Recurring concern

Inadequate professional registration and fitness-to-practise safeguards

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First reported 20 Dec 2013•Latest report 28 Dec 2025

Definition

What this concern includes

Includes failures of professional registration, verification and fitness-to-practise safeguards, including checking registration status, communicating relevant concerns, applying provisional conditions or restrictions, and preventing continued clinical practice when unresolved concerns create an identified safety risk.

Not included

  • Excludes failures of clinical competence, supervision or appointment processes where no professional registration or fitness-to-practise safeguard is identified.
  • Excludes generic regulatory, governance or information-sharing deficiencies not specifically tied to professional registration status or fitness to practise.
  • Excludes routine employment checks unrelated to professional registration or unresolved fitness-to-practise concerns.
  • Excludes failures confined to a named specialist workforce or service where the shared unsafe condition is not a registration or fitness-to-practise safeguard failure.
Reports
6

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
10

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.

Department of Health and Social Care3
General Medical Council3
Care Quality Commission1
Cumbria County Council1
Faculty of Physician Associates1
Health and Care Professions Council1
Health Services Safety Investigations Body1
Ministry of Housing, Communities and Local Government1
NHS England1
North Cumbria Integrated Care NHS Foundation Trust1
University Hospital Lewisham1
University of Wolverhampton1
West Midlands Ambulance Service University NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    Mohamed Abdisamad · 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

    Mohamed Abdisamad underwent a non-therapeutic male circumcision on 12 February 2023 and developed symptoms of illness three to four days later. He suffered a cardiorespiratory arrest while being taken to hospital and was declared dead on 19 February 2023; the inquest recorded invasive Streptococcus pyogenes infection following male circumcision as the medical cause of death. The report raised concerns about the lack of training, accreditation, record keeping, consent, infection-control requirements and aftercare requirements for individuals conducting such 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

    Lack of external accreditation and registration for NTMC practitioners

    Wider context from the report

    “2. There is no system of external accreditation and/or registration for individuals who conduct a Non-Therapeutic Male Circumcisions (NTMC). ”

    Source location

    Mohamed Abdisamad · 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

    Existing professional regulation and CQC registration provide safety and quality oversight when regulated healthcare professionals perform male circumcision.

    Verbatim wording from the response

    “If an NTMC procedure is carried out by a regulated healthcare professional, they will be subject to oversight by the relevant professional regulator such as the GMC for”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 29 December 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

    Circumcisions performed by non-registered healthcare professionals, including non-therapeutic procedures, fall outside CQC regulatory scope.

    Verbatim wording from the response

    “The CQC provides oversight of services provided by registered health professionals performing male circumcision, ensuring consistent standards of safety and quality in those cases. This includes both therapeutic and non-therapeutic male circumcision. Circumcision carried out by individuals who are not registered healthcare professionals remain outside of CQC regulatory scope. This includes any non-therapeutic circumcision, regardless of the purposes for carrying out the circumcision.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 29 December 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

    Responsibility for the reported issues rests with DHSC, which has provided the comprehensive government response; MHCLG has nothing further to add.

    Verbatim wording from the response

    “MHCLG is responsible for the overall stewardship of the local government sector, but we are not responsible for all the services that councils deliver. Councils deliver a very wide range of services to residents, within a national legislative framework. Decisions around management are often taken locally, but the lead Government department for any particular issue delivered by a local authority is responsible for working with councils to ensure effective delivery.”

    Source location

    Response from MHCLG
    Page 1 · response
    Published 29 December 2025

    Open published response
  2. Manchester North

    AI-generated summary

    Susan Pollitt · 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

    Susan Pollitt was admitted to hospital after collapsing at home and developed ascites during her admission. An ascitic drain was inserted, remained in place for 21 hours, and was clamped; she developed bacterial peritonitis and died on 16 July 2023. The principal concerns included the lack of regulatory oversight and national training and competency frameworks for Physician Associates, and limited understanding of their role and responsibilities in managing ascitic drains.

    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 require employers to verify Physician Associate registration

    Wider context from the report

    “2. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so, nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate. ”

    Source location

    Susan Pollitt · 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

    Remind employers to check physician associates’ voluntary register before employment and at regular intervals.

    Verbatim wording from the response

    “This statement highlights why formal regulation is so important. Neither the RCP nor the FPA has regulatory powers to mandate registration. In the absence of this, the FPA writes to employers on a regular basis reminding them of the existence of the PAMVR and, importantly, of the need to check that a PA is registered on the PAMVR before employment, as well as checking at regular intervals during their employment.”

    Source location

    Response from Faculty of Physician Associates
    Page 2 · response
    Published 8 August 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

    Begin statutory regulation of physician associates and anaesthesia associates from December 2024.

    Verbatim wording from the response

    “In 2017, the Department of Health and Social Care (DHSC) consulted on which healthcare regulator would be most suitable to regulate one, some, or all the medical associate professions, which include PAs and AAs. Surgical care practitioners are the third profession in this group but are not included in those we will regulate. Following the consultation, the Government determined the GMC was most appropriate and formally asked us to take on the regulation of PAs and AAs which we agreed to do. The UK and Scottish parliaments approved the legislation (Anaesthesia Associates and Physician Associates Order 2024) earlier this year and it has been granted Royal Assent. This means the GMC will become the regulator of PAs and AAs from December 2024 and, from December 2026, they will have protected titles in law (‘Physician Associate’ and ‘Anaesthesia Associate’).”

    Source location

    Response from GMC
    Page 2 · response
    Published 8 August 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

    Strongly encourage physician associates to join the GMC register as soon as possible.

    Verbatim wording from the response

    “We anticipate that employers will make GMC registration a condition for their PAs in the same way as they have done up to now in relation to voluntary registration. Although GMC registration doesn’t become a legal requirement for practice until December 2026, we will strongly encourage all PAs to join our register as soon as possible.”

