Recurring concern

Inadequate deprivation of liberty safeguarding for people lacking capacity

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First reported 29 Jan 2015•Latest report 10 Jul 2025

Definition

What this concern includes

Includes failures of the Deprivation of Liberty Safeguards process that are specifically intended to protect people lacking capacity, including recognition, assessment, applications, authorisation, review, renewal, procedural accuracy and related safeguarding communication.

Not included

Excludes generic staff training, documentation or communication deficiencies not explicitly tied to Deprivation of Liberty Safeguards.
Excludes failures concerning mental capacity or best-interests decision-making that do not also concern deprivation-of-liberty safeguards.
Excludes unrelated safeguarding systems, care quality issues and restrictions that are not connected to a Deprivation of Liberty Safeguards process.

Reports: 11
Individual concerns: 12
Date range: 2015–2025
Stated actions: 25

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.

Birmingham City Council2

Care Quality Commission2

Greater Manchester Mental Health NHS Foundation Trust2

Abbey Court Independent Hospital1

Achieve Together Limited1

Central Bedfordshire Council1

Chippenham Community Hospital1

Durham County Council1

Great Western Hospitals NHS Foundation Trust1

Howlish Hall Residential Care Home1

Kerria Court1

Manchester University NHS Foundation Trust1

Nottinghamshire County Council1

Sandwell and West Birmingham Hospitals NHS Trust1

Sussex Partnership NHS Foundation Trust1

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.

10 Jul2025
County Durham and Darlington
Concerns raised1
1. Failure to apply for DoLS assessments for residents lacking mental capacity
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 4
1. Action
  Work with the new care-home manager to submit required DoLS applications and renew expired authorisations.
  Stated by Durham County CouncilStated completed
2. Action
  Apply DoLS considerations to all residents moved during the care-home closure.
  Stated by Durham County CouncilStated completed
3. Action
  Reinforce the importance of DoLS during upcoming Care Home Strategic Provider Forum sessions.
  Stated by Durham County CouncilStated in progress
1. Action
  Work with commissioning and safeguarding teams to explore identifying care homes without active DoLS authorisations or with overdue renewals.
  Stated by Durham County CouncilStated in progress
AI-generated summary

Patricia Heaviside · 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

Patricia Heaviside, a resident of Howlish Hall Care Home, suffered an unwitnessed fall on 4 October 2024, fractured her left hip, and died on 26 December 2024 as a consequence of the fracture. Concerns included the failure to implement recommended falls-prevention equipment, failures to share relevant information with family and social services, and apparent reluctance to provide adequate resources for falls prevention. The report also raised concerns that no DoLS assessment application appeared to have been made despite her lack of mental capacity and inability to keep herself safe.

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 apply for DoLS assessments for residents lacking mental capacity
Wider context from the report
“(6) Despite it being recognised that the Deceased lacked mental capacity to make decisions about where she lived and was unable to keep herself safe, it appears that the home did not make any application for a DoLS assessment for the Deceased. Indeed I received evidence that when a new home manager was appointed at Howlish Hall in January 2025 none of the residents were subject to a DoLS, despite a large number of the residents lacking mental capacity. ”
Source location
Patricia Heaviside · 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
Work with the new care-home manager to submit required DoLS applications and renew expired authorisations.

Verbatim wording from the response
“(6) Despite it being recognised that the Deceased lacked mental capacity to make decisions about where she lived and was unable to keep herself safe, it appears that the home did not make any application for a DoLS assessment for the Deceased. Indeed I received evidence that when a new home manager was appointed at Howlish Hall in January 2025 none of the residents were subject to a DoLS, despite a large number of residents lacking mental capacity.”

Source location
Response from Durham County Council
Page 4 · response
Published 17 July 2025
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
Apply DoLS considerations to all residents moved during the care-home closure.

Verbatim wording from the response
“DoLS considerations have been applied to all residents who have transitioned to a new care home placement as part of the care home closure work for Howlish Hall.”

Source location
Response from Durham County Council
Page 4 · response
Published 17 July 2025
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 the importance of DoLS during upcoming Care Home Strategic Provider Forum sessions.

Verbatim wording from the response
“Deprivation of Liberty Safeguards is a regular agenda item and discussion point at our Care Home Strategic Provider Forum meetings, and we will continue to reinforce its importance in upcoming forum sessions. To strengthen oversight, commissioning and safeguarding teams will work with the DoLS team to explore ways of identifying care homes that currently have no active DoLS authorisations in place or where renewals may be overdue. This will help us highlight potential gaps and ensure timely action is taken to proactively address any issues with the care home.”

