10 Jun 2026 Lesley Katherine HIGGINSON · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 2
Lack of clarity about the policy for declining welfare calls View source Failure to apply clear criteria for determining whether welfare checks are healthcare related and should be accepted or rejected View source
×
AI-generated summary
Lesley Katherine HIGGINSON · 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
Lesley Katherine HIGGINSON, a medically vulnerable adult aged 72, was found deceased at home on 18 January 2026 after failed remote welfare and medication contacts. A principal concern was uncertainty about the ambulance service policy for declining welfare-check requests, including whether the request in these circumstances was properly rejected and whether responsibility was affected by the police RCRP policy.
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 clarity about the policy for declining welfare calls
Wider context from the report “It is important to know whether there is an established policy for declining welfare calls, and if so, when it was introduced. It leaves patients in a difficult position when aligned with the constabulary Right Care Right Person (RCRP) policy which was published nationally on 23 June 2023 and implemented in the Cheshire region in January 2024. The RCRP policy states that the police in Cheshire (and in other areas nationally) will not respond to welfare check calls when healthcare are best placed to support those who may be in crisis. It is unclear from the ambulance service response whether a request for a welfare check, in the circumstances of this death, is to be deemed to be healthcare related and whether the ambulance service properly rejected the request, on the grounds stated.
” Source location Lesley Katherine HIGGINSON · Prevention of Future Deaths report
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 Failure to apply clear criteria for determining whether welfare checks are healthcare related and should be accepted or rejected
Wider context from the report “It is important to know whether there is an established policy for declining welfare calls, and if so, when it was introduced. It leaves patients in a difficult position when aligned with the constabulary Right Care Right Person (RCRP) policy which was published nationally on 23 June 2023 and implemented in the Cheshire region in January 2024. The RCRP policy states that the police in Cheshire (and in other areas nationally) will not respond to welfare check calls when healthcare are best placed to support those who may be in crisis. It is unclear from the ambulance service response whether a request for a welfare check, in the circumstances of this death, is to be deemed to be healthcare related and whether the ambulance service properly rejected the request, on the grounds stated.
” Source location Lesley Katherine HIGGINSON · Prevention of Future Deaths report
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 and implement Concern for Welfare Response Criteria Guidelines governing receipt, recording, escalation and ambulance responses.
Verbatim wording from the response “This advice was in accordance with the NWAS Concern for Welfare policy, which covers the receipt, recording, escalation and NWAS responses in relation to concern for welfare of a patient. Where such calls are received, the guidelines provide that the patient’s location needs to be known and there needs to be a confirmed medical need.” Source location Response from North West Ambulance Service
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 concern-for-welfare ambulance deployment criteria and limitations to police, acute trusts, mental health organisations and councils through system-partner engagement.
Verbatim wording from the response “The Concern for Welfare Response Criteria Guidelines Policy was introduced in May 2024, in response to the Right Care, Right Person (RCRP) National Partnership Agreement. NWAS have been clear and transparent with local system partners, including the Police, Acute Trusts, Mental Health Organisations and Councils regarding the deployment of ambulances when concern for welfare calls are made to the service and the circumstances in which an ambulance will and will not be deployed. NWAS and other system partners have previously noted that there is a gap in services for members of the public who may need concern for welfare call outs and this has been discussed in both strategic and tactical RCRP meetings, but not something that NWAS are able to fulfil unilaterally.” Source location Response from North West Ambulance Service
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 Meet with Okay Each Day and explain when ambulances will and will not be deployed for concern-for-welfare calls.
Verbatim wording from the response “NWAS have also met with the Okay Each Day service who have been advised as to the circumstances in which an ambulance will and will not be deployed when concern for welfare calls are received. It was recommended by NWAS that Okay Each Day explore whether they could set up a pathway with other agencies to make initial contact with a patient where their exact location cannot be determined or for them to consider their own response team to conduct these enquiries.” Source location Response from North West Ambulance Service
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 NWAS cannot unilaterally provide welfare callouts for people whose needs or locations cannot be established.
