshire-Mental-Health-NHS-Trust
Page 1 · 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
Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.

Verbatim wording from the response
“DH will continue their discussions with MoD and NHSE on this issue and these discussions will address the specific concerns you have raised in your report. Unfortunately, PHE are not in a position to advise on this matter further.”

Source location
2015-0068-Response-by-Public-Health-England
Page 1 · 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 Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.

Verbatim wording from the response
“I am aware you have also written to the Department of Health (DH), and I understand that DH, the Ministry of Defence (MoD) and NHS England (NHSE) work closely together to ensure that service personnel receive the right health services. These organisations are also aware of the need for effective patient note transfer between the MoD and the NHS.”

Source location
2015-0068-Response-by-Public-Health-England
Page 1 · 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 mental health providers named in the report are expected to comment on the particular case and address concerns locally.

Verbatim wording from the response
“Finally, I have been advised that the mental health providers named in your report are expected to provide comment on the detail of this particular case and to address your concerns from their local perspective.”

Source location
2015-0068-Response-by-Public-Health-England
Page 2 · 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
Local mental health providers are expected to address the specific case and concerns from their local perspective.

Verbatim wording from the response
“Firstly, I would expect the mental health providers named in your report to provide comment on the detail of this particular case and to address your concerns from their local perspective.”

Source location
2015-0068-Response-by-Department-of-Health2
Page 1 · response
Published 20 February 2015
Open published response
28 Dec2014
Mid Kent and Medway
Concerns raised1
1. Failure to inform and involve agencies and carers in custodial welfare management
This report raised 27 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
  Review the establishment’s information-sharing policy to ensure it reflects current legislation and best practice.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Introduce a more rigorous ACCT quality-assurance process with individual feedback to case managers.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Formulate an information-sharing protocol covering all relevant agencies providing services at HMYOI Cookham Wood.
  Stated by HM Prison and Probation ServiceStated in progress
1. Action
  Require Cookham Wood case workers to facilitate regular community visits, significant-incident updates, and community and parental participation in ACCT reviews.
  Stated by Medway Council (Youth Offending TeamStated completed
AI-generated summary

Alex Kelly · 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

Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

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 inform and involve agencies and carers in custodial welfare management
Wider context from the report
“Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
Source location
Alex Kelly · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the establishment’s information-sharing policy to ensure it reflects current legislation and best practice.

Verbatim wording from the response
“Prison Service Instruction (PSI) 08/2012 Care and Management of Young People sets out a requirement for each under 18 YOI to have an information sharing policy to ensure that relevant information is shared with professionals, parents or carers and others, at appropriate intervals. HMYOI Cookham Wood has such a policy, and the Governor is currently conducting the annual review that is undertaken to ensure that it always reflects current legislation and best practice. It mandates that information is shared with families and other appropriate bodies or persons (for example, the YOT), on each of the following occasions:”

Source location
2014-0555-Response-by-Ministry-of-Justice
Page 4 · response
Published 28 December 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
Introduce a more rigorous ACCT quality-assurance process with individual feedback to case managers.

Verbatim wording from the response
“As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

Source location
2014-0555-Response-by-Ministry-of-Justice
Page 5 · response
Published 28 December 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
Formulate an information-sharing protocol covering all relevant agencies providing services at HMYOI Cookham Wood.

Verbatim wording from the response
“The responses from Oxleas NHS Trust and the Central and North West London (CNWL) NHS Foundation Trust have responded in detail to the concerns that you addressed to healthcare at HMYOI Cookham Wood, but I would like to add one point with regard to the sharing of information.”

Source location
2014-0555-Response-by-Ministry-of-Justice
Page 6 · response
Published 28 December 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
Require Cookham Wood case workers to facilitate regular community visits, significant-incident updates, and community and parental participation in ACCT reviews.