Source location
Response from Durham County Council
Page 4 · response
Published 17 July 2025
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
Work with commissioning and safeguarding teams to explore identifying care homes without active DoLS authorisations or with overdue renewals.

Verbatim wording from the response
“Deprivation of Liberty Safeguards is a regular agenda item and discussion point at our Care Home Strategic Provider Forum meetings, and we will continue to reinforce its importance in upcoming forum sessions. To strengthen oversight, commissioning and safeguarding teams will work with the DoLS team to explore ways of identifying care homes that currently have no active DoLS authorisations in place or where renewals may be overdue. This will help us highlight potential gaps and ensure timely action is taken to proactively address any issues with the care home.”

Source location
Response from Durham County Council
Page 4 · response
Published 17 July 2025
Open published response
27 Dec2019
Nottinghamshire
Concerns raised1
1. Lack of training in deprivation of liberty assessment
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

Enid Baber · 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

Enid Baber, who was cognitively impaired, died suddenly after getting into or falling backwards into a bath late at night or in the early hours of the morning. The report raised concerns that people living in their own homes with significant restrictions on their liberty might be unlawfully deprived of liberty without adequate safeguards, partly because relevant social workers were not required or prompted to assess this and had not received specific training.

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 training in deprivation of liberty assessment
Wider context from the report
“Enid Baber was not free to leave her property. This was a fact which was well known to Nottinghamshire County Council who had been involved in coordinating her package of care. She was also under a measure of supervision and control during the day. I concluded, after hearing evidence on the point, that although in my finding she was not being deprived of her liberty, this was a very finely balanced decision. I was advised that Nottinghamshire County Council has a team which deals with deprivation of liberty (‘DOL’) in community settings although the evidence I received was that the team dealing with dementia cases did not routinely or actively carry out an assessment as to whether or not persons in Mrs Baber’s situation are deprived of their liberty. They have not received specific training on this difficult assessment process. In this case, Mrs Baber’s circumstances fell only narrowly short of a deprivation of liberty and only minor changes would have resulted in a different conclusion. There was no mechanism by which the social workers working with Mrs Baber were required or prompted to consider the issue of deprivation of liberty and they had not been trained to do so. Had Mrs Baber been deprived of her liberty then she has a human right for that detention to be kept under review and I remained concerned that this particular class of persons, that is, persons who remain in their own home but who have significant restrictions on their liberty, may be unlawfully deprived of their liberty without adequate safeguards being in place and that this may potentially become unsafe by, for example, insufficient attention to the safety implications of being locked in your own home. ”
Source location
Enid Baber · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 May2017
Wiltshire and Swindon
Concerns raised1
1. Lack of knowledge of Mental Capacity Act safeguarding measure limitations in privately funded community care
This report raised 8 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

Doreen Helen MILLER · Prevention of Future Deaths report

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

Report summary

Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.

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 knowledge of Mental Capacity Act safeguarding measure limitations in privately funded community care
Wider context from the report
“d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately. One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases. ”
Source location
Doreen Helen MILLER · Prevention of Future Deaths report
Page 3 · concerns
Open source report
5 Dec2016
Cheshire
Concerns raised1
1. Failure to implement Deprivation of Liberty Safeguarding procedures accurately
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