Verbatim wording from the response “The Concern for Welfare Response Criteria Guidelines Policy was introduced in May 2024, in response to the Right Care, Right Person (RCRP) National Partnership Agreement. NWAS have been clear and transparent with local system partners, including the Police, Acute Trusts, Mental Health Organisations and Councils regarding the deployment of ambulances when concern for welfare calls are made to the service and the circumstances in which an ambulance will and will not be deployed. NWAS and other system partners have previously noted that there is a gap in services for members of the public who may need concern for welfare call outs and this has been discussed in both strategic and tactical RCRP meetings, but not something that NWAS are able to fulfil unilaterally.” Source location Response from North West Ambulance Service
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 Concern for Welfare policy was sufficient because the call lacked a verified location and confirmed physical or mental health need.
Verbatim wording from the response “The NWAS Mental Health and Suicide Prevention Lead has listened to the 999 calls made in respect of Ms Higginson and has confirmed that the 999 call from Okay Each Day at 15:16 hrs was handled appropriately and in line with the concern for welfare policy. It could not be determined that Ms Higginson was at the specified location nor could it be determined that she had a confirmed physical or mental health complaint. It was therefore correct that NWAS did not deploy an ambulance to Ms Higginson based on the information provided at the time of the call.” Source location Response from North West Ambulance Service
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 Other services must independently investigate whether an uncontactable person requires physical or mental healthcare.
Verbatim wording from the response “As an ambulance service, our primary function is to prioritise and respond to the medical needs of our patients whether this is face-to-face or via other methods. A confirmed physical or mental health complaint means that the caller has evidence or good reason to believe that the patient or service user is currently suffering from a physical or mental health issue that requires either a face-to-face assessment or telephone response. It cannot be assumed that an individual being uncontactable, means that they require medical assistance. Nor do NWAS have the capacity to conduct thorough enquiries, on behalf of other services, to determine whether an individual is experiencing physical or mental health concerns. It is incumbent upon these services to arrange for and execute such inquiries autonomously.” Source location Response from North West Ambulance Service
Open published response
20 May 2026 [PM] · Prevention of Future Deaths report Kent & Medway
View report summary
Concerns raised 1
Lack of face-to-face update or refresher training for officers undertaking community welfare checks View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Kent Police
Deliver refresher training on welfare checks, highlighting suicide risk and consideration of mental health and other agency support for suspects under investigation for child sexual abuse offences.
View source
×
AI-generated summary
[PM] · 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 deceased was arrested on 18 June 2025, released on bail, and found deceased at his home on 19 June 2025. The inquest concluded that he died by suicide. Concerns included the absence of a Kent Police policy or standard operating procedure for risk assessing and safety-netting people arrested for this type of offence, and the lack of required face-to-face refresher training for officers conducting welfare checks.
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 face-to-face update or refresher training for officers undertaking community welfare checks
Wider context from the report “2. I heard evidence that, following initial basic training, officers at Kent Police are not required to undertake any face-to-face update or refresher training regarding welfare checks that they undertake regularly in the community . For the avoidance of doubt, I found that relevant officer undertaking the welfare check on the evening of 18 June 2025 was 'kind and compassionate' and did 'her best to conduct the welfare check'; however, it is not difficult to see that a lack of ongoing training raises risk in the future .
” Source location [PM] · Prevention of Future Deaths report
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 refresher training on welfare checks, highlighting suicide risk and consideration of mental health and other agency support for suspects under investigation for child sexual abuse offences.
Verbatim wording from the response “We also utilise a comprehensive Suspect Information Pack, which is currently being refreshed. In support of the above measures, the Detective Chief Inspector in (POLIT) has met with the Chief Inspector, who leads the Medway district where [PM] died. The Chief Inspector will oversee the delivery of refresher training on welfare checks, aligned with the force-wide Right Care, Right Person (RCRP) refresher programme.” Source location Response from Kent Police
Open published response
19 May 2026 Catherine Mary MORGAN · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1
Failure to use a viable welfare-check pathway when the resident is not known to be at the address View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
College of Policing Metropolitan Police Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
College of Policing
Review Right Care Right Person and Missing Persons guidance jointly to identify clarifications supporting operational decision-making.
