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

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
25

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

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.

  1. Bedfordshire and Luton

    AI-generated summary

    Margaret Emily Flemming · Prevention of Future Deaths report

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

    Report summary

    Margaret Emily Flemming, a care-home resident with dementia, was seen by a doctor and prescribed antibiotics over 17–18 January 2015, and died peacefully at the care home the following day. The report raised concerns about delays in completing a Best Interests Assessment after an urgent Deprivation of Liberty Safeguarding Authorisation request, while she remained vulnerable and confused.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in completing Best Interests Assessments following urgent Deprivation of Liberty Safeguarding Authorisation requests

    Wider context from the report

    “1. An urgent Request for a Deprivation of Liberty Safeguarding Authorisation was placed with Central Bedfordshire Council on 8th October 2014 and yet the Best Interests Assessment did not take place until 7th January 2015. The deceased remained vulnerable throughout this period. ”

    Source location

    Margaret Emily Flemming · 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

    Apply a risk-based approach and waiting list to prioritise DoLS assessments.

    Verbatim wording from the response

    “Since March 2014, the Council has adopted a risk based approach, prioritising DoLS assessments on the basis of risk of harm to the person concerned, and using a waiting list for those assessed as low risk. As there was no indication of concerning with Mrs Flemming’s care package, no concerns raised by her family, and no indication of undue or excessive physical or medical restraint being used, the request relating to Mrs Flemming was assessed as low risk. Because of this, it meant that Mrs Flemming’s Best Interests Assessment did not take place until 9th January 2015. The outcome of this was that restrictions amounting to continuous supervision and control had been in place for frequent and prolonged period since Mrs Flemming’s admission on 22nd May 2009, she was not free to leave, and the placement was in her best interests.”

    Source location

    2015-0029-Response-by-Central-Bedfordshire-Council
    Page 1 · response
    Published 29 January 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

    Recruit temporary qualified staff to address increased DoLS assessment activity.

    Verbatim wording from the response

    “The Council has adopted the prioritisation approach and waiting list as a temporary measure, in order to be able to respond to the ten fold increase in DoLS activity. Part of the strategy to respond to this increase has been to recruit temporary qualified staff, and train additional staff to perform the Best Interests Assessor function. The Council is maintaining its investment in these staff to deal with the increase in activity.”

    Source location

    2015-0029-Response-by-Central-Bedfordshire-Council
    Page 2 · response
    Published 29 January 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 additional staff to perform the Best Interests Assessor function.

    Verbatim wording from the response

    “The Council has adopted the prioritisation approach and waiting list as a temporary measure, in order to be able to respond to the ten fold increase in DoLS activity. Part of the strategy to respond to this increase has been to recruit temporary qualified staff, and train additional staff to perform the Best Interests Assessor function. The Council is maintaining its investment in these staff to deal with the increase in activity.”

    Source location

    2015-0029-Response-by-Central-Bedfordshire-Council
    Page 2 · response
    Published 29 January 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

    Maintain investment in temporary and additional assessment staff to address increased DoLS activity.

    Verbatim wording from the response

    “The Council has adopted the prioritisation approach and waiting list as a temporary measure, in order to be able to respond to the ten fold increase in DoLS activity. Part of the strategy to respond to this increase has been to recruit temporary qualified staff, and train additional staff to perform the Best Interests Assessor function. The Council is maintaining its investment in these staff to deal with the increase in activity.”

    Source location

    2015-0029-Response-by-Central-Bedfordshire-Council
    Page 2 · response
    Published 29 January 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

    Procure external specialist support to undertake assessments on the DoLS waiting list.

    Verbatim wording from the response

    “Whilst the waiting list is reducing (from 237 in January to 209 in February) this is not a position the Council wishes to maintain. We are currently in the process of procuring external specialist support to undertake all of the assessments on the waiting list.”

    Source location

    2015-0029-Response-by-Central-Bedfordshire-Council
    Page 2 · response
    Published 29 January 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 Council considered the care provided during the delayed DoLS assessment appropriate and in the deceased’s best interests.

    Verbatim wording from the response

    “Since March 2014, the Council has adopted a risk based approach, prioritising DoLS assessments on the basis of risk of harm to the person concerned, and using a waiting list for those assessed as low risk. As there was no indication of concerning with Mrs Flemming’s care package, no concerns raised by her family, and no indication of undue or excessive physical or medical restraint being used, the request relating to Mrs Flemming was assessed as low risk. Because of this, it meant that Mrs Flemming’s Best Interests Assessment did not take place until 9th January 2015. The outcome of this was that restrictions amounting to continuous supervision and control had been in place for frequent and prolonged period since Mrs Flemming’s admission on 22nd May 2009, she was not free to leave, and the placement was in her best interests.”

    Source location

    2015-0029-Response-by-Central-Bedfordshire-Council
    Page 1 · response
    Published 29 January 2015

    Open published response
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Data last updated 7 September 2026