Brian Gerrard · 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

Brian Gerrard had moderately severe mixed Alzheimer’s/vascular dementia, depression and intermittent infections, and died after becoming undernourished because he was not eating sufficiently. The inquest concluded that he died from natural causes, namely lack of eating due to dementia. Concerns related to staff understanding and management of best-interests meetings, identification of lack of capacity, and implementation of Deprivation of Liberty Safeguarding procedures, including inaccurate and contradictory information in an application.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to implement Deprivation of Liberty Safeguarding procedures accurately
Wider context from the report
“The MATTERS OF CONCERN relate to (1) the understanding of staff in relation to the proper management of a best interests meeting, (2) the identification of lack of capacity and (3) the implementation of Deprivation of Liberty Safeguarding procedures. All such deficiencies appeared to warrant an amendment of procedures and a requirement for appropriate training. On 26th September 2014 a best interests, multidisciplinary meeting was called at your hospital to decide upon what action to take to address the fact that the deceased was not eating sufficiently and might be close to death. Those present at the meeting included the deceased’s named nurse who took the minutes of the meeting, the deceased’s wife, a psychiatrist who was the deceased’s responsible clinician and a General Practitioner from the deceased’s medical practice. The meeting decided that it was in the deceased’s best interests to remain at your hospital rather than being transferred to a general hospital for treatment. In that regard the minute of the meeting correctly reflected what had been agreed. However, it was also minuted that the deceased had determined to die and that to achieve this aim he was deliberately not eating and that he had capacity to make such a decision. Such did not represent the opinion of the psychiatrist / responsible clinician nor the opinion of the general practitioner, both of whom were of the view that the deceased did not have capacity and that he had not formulated a plan to die but that his lack of eating was a product of his illness. Thereafter an application for a Deprivation of Liberty Safeguard contained inaccurate and contradictory information and appeared to demonstrate a lack of familiarity with procedures. For instance, the application asserted that the deceased had capacity to make decisions with regard to his care needs when such did not represent the opinions of the clinicians responsible for the deceased’s care. ”
Source location
Brian Gerrard · Prevention of Future Deaths report
Page 1 · concerns
Open source report
3 Aug2016
Birmingham and Solihull
Concerns raised2
1. Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk
2. Delays in processing DOLS applications
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 14
1. Action
  Introduce a staff aide-memoire prompt for identifying and applying for DoLS.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated planned
2. Action
  Continue rolling audits of DoLS compliance among focused-care patients.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
3. Action
  Deliver ongoing DoLS education and awareness workshops for multidisciplinary staff.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
1. Action
  Make a recorded DoLS workshop available as an internal training resource and publicise it across the organisation.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated planned
2. Action
  Audit wards and units to confirm DoLS awareness and support systems for new and temporary staff.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completed
3. Action
  Strengthen Safeguarding Level 2 training with local scenarios and prioritised delivery for staff serving patients likely to need DoLS.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
4. Action
  Target relevant medical staff and require consultants to discuss DoLS implications and treatment impact with their teams.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
5. Action
  Develop and introduce a DoLS e-learning module for nursing staff.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
6. Action
  Include DoLS policy and procedure requirements in induction for new staff.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completed
7. Action
  Inspect wards and units to check whether DoLS are in place or required, and feed findings back to managers.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
8. Action
  Work with Birmingham and Sandwell local authorities to streamline DoLS applications and address late responses.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
9. Action
  Centrally monitor and report local-authority response periods for DoLS applications.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated planned
10. Action
  Invest resources to reduce the backlog of Deprivation of Liberty Safeguards assessments.
  Stated by Birmingham City CouncilStated in progress
11. Action
  Process future Deprivation of Liberty Safeguards applications more quickly.
  Stated by Birmingham City CouncilStated planned
Respondent positions 3
1. Position
  Existing policies, procedures and the DoLS framework remain suitable; further work should raise awareness rather than revise the process.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustExisting arrangements considered sufficient
1. Position
  For a person's new hospital circumstances, the hospital must determine whether deprivation exists and request a fresh DOLS process.
  Stated by Birmingham City CouncilRedirects responsibility
2. Position
  The council could not immediately process DOLS applications faster because resources and nationally qualified assessors and advocates were insufficient.
  Stated by Birmingham City CouncilUnable to act
AI-generated summary

Winston Harris · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk
Wider context from the report
“(3) At no time did staff consider if Mr Harris should be subject to an emergency DOLS despite him having dementia and having tried to leave the ward on 16/03/2016. He had previously been assessed as requiring and DOLS. ”
Source location
Winston Harris · 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 DOLS applications
Wider context from the report
“(4) The application for DOLS order was not processed before Mr Harris’s death. I heard evidence that it often takes many months to process a DOLS application. Given these are extremely vulnerable people applications should be processed more quickly. ”
Source location
Winston Harris · 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
Introduce a staff aide-memoire prompt for identifying and applying for DoLS.

Verbatim wording from the response
“As you would expect we have the necessary policies and procedures in place. These provide both advice and instruction to staff. Having re-checked that material it remains suitable and is available to staff through our Intranet web site. What we have decided we need in order to augment that approach is an aide memoire or prompt for staff. This will be in place by the end of October.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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 rolling audits of DoLS compliance among focused-care patients.

Verbatim wording from the response
“The Trust is a national pilot site for work on Focused Care. Very commonly such patients are in receipt of capacity assessment, which then drives their additional nursing and care needs. These patients are registered centrally via our Safeguarding system. We have audited the compliance with DOLS for such patients. That audit continues on a rolling basis and we would expect to see the volume of cases rise among that cohort.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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
Deliver ongoing DoLS education and awareness workshops for multidisciplinary staff.