View source
College of Policing
Identify emerging risk-based operational practice, including escalation routes to specialist missing person teams for uncertain incident classifications.
View source
College of Policing
Produce interoperability guidance for ambiguous Right Care Right Person and Missing Persons cases, including escalation to appropriately trained specialist teams.
View source
Metropolitan Police Service
Develop an updated Concern for Welfare policy with practical scenarios addressing deployment and Local Missing Hub referral decisions.
View source
Metropolitan Police Service
Review guidance, training and quality-assurance arrangements so advice to callers is practical, achievable and aligned with partner-agency responsibilities.
View source
Metropolitan Police Service
Reinforce escalation and supervisory review when agency responsibility is uncertain, disputed or associated with increasing concern.
View source
Metropolitan Police Service
Incorporate learning from the case into ongoing MetCC training, briefings and governance processes.
View source See 4 more actions
×
AI-generated summary
Catherine Mary MORGAN · 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
Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.
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 use a viable welfare-check pathway when the resident is not known to be at the address
Wider context from the report “2. A call handler informed SLAM to call London Ambulance Service to do a welfare check at
the home address of the patient in circumstances where the ambulance service will only
attend an address if the resident is known to be there ;
” Source location Catherine Mary MORGAN · Prevention of Future Deaths report
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 Right Care Right Person and Missing Persons guidance jointly to identify clarifications supporting operational decision-making.
Verbatim wording from the response “The College has already commenced work to address this issue through the following activity:” Source location Response from College of Policing
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 Identify emerging risk-based operational practice, including escalation routes to specialist missing person teams for uncertain incident classifications.
Verbatim wording from the response “2. Identification of emerging operational practice” Source location Response from College of Policing
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 Produce interoperability guidance for ambiguous Right Care Right Person and Missing Persons cases, including escalation to appropriately trained specialist teams.
Verbatim wording from the response “2. Development of interoperability guidance between RCRP and Missing Persons frameworks” Source location Response from College of Policing
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 an updated Concern for Welfare policy with practical scenarios addressing deployment and Local Missing Hub referral decisions.
Verbatim wording from the response “In addition, the MPS is developing an updated Concern for Welfare policy, supported by practical scenarios to assist decision making. This will support increased clarity around when deployment is required or when referral to LMHs is appropriate, particularly in circumstances involving vulnerability and potential missing person risk.” Source location Response from MPS
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 guidance, training and quality-assurance arrangements so advice to callers is practical, achievable and aligned with partner-agency responsibilities.
Verbatim wording from the response “The MPS has reviewed the circumstances of this aspect of the incident. We recognise the importance of ensuring that advice provided by Met Command and Control (MetCC) staff is consistent with the responsibilities and capabilities of partner agencies and reflects the processes set out within RCRP and associated arrangements.” Source location Response from MPS
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 escalation and supervisory review when agency responsibility is uncertain, disputed or associated with increasing concern.
Verbatim wording from the response “In response to the concern raised by the Coroner, the MPS will review guidance, training and quality assurance arrangements to reinforce that where police are not the appropriate agency to respond, advice provided to callers should be practical, achievable and consistent with the responsibilities of the agency to which they are being directed. This will include reinforcing escalation and supervisory review where there is uncertainty, disagreement or increasing concern regarding the most appropriate agency response. Learning from this case will be incorporated into ongoing training, briefing and governance processes within MetCC.” Source location Response from MPS
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 learning from the case into ongoing MetCC training, briefings and governance processes.