Verbatim wording from the response
“Point 3,a; The arrangements now in place, require Case Workers at Cookham Wood, to encourage the external YOT and Social Workers (where a Looked After Child (LAC)) to visit young persons in custody at least monthly, to meet with the young”

Source location
2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014
Open published response
2 Sep2014
South Yorkshire (Western)
Concerns raised1
1. Failure to routinely provide prisoner escort records to the Youth Offending Service
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review contractor operational policies to ensure staff understand and follow prisoner escort record information-sharing requirements.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Remind contractor staff that Youth Offending Service employees may access relevant Prisoner Escort Record information.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Reinforce Youth Offending Service information-sharing responsibilities through staff briefings and safer custody training.
  Stated by HM Prison and Probation ServiceStated planned
1. Action
  Review the format and content of the Prisoner Escort Record with the Ministerial Council on Deaths in Custody.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Communicate the inquest findings to the NOMS team reviewing the Prisoner Escort Record.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Peter Stanley · 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

Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

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 routinely provide prisoner escort records to the Youth Offending Service
Wider context from the report
“(5) A prisoner escort record (known commonly as a PER) would have been handed over from the police to the privatised court detention officers when Peter was produced before the magistrates. This contains details (inter alia) of risks, self harm issues, medical attention and warning markers. I understand that the Youth Offending Service believe that the PER should be routinely given to them it would inform assessments as to the immediate needs of the young person. This would only arise, of course, in the relatively few cases where the young person has spent a period in police cells. ”
Source location
Peter Stanley · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review contractor operational policies to ensure staff understand and follow prisoner escort record information-sharing requirements.

Verbatim wording from the response
“I can confirm that PECS entirely accepts your recommendation and we have reviewed our contractor’s operational policies to ensure that their staff understand and adhere to this in future.”

Source location
2014-0390-Response-by-NOMS
Page 1 · response
Published 2 September 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
Remind contractor staff that Youth Offending Service employees may access relevant Prisoner Escort Record information.

Verbatim wording from the response
“The content of the PER form can be shared with any appropriate party who needs access to the prisoner in order to conduct interviews or assessments. We have taken steps to remind Geo Amey that employees of the Youth Offending Service clearly fall into this category. This will be reinforced in staff briefings and safer custody training going forward.”

Source location
2014-0390-Response-by-NOMS
Page 2 · response
Published 2 September 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
Reinforce Youth Offending Service information-sharing responsibilities through staff briefings and safer custody training.

Verbatim wording from the response
“The content of the PER form can be shared with any appropriate party who needs access to the prisoner in order to conduct interviews or assessments. We have taken steps to remind Geo Amey that employees of the Youth Offending Service clearly fall into this category. This will be reinforced in staff briefings and safer custody training going forward.”

Source location
2014-0390-Response-by-NOMS
Page 2 · response
Published 2 September 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
Review the format and content of the Prisoner Escort Record with the Ministerial Council on Deaths in Custody.

Verbatim wording from the response
“NOMS is currently reviewing the format and content of the PER form as part of our work with the Ministerial Council on Deaths in Custody. I will ensure that the findings of this inquest are communicated to the NOMS team involved in this work.”

Source location
2014-0390-Response-by-NOMS
Page 2 · response
Published 2 September 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
Communicate the inquest findings to the NOMS team reviewing the Prisoner Escort Record.

Verbatim wording from the response
“NOMS is currently reviewing the format and content of the PER form as part of our work with the Ministerial Council on Deaths in Custody. I will ensure that the findings of this inquest are communicated to the NOMS team involved in this work.”