Verbatim wording from the response
“We have a well-developed training approach with staff. In recognising that the framework around DoLS is in place, the focus of attention is on the need to raise awareness, rather than revise the process. A programme of ongoing education and awareness is well advanced. To date it has included:”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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
Make a recorded DoLS workshop available as an internal training resource and publicise it across the organisation.

Verbatim wording from the response
“• Videoing one of the workshops so that it can be shared both with those staff who could not attend, and as a training resource available on our Intranet. By the end of October this video will have been widely publicised inside the organisation.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Audit wards and units to confirm DoLS awareness and support systems for new and temporary staff.

Verbatim wording from the response
“• Structured audit with ward sisters and Unit matrons across the Trust, as the majority of the patients who may need a DoLS will be in these inpatient areas, to obtain confirmation that they have raised awareness of DoLS with all their staff and have systems in place to support new starters and temporary staff.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Strengthen Safeguarding Level 2 training with local scenarios and prioritised delivery for staff serving patients likely to need DoLS.

Verbatim wording from the response
“• Strengthening the existing Safeguarding Level 2 staff training, which already includes the Mental Capacity Act and DoLS, by using local scenarios and improving the content and prioritising current training for those who may have more patients needing a DoLS.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Target relevant medical staff and require consultants to discuss DoLS implications and treatment impact with their teams.

Verbatim wording from the response
“• Targeting medical staff who carry out consent procedures with patients to promote earlier consideration of the potential need for critical care in the event of a complication. Also all Consultants will be required to share this with their team to understand why DoLS may need to be applied and how treatments may impact on the need for a DoLS.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Develop and introduce a DoLS e-learning module for nursing staff.

Verbatim wording from the response
“• An e-learning DoLS module is in development for nursing staff (ready by the end of November), and induction processes have been updated to include DoLS policy and procedure requirements for new staff.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Include DoLS policy and procedure requirements in induction for new staff.

Verbatim wording from the response
“• An e-learning DoLS module is in development for nursing staff (ready by the end of November), and induction processes have been updated to include DoLS policy and procedure requirements for new staff.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Inspect wards and units to check whether DoLS are in place or required, and feed findings back to managers.

Verbatim wording from the response
“We will use our continuing programme of in-house inspections to check that DoLS are in place or required, feeding our findings back to the ward and unit managers. The next round of visits take place on November 1st and 2nd and are focussing on the wards. Awareness of DOLS will be a key indicator in that process.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 3 · response
Published 3 August 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
Work with Birmingham and Sandwell local authorities to streamline DoLS applications and address late responses.

Verbatim wording from the response
“Partnership working We are aware that both Birmingham and Sandwell Local Authorities are struggling to process the volume of DoLS requests they receive. However, we are working with them to see if there is a more streamlined approach to address the late responses to applications made by the Trust. The response periods will be centrally monitored and reported to me. Clearly as our volume of applications rises the resourcing issue will need to be faced.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Centrally monitor and report local-authority response periods for DoLS applications.

Verbatim wording from the response
“Partnership working We are aware that both Birmingham and Sandwell Local Authorities are struggling to process the volume of DoLS requests they receive. However, we are working with them to see if there is a more streamlined approach to address the late responses to applications made by the Trust. The response periods will be centrally monitored and reported to me. Clearly as our volume of applications rises the resourcing issue will need to be faced.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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
Invest resources to reduce the backlog of Deprivation of Liberty Safeguards assessments.

Verbatim wording from the response
“Following the Supreme Court judgment in P v Cheshire West and Chester County Council and Another; P and Q v Surrey County Council [2013] UKSC 19, [2014] COPLR 313, SC (referred to as Cheshire West and MIG and MEG), there was an immediate eleven-fold increase in the number of applications for Deprivation of Liberty Safeguards (DOLS) in England. Birmingham, as in every other local authority area, experienced this increase and saw its referrals for this work rise from 198 in 2013/14 to 3,278 authorised in the last 12 months. No additional resources have been made available to local authorities to meet this increase. In such circumstances, very large backlogs of assessments mounted, and in Birmingham this was the case as in all other areas.”

Source location
2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 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
Process future Deprivation of Liberty Safeguards applications more quickly.