Verbatim wording from the response “In response to the concern raised by the Coroner, the MPS will review guidance, training and quality assurance arrangements to reinforce that where police are not the appropriate agency to respond, advice provided to callers should be practical, achievable and consistent with the responsibilities of the agency to which they are being directed. This will include reinforcing escalation and supervisory review where there is uncertainty, disagreement or increasing concern regarding the most appropriate agency response. Learning from this case will be incorporated into ongoing training, briefing and governance processes within MetCC.” Source location Response from MPS
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 Healthcare providers must undertake initial reasonable enquiries when a patient leaves a healthcare setting, using the most appropriate agency or agencies.
Verbatim wording from the response “The MPS Right Care, Right Person policy and toolkit place responsibility on healthcare providers to undertake initial reasonable enquiries when a patient leaves a healthcare setting. Those enquiries should be progressed through the most appropriate agency or agencies based on the circumstances and should not rely on referral to a single service as a default position. The MPS also recognises the importance of clear escalation routes where there are concerns that the available arrangements are insufficient to manage the presenting risk.” Source location Response from MPS
Open published response
4 Feb 2026 Ryan Harding · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Delays and non-occurrence of scheduled morning welfare checks due to lack of staff View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Clyde & Co Claims LLP
Reissue written instructions and reminders on correct unlock procedures and welfare checks, including communication through safety meetings.
View source
Clyde & Co Claims LLP
Update initial and refresher training to instruct officers on positive-response welfare checks during unlock.
View source
Clyde & Co Claims LLP
Issue updated welfare-check procedures requiring physical checks during morning unlock.
View source
Clyde & Co Claims LLP
Amend residential wing ledgers to require daily recorded welfare checks, including weekends.
View source
Clyde & Co Claims LLP
Operate enhanced daily compliance checks using CCTV review, rotational unit sampling, issue escalation and management follow-up.
View source
Clyde & Co Claims LLP
Review welfare-check compliance and trends through monthly multidisciplinary Safety Meetings.
View source See 3 more actions
×
AI-generated summary
Ryan Harding · 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
Ryan Harding died overnight between 7 and 8 January 2023 in his prison cell after consuming drugs. Concerns included prison infrastructure and gatehouse security measures that required upgrading to reduce illicit materials entering the prison, and a delayed morning welfare check due to insufficient staffing.
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 and non-occurrence of scheduled morning welfare checks due to lack of staff
Wider context from the report “(3) On the morning of 8th January 2023, the scheduled morning welfare check did not take place . The evidence of officers was that this was delayed for lack of a staff member and had been delayed on other occasions .
” Source location Ryan Harding · Prevention of Future Deaths report
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 Reissue written instructions and reminders on correct unlock procedures and welfare checks, including communication through safety meetings.
Verbatim wording from the response “Following Mr Harding’s death, written instructions on correct unlock procedures and reminders of the correct process to follow when conducting welfare checks were re-issued to staff. Reminders on the correct process were also given at safety meetings. In addition, enhanced managerial checks were introduced to ensure compliance with the instructions, including daily checks being done by the prison’s Senior Managers via CCTV footage.” Source location 2026-0054 - Response from HM Prison Parc
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 initial and refresher training to instruct officers on positive-response welfare checks during unlock.
Verbatim wording from the response “modification to reflect a change in the timing of the welfare checks. PCOs have also received refresher training, and written and verbal instructions, confirming the correct way to conduct unlock procedures and welfare checks.” Source location 2026-0054 - Response from HM Prison Parc
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 Issue updated welfare-check procedures requiring physical checks during morning unlock.
Verbatim wording from the response “Following the introduction of the HMPPS framework, the HMP & YOI Parc Senior Leadership Team carefully considered measures to ensure the correct performance of enhanced roll checks and welfare checks during morning unlock resulting in a decision to align the local policy at HMP & YOI Parc with national policy set out in PSI 75/2011 and the HMPPS Framework.” Source location 2026-0054 - Response from HM Prison Parc
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 Amend residential wing ledgers to require daily recorded welfare checks, including weekends.