Source location
2014-0390-Response-by-NOMS
Page 2 · response
Published 2 September 2014
Open published response
28 Aug2014
Inner South London
Concerns raised1
1. Failure to relay full and detailed high-risk information to the missing persons unit
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review the response and existing measures against the inquest findings to ensure they address the identified issues and are embedded in current practice.
  Stated by Metropolitan Police ServiceStated completed
2. Action
  Complete the Metropolitan Police missing-person reporting form when a child arrives.
  Stated by Ethelbert Childrens ServicesStated completed
3. Action
  Provide the police with current circumstances and relevant additional details by telephone when reporting a child missing.
  Stated by Ethelbert Childrens ServicesStated completed
1. Action
  Complete and pass a vulnerability assessment to Kent Police for each child at placement.
  Stated by Ethelbert Childrens ServicesStated completed
2. Action
  Prepare risk assessment reports for missing looked-after children’s strategy meetings and pass them to police to inform search-risk and resource decisions.
  Stated by London Borough of BexleyStated completed
Respondent positions 2
1. Position
  Implemented information-sharing arrangements, vulnerability assessments, reporting forms and telephone notifications address concerns about missing children’s information and risk assessment.
  Stated by Ethelbert Childrens ServicesExisting arrangements considered sufficient
1. Position
  Email transmission of updated missing-person information is constrained because the relevant police forces lack facilities to receive it.
  Stated by Ethelbert Childrens ServicesUnable to act
AI-generated summary

Lauren Barfoot · 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

Lauren Barfoot was a 14-year-old looked-after child who went missing from Micawber House on 22 June 2012 and was later discovered in the porch of her putative father’s home. The report identified concerns about failures to share information, classify the level of risk, conduct an effective search, and hold a timely strategy meeting. The inquest concluded that her accidental death was contributed to by failures in sharing information and pooling and using resources.

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 relay full and detailed high-risk information to the missing persons unit
Wider context from the report
“(2) There was a failure by Ethelbert’s Children’s Services to relay full and detailed information to the Missing Person’s Unit (Greenwich) as to the level of risk classified as “high” in relation to Lauren’s misuse of solvent abuse and vulnerability of sexual exploitation. ”
Source location
Lauren Barfoot · 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
Review the response and existing measures against the inquest findings to ensure they address the identified issues and are embedded in current practice.

Verbatim wording from the response
“I enclose a report detailing our actions, addressing the specific issues of information sharing and risk assessment, but also our broader response to the serious case review that followed Lauren's death. I have caused our response to be reviewed in light of the inquest to ensure that those measures introduced following the serious case review account for the issues raised in your report and are fully embedded in current practice.”

Source location
2014-0385-Response-by-Metropolitan-Police
Page 1 · response
Published 28 August 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
Complete the Metropolitan Police missing-person reporting form when a child arrives.

Verbatim wording from the response
“• Met Police Missing Person Reporting Form”

Source location
2014-0385-Response-by-Ethelbert-Childrens-Services1
Page 1 · response
Published 28 August 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
Provide the police with current circumstances and relevant additional details by telephone when reporting a child missing.

Verbatim wording from the response
“Once you have had an opportunity to review the action list we trust that you will find the steps that we have implemented, address concerns in respect of the collation of information as to the risk assessment of a child and contact details which can be shared with other agencies.”

Source location
2014-0385-Response-by-Ethelbert-Childrens-Services1
Page 1 · response
Published 28 August 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
Complete and pass a vulnerability assessment to Kent Police for each child at placement.

Verbatim wording from the response
“• Vulnerability Assessment”

Source location
2014-0385-Response-by-Ethelbert-Childrens-Services1
Page 1 · response
Published 28 August 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
Prepare risk assessment reports for missing looked-after children’s strategy meetings and pass them to police to inform search-risk and resource decisions.

Verbatim wording from the response
“A risk assessment report is required in preparation for any strategy meetings for missing looked after children. A strategy meeting is held within three days of a child going missing. The social worker will provide a risk assessment report to the meeting in accordance with the Bexley Practice Guidance pro-forma for assessing risk. The meeting is chaired by the Independent Reviewing Officer for the child. The risk assessment report requires comprehensive information about all possible contacts and locations where the child may be found, including any information known about risks presenting to the young person. The risk assessment report will be passed to the police at the strategy meeting in order that they can assess the level of risk and resources required so that they can carry out an effective search for the missing young person.”

Source location
2014-0385-Response-by-Bexley-Borough-Council
Page 2 · response
Published 28 August 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
Implemented information-sharing arrangements, vulnerability assessments, reporting forms and telephone notifications address concerns about missing children’s information and risk assessment.