Verbatim wording from the response
“In Birmingham great efforts and resources have been invested to address the problem, which is now delivering significant results, with the waiting list for assessment considerably reduced. Plans are thereafter in place to ensure that in future applications will be processed more quickly.”

Source location
2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 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
Existing policies, procedures and the DoLS framework remain suitable; further work should raise awareness rather than revise the process.

Verbatim wording from the response
“As you would expect we have the necessary policies and procedures in place. These provide both advice and instruction to staff. Having re-checked that material it remains suitable and is available to staff through our Intranet web site. What we have decided we need in order to augment that approach is an aide memoire or prompt for staff. This will be in place by the end of October.”

Source location
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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
For a person's new hospital circumstances, the hospital must determine whether deprivation exists and request a fresh DOLS process.

Verbatim wording from the response
“In relation to the case of Mr Harris, his application for a DOLS had been prioritised for action on receipt in February 2016, but by the time the lengthy assessment process had been completed, he had been admitted to hospital. Since a DOLS assessment is specific to each care setting, this could not then be authorised. It was therefore the duty of the hospital to judge if his new circumstances also constituted a deprivation of liberty and request the process be started afresh. Indeed, had the DOLS been in place in the care home, this would have had no legal power or application once Mr Harris was admitted to hospital.”

Source location
2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 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 council could not immediately process DOLS applications faster because resources and nationally qualified assessors and advocates were insufficient.

Verbatim wording from the response
“Following the Supreme Court judgment in P v Cheshire West and Chester County Council and Another; P and Q v Surrey County Council [2013] UKSC 19, [2014] COPLR 313, SC (referred to as Cheshire West and MIG and MEG), there was an immediate eleven-fold increase in the number of applications for Deprivation of Liberty Safeguards (DOLS) in England. Birmingham, as in every other local authority area, experienced this increase and saw its referrals for this work rise from 198 in 2013/14 to 3,278 authorised in the last 12 months. No additional resources have been made available to local authorities to meet this increase. In such circumstances, very large backlogs of assessments mounted, and in Birmingham this was the case as in all other areas.”

Source location
2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 2016
Open published response
28 Jul2016
Manchester City
Concerns raised1
1. Failure to consider DoLS authorisation in the community
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.
Respondent positions 1
1. Position
  A finding of lacking mental capacity alone does not require a DoLS authorisation; the decision depends on specific care arrangements and possible liberty deprivation.
  Stated by Manchester University NHS Foundation TrustDisputes the concern
AI-generated summary

Leslie Johnson · 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

Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the 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
Failure to consider DoLS authorisation in the community
Wider context from the report
“1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken. ”
Source location
Leslie Johnson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
A finding of lacking mental capacity alone does not require a DoLS authorisation; the decision depends on specific care arrangements and possible liberty deprivation.

Verbatim wording from the response
“As I am sure you are aware, mental capacity (as defined in the Mental Capacity Act 2005) is decision specific and a finding of ‘lack of mental capacity’ alone is not sufficient to justify a DOLS emergency or standard authorisation. This requires a finding of lack of mental capacity to make decisions about location and manner of care and judgement about the specific manner of care in place at the material time. With regards to a DOLS emergency or standard authorisation, this is about the manner in which a person is cared for not about the care provided per se. It is therefore a matter of judgement for the responsible person with overall responsibility for the environment in which a person is cared for, to decide whether there has been or is a risk of an Article 5 breach in which case authorisation can be sought.”

Source location
MORRISON-Leslie-Response
Page 2 · response
Published 28 July 2016
Open published response
29 Apr2016
Brighton and Hove
Concerns raised1
1. Failure to consider a Deprivation of Liberty Safeguards authorisation for a patient lacking capacity
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

Jack MOLYNEUX · 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

Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.

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 consider a Deprivation of Liberty Safeguards authorisation for a patient lacking capacity
Wider context from the report
“Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above. Mobility He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month. His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth. His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it. With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged. At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death. I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed. Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death. When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content. Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016. ”
Source location
Jack MOLYNEUX · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Apr2016
Manchester South
Concerns raised1
1. Lack of understanding of the outcome of urgent DOLS applications
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 2
1. Action
  Deliver bespoke Deprivation of Liberty Safeguards training to senior clinical staff, including its relationship with the Mental Health Act and place-specific requirements.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progress
2. Action
  Require all staff to complete a mandatory Deprivation of Liberty Safeguards training package and monitor completion through the ward manager.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Legislation and the code of practice provide no straightforward legal solution when urgent DoLS authorisation expires before standard authorisation is granted.
  Stated by Greater Manchester Mental Health NHS Foundation TrustUnable to act
AI-generated summary

Dennis Bennett · 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

Dennis Bennett had dementia and was admitted under the Mental Health Act before receiving end-stage palliative care on a mental health ward, where he died of natural causes on 7 February 2016. Concerns included an urgent deprivation of liberty application made while he was already detained under Section 3, uncertainty about the application’s continuation, confusion about place-specific authorisations, and limited consideration of whether the application was needed while he was compliant and receiving palliative care.