Verbatim wording from the response “Officers are required to record the welfare checks in the unit ledger each day to acknowledge that all prisoners have been checked on and that they are not concerned for the prisoners’ welfare. The Residential Wing Ledger has been amended to include the following wording:” Source location 2026-0054 - Response from HM Prison Parc
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate enhanced daily compliance checks using CCTV review, rotational unit sampling, issue escalation and management follow-up.
Verbatim wording from the response “Following Mr Harding’s death, written instructions on correct unlock procedures and reminders of the correct process to follow when conducting welfare checks were re-issued to staff. Reminders on the correct process were also given at safety meetings. In addition, enhanced managerial checks were introduced to ensure compliance with the instructions, including daily checks being done by the prison’s Senior Managers via CCTV footage.” Source location 2026-0054 - Response from HM Prison Parc
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 welfare-check compliance and trends through monthly multidisciplinary Safety Meetings.
Verbatim wording from the response “Each month a multidisciplinary Safety Meeting takes place at HMP & YOI Parc at which a Safety Team Senior Manager will discuss the welfare checks completed preceding month in relation to completed quality assurance and areas where issues have been raised. This will allow in-depth discussion, understanding of any issues and identification of trends and individuals requiring further support and/or performance management. Senior Managers have been reminded by the Deputy Director of the requirement to conduct daily compliance checks.” Source location 2026-0054 - Response from HM Prison Parc
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 Welfare checks could safely be conducted by one officer, and there was no requirement for officers to conduct them in pairs.
Verbatim wording from the response “Welfare checks could, and can, safely be conducted by a single officer and there was and is no requirement for officers to conduct welfare checks in pairs.” Source location 2026-0054 - Response from HM Prison Parc
Open published response
20 Oct 2025 Marc Daniel DAVIES · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2
Inadequate documentation of welfare checks View source Inadequate welfare checks on residents View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Marc Daniel DAVIES · 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
Marc Daniel Davies was found unconscious at the Huntsman Hotel on 16 October 2024 after staff were alerted that he was unwell. He was not revived and died at the hotel; the inquest recorded the medical cause of death as the combined toxic effects of methadone, clonazepam and nitrazepam. The report raises concerns about inadequate welfare checks, insufficient documentation, and a lack of evidence that staff had been trained to conduct or document welfare checks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate documentation of welfare checks
Wider context from the report “MCC contracted with MJ Events to provide safe guards; officers to ensure the security of the premises and the welfare of the residents. The officers were expected to undertake welfare checks if they had concerns about residents, including if they were under the influence of drugs or alcohol.
Managers from MCC and MJ Events who gave evidence to the inquest both agreed the welfare checks undertaken by the guards on duty on 16/10/2024, and documentation completed , were inadequate .
There was no evidence that the staff had received training on how to conduct welfare checks or what should be documented.
A failure to check on the welfare of staff and to reliably pass that information on to others could again result in a resident not receiving medical care in a timely manner.
Kindly advise me as to the training that you intend to provide to staff to ensure that they are properly equipped with the skills to discharge their duties at work.
” Source location Marc Daniel DAVIES · Prevention of Future Deaths report
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 Inadequate welfare checks on residents
Wider context from the report “MCC contracted with MJ Events to provide safe guards; officers to ensure the security of the premises and the welfare of the residents. The officers were expected to undertake welfare checks if they had concerns about residents, including if they were under the influence of drugs or alcohol.
Managers from MCC and MJ Events who gave evidence to the inquest both agreed the welfare checks undertaken by the guards on duty on 16/10/2024 , and documentation completed, were inadequate .
There was no evidence that the staff had received training on how to conduct welfare checks or what should be documented.
A failure to check on the welfare of staff and to reliably pass that information on to others could again result in a resident not receiving medical care in a timely manner.
Kindly advise me as to the training that you intend to provide to staff to ensure that they are properly equipped with the skills to discharge their duties at work.
” Source location Marc Daniel DAVIES · Prevention of Future Deaths report
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 Issue and implement a prescriptive welfare-check form with recording and response guidance across all three temporary accommodation sites.