Verbatim wording from the response
“Once you have had an opportunity to review the action list we trust that you will find the steps that we have implemented, address concerns in respect of the collation of information as to the risk assessment of a child and contact details which can be shared with other agencies.”

Source location
2014-0385-Response-by-Ethelbert-Childrens-Services1
Page 1 · response
Published 28 August 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
Email transmission of updated missing-person information is constrained because the relevant police forces lack facilities to receive it.

Verbatim wording from the response
“We continue to explore the possibility of sending an updated missing person form by email, to the police as outlined in action list, although to date our conversations with the Met have not proved successful.”

Source location
2014-0385-Response-by-Ethelbert-Childrens-Services1
Page 1 · response
Published 28 August 2014
Open published response
5 Aug2014
Norfolk
Concerns raised1
1. Failure to communicate concerns about care home adequacy
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 2
1. Action
  Embed feedback to safeguarding referrers as an integral part of the safeguarding process.
  Stated by Norfolk County Council Community ServicesStated in progress
2. Action
  Continue working with the hospital to support safe discharges for older people returning to residential homes.
  Stated by Norfolk County Council Community ServicesStated in progress
AI-generated summary

JOHN HENRY WILSHER · 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 Wilsher, a resident of Springdale Care Home, deteriorated after falls and was found to have extradural and subdural haemorrhages. He died on 21 December 2013 after discharge from hospital to the care home, which quickly became unable to cope with his mobility. Concerns included inaccurate discharge information, inadequate communication about his care needs and prior referral, and delays or gaps in care assessments.

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 communicate concerns about care home adequacy
Wider context from the report
“(2) Concerns were raised by the GP and a referral made to NCC Community Services on 25 November 2013 as to the suitability of the Care Home in providing care to Mr Wilsher due to his deteriorating condition. He was admitted to NNUH on 27 November 2013 for assessment and plans were made for discharge to the Care Home. Neither NNUH nor the Care Home were aware concerns had already been raised (prior to a further deterioration in his condition) as to the adequacy of the Care Home to cope with his needs. On Mr Wilsher’s discharge to the Care Home it quickly became apparent they could not cope with his needs. ”
Source location
JOHN HENRY WILSHER · 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
Embed feedback to safeguarding referrers as an integral part of the safeguarding process.

Verbatim wording from the response
“I confirm that the importance of giving appropriate feedback to the person who raised the safeguarding concern (the “referrer”) has been acknowledged and it is agreed that this should be an integral part of the safeguarding process. The Multi-Agency Safeguarding Hub (“MASH”) and the safeguarding manager within Norfolk Council have been working with colleagues to ensure this action is embedded in the safeguarding process. This will ensure a more outcome focussed safeguarding process. This will also enable the referrer to be clear when the council has assessed an issue not to fall within the safeguarding arena.”

Source location
2014-0360-Response-by-Norfolk-County-Council
Page 1 · response
Published 5 August 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
Continue working with the hospital to support safe discharges for older people returning to residential homes.

Verbatim wording from the response
“Norfolk County Council Community Services continues to work closely with the Norfolk & Norwich Community Hospital to ensure safe discharges are made. There are social care practitioners linked to those Wards which care for older people who, if requested, are available to support any health staff who are directly in contact with residential home managers and staff.”

Source location
2014-0360-Response-by-Norfolk-County-Council
Page 1 · response
Published 5 August 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group

Concerns raised1

Failure to communicate significant risk information to ambulance and psychiatric staff

Concerns raised1

Failure to make potentially important CANDI service information accessible to other services within the Trust

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

Failure to provide Appropriate Adults with relevant custody risk information

Concerns raised1

Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff

Concerns raised1

Failure to share patient information accurately with other agencies involved in care

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.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure to inform and involve agencies and carers in custodial welfare management

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

Concerns raised1

Failure to routinely provide prisoner escort records to the Youth Offending Service

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 2

Respondent positions 1

Actions described in response 6

Respondent positions 4

Actions described in response 4

Actions described in response 5