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 understanding of the outcome of urgent DOLS applications
Wider context from the report
“1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act. 2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council. 3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific. 4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests. Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients. ”
Source location
Dennis Bennett · 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
Deliver bespoke Deprivation of Liberty Safeguards training to senior clinical staff, including its relationship with the Mental Health Act and place-specific requirements.

Verbatim wording from the response
“The use of DoLs is rare within the Moorside Unit and Bollin/Greenway Ward. In order to ensure staff have a good understanding of the DoLs process and its relationship to the Mental Health Act senior clinical staff will be provided with further bespoke training about DoLs which will incorporate the concerns you raise.”

Source location
Dennis-Bennett-Response
Page 2 · response
Published 12 April 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
Require all staff to complete a mandatory Deprivation of Liberty Safeguards training package and monitor completion through the ward manager.

Verbatim wording from the response
“I can confirm that in order to ensure all staff have an increased knowledge about DoLs the staff group have been asked to complete a DoLs training package which includes this information. The completion of this training is mandatory and will be monitored by the ward manager.”

Source location
Dennis-Bennett-Response
Page 3 · response
Published 12 April 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
Legislation and the code of practice provide no straightforward legal solution when urgent DoLS authorisation expires before standard authorisation is granted.

Verbatim wording from the response
“Nationally it is reported that there are an increasing number of situations in which an application for standard and urgent authorisation for DoLs has been made by the Managing Authority but the Supervisory Body has not granted the standard authorisation by the time the urgent authorisation has expired.”

Source location
Dennis-Bennett-Response
Page 2 · response
Published 12 April 2016
Open published response
6 Nov2015
Brighton and Hove
Concerns raised1
1. Failure to recognise, document and communicate Deprivation of Liberty Safeguarding Order status across care settings
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

Mr Brian James SHILLINGLAW · 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

The supplied text does not provide the circumstances or date of Mr Brian James SHILLINGLAW’s death. The principal concerns relate to the creation, updating and use of care plans and risk assessments, communication and coordination among staff, observation policy, and recording and communicating Deprivation of Liberty Safeguarding status.

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 recognise, document and communicate Deprivation of Liberty Safeguarding Order status across care settings
Wider context from the report
“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”
Source location
Mr Brian James SHILLINGLAW · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Aug2015
Birmingham and Solihull
Concerns raised1
1. Failure to reassess and renew deprivation of liberty safeguarding orders when required
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.

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

Eliza Simpson · 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

Eliza Simpson left Roseneath Care Home unobserved on 2 April 2015 and was found recently deceased at a local allotment on 6 April 2015. The inquest recorded the medical cause of death as ischaemic heart disease due to coronary artery disease and concluded that the death was accidental. Concerns included the lack of a system to reassess and renew expired deprivation of liberty safeguarding orders and the absence of CCTV, which hampered the police investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to reassess and renew deprivation of liberty safeguarding orders when required
Wider context from the report
“(1) The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate, seeking further order. In this case the home would have had no legal authority to hold Mrs. Simpson if she had been detected attempting to leave the premises on the 2nd April 2015. The very act of assessing Mrs. Simpson and renewing an application would have served to enforce to the Care Home and its staff the risk of her absconding and may have resulted in closer observation. Although the Roseneath Care Home has now closed if such a system is not standard in Care Homes this issue may arise elsewhere. ”
Source location
Eliza Simpson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to apply for DoLS assessments for residents lacking mental capacity

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

Lack of training in deprivation of liberty assessment

Concerns raised1

Lack of knowledge of Mental Capacity Act safeguarding measure limitations in privately funded community care

Concerns raised1

Failure to implement Deprivation of Liberty Safeguarding procedures accurately

Concerns raised2

Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk

Delays in processing DOLS applications

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.14

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to consider DoLS authorisation in the community

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 4

Actions described in response 14

Respondent positions 3

Respondent positions 1