Verbatim wording from the response “Action Taken:
MJ Events have reviewed their Welfare Check form and developed and issued a new template form for use throughout Monmouthshire Council’s three temporary accommodation sites. The form is more prescriptive and, for the benefit of Safe Guards, the guidance explains what detail needs to be recorded, by whom, and what action should be taken. (See Appendix 1). This revised template form is now in use.” Source location Response from Monmouthshire County Council & MJ Events
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 Upgrade induction training with specific welfare-check guidance and place the protocol alongside welfare-check forms at all three sites.
Verbatim wording from the response “Action Taken:
MJ Events have reviewed their approach to staff training. MJ Events have upgraded their Induction Training to include specific guidance in conducting welfare checks.” Source location Response from Monmouthshire County Council & MJ Events
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt Welfare Response Bags and require Safe Guards to carry them during welfare checks.
Verbatim wording from the response “Having review procedures, MJ Events have adopted the use of Welfare Response Bags. Staff are required to carry the Welfare Response Bags when undertaking welfare checks to eliminate wasted time returning to the office to collect items to support a resident. Safe Guards will also always carry radios and body cams to” Source location Response from Monmouthshire County Council & MJ Events
Open published response
14 Mar 2025 Alexander Robert EASTWOOD · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to undertake welfare checks on child contact-sport participants View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department for Digital, Culture, Media and Sport
×
AI-generated summary
Alexander Robert EASTWOOD · 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
On 29 June 2024, 15-year-old Alexander Eastwood became unresponsive after taking part in a kickboxing competition in Wigan. He was found to have a significant brain bleed, underwent surgery, and was declared deceased on 2 July 2024. The investigation identified concerns about the lack of guidance or regulation for children participating in contact sports, including minimum standards for medical support, rest periods, welfare checks, risk assessments and critical incident planning.
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 undertake welfare checks on child contact-sport participants
Wider context from the report “1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation.
2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant.
3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards must be met to provide safeguarding for a child participant.
4. This includes
a. no minimum standard of what medical support may be required,
b. maximum rounds or periods of rest
c. welfare checks on participants being undertaken ,
d. no risk assessment and critical incident plan
5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ’ sports involving children.
” Source location Alexander Robert EASTWOOD · Prevention of Future Deaths report
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 Direct regulation of sport does not fall within the government’s role or functions.
Verbatim wording from the response “You raised a number of concerns about the current system and I am keen to consider how best to address them. I am mindful that the government does not, and should not, regulate sport directly. However, I am concerned that the current system, which allows individual clubs to decide whether to affiliate to a National Governing Body and their associated standards, does not offer sufficient protection to children and parents.” Source location Response from Department For Culture, Media And Sport
Open published response
20 Jan 2025 Student A · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Delays in actioning welfare checks and physically attending rooms View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Unite Students
Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.
View source
Unite Students
Review Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.
View source
Unite Students
Provide 24/7 staffing at all sites to support student welfare and response capacity.
View source
×
AI-generated summary
Student A · 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
Student A was found unresponsive in his student accommodation on 28 July 2024 and paramedics verified his death shortly thereafter; the medical cause was asphyxiation and the inquest conclusion was suicide. The principal concerns were delays in carrying out the welfare check and calling emergency services, limited assessment of Student A’s condition, failure to provide basic assistance or first aid, and possible inadequacy or ineffectiveness of staff training and procedures.
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 actioning welfare checks and physically attending rooms
Wider context from the report “1. On 28 July 2024, the request for a welfare check was received by staff at Somerset Court, from the Emergency Control Centre (the ECC) for Unite Students, at approximately 07:00. The basis of the request was that Student A’s mother had been unable to contact her son. The member of staff advised the ECC that they would try to ‘call the student and if he did not answer I would then go to his room.’ At approximately 10:15, the staff member called Student A’s mobile telephone three times, ‘but it did not ring it only beeped.’ At approximately 10:50, the staff member went upstairs to Student A’s room and received a call from the ECC but ‘ignored the call’ to go to Student A’s room.
