Recurring concern

Unreliable welfare-check processes for people whose health is of concern

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First reported 28 May 2014•Latest report 10 Jun 2026

Definition

What this concern includes

Includes failures of welfare-check processes for people whose health or welfare is of concern, including unclear purpose, frequency or criteria, inconsistent understanding of what constitutes a check, inadequate recording requirements and related controls needed to ensure checks are meaningful and traceable.

Not included

  • Excludes routine patient observations, continuous observation, clinical monitoring and named mental-health observation systems unless the assertion specifically concerns a welfare-check process.
  • Excludes failures limited to conducting welfare checks for people in distress where the broader concern is completion of a distress check rather than the health-concern welfare-check process.
  • Excludes generic policy, training, documentation or staffing deficiencies unless they directly undermine the definition, delivery or recording of required welfare checks.
  • Excludes non-person checks, such as premises, equipment or prisoner-security checks, unless the assertion concerns a person's health or welfare.
Reports
28

Distinct published reports

Individual concerns
34

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
54

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.

Ministry of Justice6
HM Prison and Probation Service3
Department of Health and Social Care2
Dorset Healthcare University NHS Foundation Trust2
Metropolitan Police Service2
NHS England2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Cardiff & Vale University LHB1
Care Quality Commission1
Care UK1
College of Policing1
Department for Digital, Culture, Media and Sport1
Depaul UK1
Devon & Cornwall Police1
Exeter Prison1

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. Cheshire

    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
    Page 3 · 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

    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
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    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
    Page 2 · response
    Published 13 August 2026

    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
    Page 2 · response
    Published 13 August 2026

    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
    Page 2 · response
    Published 13 August 2026

    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
    Page 2 · response
    Published 13 August 2026

    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
    Page 2 · response
    Published 13 August 2026

    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
    Page 2 · response
    Published 13 August 2026

    Open published response
  2. Kent & Medway

    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
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    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
    Page 3 · response
    Published 13 August 2026

    Open published response
  3. Kent and Medway

    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
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review 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
    Page 1 · response
    Published 28 July 2026

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    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
    Page 1 · response
    Published 28 July 2026

    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
    Page 2 · response
    Published 28 July 2026

    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
    Page 3 · response
    Published 28 July 2026

    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
    Page 4 · response
    Published 28 July 2026

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    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
    Page 4 · response
    Published 28 July 2026

    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
    Page 4 · response
    Published 28 July 2026

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    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
    Page 4 · response
    Published 28 July 2026

    Open published response
  4. South Wales Central

    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
    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

    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
    Page 4 · response
    Published 4 February 2026

    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
    Page 4 · response
    Published 4 February 2026

    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
    Page 4 · response
    Published 4 February 2026

    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
    Page 5 · response
    Published 4 February 2026

    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
    Page 4 · response
    Published 4 February 2026

    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
    Page 6 · response
    Published 4 February 2026

    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
    Page 3 · response
    Published 4 February 2026

    Open published response
  5. Gwent

    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
    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

    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
    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

    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
    Page 4 · response
    Published 23 October 2025

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    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
    Page 4 · response
    Published 23 October 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

    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
    Page 4 · response
    Published 23 October 2025

    Open published response
  6. Manchester West

    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
    Page 2 · 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

    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
    Page 1 · response
    Published 17 March 2025

    Open published response
  7. Inner North London

    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
    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

    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
    Page 2 · response
    Published 28 January 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

    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
    Page 3 · response
    Published 28 January 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

    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
    Page 3 · response
    Published 28 January 2025

    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
    Page 1 · response
    Published 28 January 2025

    Open published response
  8. Nottinghamshire

    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
    Page 1 · 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

    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
    Page 1 · response
    Published 28 January 2025

    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
    Page 1 · response
    Published 28 January 2025

    Open published response
  9. Mid Kent and Medway

    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
    Page 3 · concerns

    Open source report
  10. Liverpool and the Wirral

    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
    Page 1 · 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 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
    Page 2 · response
    Published 9 May 2024

    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
    Page 1 · response
    Published 9 May 2024

    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
    Page 2 · response
    Published 9 May 2024

    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
    Page 1 · response
    Published 9 May 2024

    Open published response
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Data last updated 7 September 2026