While at the material time there was no way of knowing whether this was an emergency or not, the concern here is that it nevertheless took hours for the request for a welfare check to be actioned in any way . Further, on getting no response from attempts at contact by telephone, there was further delay in physically attending Student A’s room .
” Source location Student A · Prevention of Future Deaths report
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 Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.
Verbatim wording from the response “We recognise that a second staff member could have attended sooner to facilitate a room entry after the call escalation at 11:00. The steps that we are taking to address this are twofold:” Source location Response from Unite Students
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 Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.
Verbatim wording from the response “More generally, we are reviewing all our procedures for dealing with calls made to the ECC to effectively triage calls received, and to ensure that appropriate questions are asked to understand the basis and potential seriousness of enquiries.” Source location Response from Unite Students
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 24/7 staffing at all sites to support student welfare and response capacity.
Verbatim wording from the response “To prepare our teams for this, they all receive training specific to the roles which they perform but, unfortunately, sometimes find themselves confronted by some of the most difficult situations imaginable. We have in recent years made the decision to have 24/7 staffing at all our sites and offer student welfare programmes; however, our teams are not emergency service professionals or staff providing supported living. We will, of course, work through the learnings from this tragic incident and will implement additional measures as necessary.” Source location Response from Unite Students
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 concern that the welfare-check request took hours to action is based on misinterpreted evidence, and the pre-escalation response was reasonable.
Verbatim wording from the response “First, we noted your concern that it “took hours for the request for a welfare check to be actioned in any way”. From our review of the information available, and in particular the witness statements you kindly disclosed, post inquest, we believe this concern is based on an understandable misinterpretation of the witness evidence given by one member of staff ████████.” Source location Response from Unite Students
Open published response
3 Dec 2024 Paul Martin GOBELL · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Lack of arrangements for welfare checks when the First Night Interview cannot take place View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Paul Martin GOBELL · 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 describe the circumstances or date of Paul Martin Gobell’s death. It raises concerns about the absence of a welfare check and ACCT after a First Night Interview was missed, communication about cell-sharing risk, and the lack of Probation input into an assessment of his suitability for open conditions.
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 arrangements for welfare checks when the First Night Interview cannot take place
Wider context from the report “1. Paul Gobell was serving a life sentence for rape. He had served fifteen years in a closed prison, most recently at HMP Prison, Whatton. In August 2021, he was deemed by the Parole Board to be suitable for a move to open conditions and was therefore transferred to HM Prison Hollesley Bay on 20/10/21. He was there for just two and a half weeks. Within a few hours of his return to HM Prison, Whatton on 04/11/21 he was subject to a Control & Restraint incident. His behaviour at this time was reported to be refractory and aggressive. During the incident he received a soft tissue injury which necessitated a trip to the A&E department at the local hospital. As a result, the usual First Night Interview did not take place that evening, nor on the following day. As a result there was no welfare check and no ACCT was opened. There is no national or local policy in place stating what arrangements should be made to carry out a welfare check when, for operational reasons, the First Night Interview cannot take place.
” Source location Paul Martin GOBELL · Prevention of Future Deaths report
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 Update the induction policy to require late-arrivals forms when normal induction cannot be facilitated.
Verbatim wording from the response “All prisons have well established first night induction processes and policies in place to ensure that prisoners receive appropriate care when entering prison custody. Welfare checks and conversations form part of this process and, in most cases, prisoners coming into reception are inducted in line with existing national and local policies. However, there may be exceptional circumstances when this does not happen, such as in the situation you have described involving Mr Gobell. HMP Whatton will update their Induction policy so that, when a normal induction cannot be facilitated, the prisoner will be asked to complete the “late arrivals form.” This form asks the prisoner to provide information that can then be used to consider the prisoner’s welfare until a face-to-face interview can be conducted.” Source location Response from HMPPS
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 published Expectations cover the identified prison safety issues, which inspectors will consider during inspections and follow up as appropriate.
Verbatim wording from the response “HMI Prisons’ inspections are carried out against published inspection criteria known as Expectations. The Inspectorate sets its own inspection criteria to ensure transparency and independence. Many of the issues highlighted in your report are covered via our Expectations, and therefore matters which our inspectors will consider on each inspection. For example, in relation to first night interviews, one of our safety expectations states:” Source location Response from HMIP
Open published response
8 Aug 2024 Sean Martin DAVIES · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1
Failure to conduct prisoner welfare checks in line with national guidance and local policies View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Sean Martin DAVIES · 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
Sean Martin Davies, who was serving an indeterminate sentence for public protection at HMP Swaleside, died by suspension in his cell on 25 February 2023. He had expressed hopelessness and left a note linking his death to the IPP sentence. Concerns included risk assessment and management for prisoners subject to IPP sentences, welfare checks not being conducted in line with guidance or policy, and shortcomings in staff training and handovers.
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 conduct prisoner welfare checks in line with national guidance and local policies
Wider context from the report “(2) It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies
” Source location Sean Martin DAVIES · Prevention of Future Deaths report
Open source report
30 Apr 2024 Marlin Burrows · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Marlin Burrows · 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
Marlin Burrows was found collapsed in his cell at HMP Garth on 15 August 2022 and died in the early hours of 16 August 2022 after being semi-conscious for nearly 15 hours. The inquest concluded that he died from multi-organ failure due to serotonin syndrome and drug toxicity, including amitriptyline toxicity. Concerns included unclear welfare-sheet purposes and guidance, poor communication of entries to medical staff, and insufficient joint consideration of the sheet by prison and healthcare 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 Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern
Wider context from the report “(1) The existing welfare sheet lacks clarity as to its exact purpose in terms of monitoring a prisoner whose health is of concern .
” Source location Marlin Burrows · Prevention of Future Deaths report
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 HMP Garth healthcare staff to develop training and awareness sessions for prison staff on welfare checklist use and guidance.
Verbatim wording from the response “In addition, the Head of Nursing and Quality for the Health & Justice Division at GMMH will work with the Healthcare staff at HMP Garth to develop some training and awareness sessions for prison staff around the use of the welfare checklist and the associated guidance once the national policy is implemented.” Source location Response from Greater Manchester Mental Health
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 consult on national guidance for managing prisoners under the influence of illicit substances, incorporating the reported welfare-check concerns.
Verbatim wording from the response “I am pleased to inform you that HMPPS is currently developing national guidance for all staff managing prisoners who are under the influence of illicit substances. The guidance has been developed by the national Substance Misuse Group with contributions from internal and external stakeholders, including from areas such as health, and safety. Its purpose is to provide structured guidance for prisons to support the development of local under the influence guidance that will ensure that there is a consistent and safe response to the management of prisoners. It is important to note that this guidance does not replace healthcare advice and in a medical emergency instructions and advice from healthcare colleagues must be followed as a priority.” Source location Response from HMPPS
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 Produce a standard operating procedure defining prison and healthcare staff responsibilities when conducting welfare checks on prisoners monitored under the influence.
Verbatim wording from the response “In the meantime, I have received assurance from the Governor of HMP Garth that following the inquest meetings have been held between prison and healthcare colleagues to ensure a joined up approach going forward. Once national guidance is available, a standard operating procedure will be produced so that all prison and healthcare staff understand what they are expected to do when carrying out welfare checks on prisoners being monitored under the influence. GMMH have also committed to developing local training and awareness sessions around the use of the welfare check sheet once national guidance has been published.” Source location Response from HMPPS
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 HMPPS is developing national guidance addressing welfare checklist concerns about purpose, completion guidance and joint consideration.
Verbatim wording from the response “Our prison partners have informed us that nationally the picture has changed. His Majesties Prison and Probation Service (HMPPS) are developing national guidance for the management of people under the influence and that this process is currently going through consultation with” Source location Response from Greater Manchester Mental Health
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.