    Source location

    Response from GMC
    Page 3 · response
    Published 8 August 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

    The FPA cannot mandate physician-associate registration because it has no regulatory powers.

    Verbatim wording from the response

    “This statement highlights why formal regulation is so important. Neither the RCP nor the FPA has regulatory powers to mandate registration. In the absence of this, the FPA writes to employers on a regular basis reminding them of the existence of the PAMVR and, importantly, of the need to check that a PA is registered on the PAMVR before employment, as well as checking at regular intervals during their employment.”

    Source location

    Response from Faculty of Physician Associates
    Page 2 · response
    Published 8 August 2024

    Open published response
  3. Black Country

    AI-generated summary

    Lauren Page Smith · Prevention of Future Deaths report

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

    Report summary

    Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.

    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

    Gap in fitness-to-practise oversight for unregistered technicians

    Wider context from the report

    “Some of the concerns I have identified are directed at multiple organisations and some are specific. During the course of the inquest I heard live evidence from Paramedic ████████, Technician ████████ and patient Safety Lead ████████ 1. An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss Smith. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics. 2. Interpretation of a 12 lead ecg is fundamental part of the job of a paramedic and the ecg was not interpreted correctly by either the paramedic technician or the attending paramedic with over 8 years’ experience. 3. Paramedic ████████ gave evidence at inquest that she’d never heard of Q waves before and didn’t see the ST elevation on the ecg. She’d never heard of the term pathological Q waves nor an AVR positive deflection. 4. Technician ████████ told me she had never heard of pathological Q waves and that she wouldn’t know what they were. She told me she didn’t recognise the ST elevation on the ecg. 5. The ecg print out clearly indicated a cardiac event in progress at the time the ecg was taken. Lauren Smith died from an acute MI. 6. I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report. 7. Lauren Smith was informed that her observations and ecg were normal. This information was not correct, and it is likely that Lauren Smith based her decision not to attend hospital on this incorrect information. 8. I was told in evidence that paramedic training includes identifying Q waves and ST elevations and any abnormal rhythms. I was told that a positive AVR deflection (which was a view) was not ‘normal’ and should have been identified as abnormal. I was told that the diagnostic monitor display reported what was seen on the ecg. 9. I heard in evidence that ecg interpretation forms part of a paramedics initial training and mandatory annual training, but I am concerned that there was no evidence at inquest of any qualitative assessment of the ecg aspect of their training. I was informed that Technician ████████ was undertaking a Paramedic BSc at Wolverhampton University. The training provider and/or regulator must ensure that training is effective. I am concerned the absence of such assessment presents a risk to patient safety at this time. 10. I heard in evidence that neither paramedic nor technician had received any further training from WMAS following the death of Lauren Smith and the internal SI investigation which specifically identified the incorrect interpretation of the ecg. I am concerned this presents a risk to patient safety at this time. 11. I am concerned that whilst ████████ and ████████ may’ve undertaken their own additional learning/self-reflection NO qualitative assessment of this learning has been undertaken and no action has been taken by their employer WMAS and no restrictions or sanctions placed on their practice nor further individual training provided by WMAS and they continue in their respective roles. I am concerned this presents a clear existing risk to patients which remained unaddressed at the time of inquest. 12. I was told in evidence that neither paramedic nor technician had been referred to the HCPC. I have reported my concern about the fitness to practice of both ████████ and ████████ to the HCPC however there appears to be a lacuna in respect of ████████. ████████ is a technician and not a fully qualified paramedic and as such is not yet registered with the HCPC. Therefore, the HCPC can take no action at the present time. I am informed the report I have made will be considered at such time as ████████ applies for full registration. I am concerned this presents a risk to patient safety at this time. 13. I am informed that as ████████ is a Student Paramedic (qualified/trained to technician level), WMAS as her employer are responsible for her professional competency. I am concerned that the lacuna I have identified in relation to her technician status has not been addressed and that despite WMAS applying the same HCPC standards to trainees as fully qualified paramedics, WMAS have taken no action in relation to ████████ fitness to practice and provided no further training. I am concerned this presents a risk to patient safety at this time. 14. I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of ████████. There has been no action to address the learning gaps identified by WMAS own internal investigation in respect of both the paramedic and technician. Therefore, I have addressed this aspect of my PFD to the CQC/Chief Inspector of Hospitals/HSIB as part of their regulation as to the safety of the West Midlands Ambulance Service considering the risk I have identified in relation to patient safety due to inaction by WMAS. ”

    Source location

    Lauren Page Smith · 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

    Add the individual's name to the HCPC Watchlist.

    Verbatim wording from the response

    “However, I have added her name to our Watchlist. This provides that should she attempt to apply for registration in the future, we will take the concerns you have raised with us into account when considering whether to admit her name to the HCPC Register.”

    Source location

    Response from Health and Care Profession Council
    Page 1 · response
    Published 22 November 2023

    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 Trust referral practices to ensure appropriate fitness-to-practise referrals are made.

    Verbatim wording from the response

    “Response The Trust follows the guidance provided by the HCPC in relation to circumstances in which a referral by an employer should be made. This guidance can be found on the HCPC website (https://www.hcpc-uk.org/employers/managing-concerns/refer-an-employee-to-us/). Reference the section ‘When to refer’, the Trust did not believe that a referral was required following the serious incident investigation. Accepting that a referral has now been made, the Trust will review its practices to ensure appropriate referrals are made.”

    Source location

    Response from West Midlands Ambulance Service
    Page 9 · response
    Published 22 November 2023

    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

    Concerns about an individual not registered with the HCPC fall outside its remit for further investigation.

    Verbatim wording from the response

    “A review of our Register has revealed that ████████ is not registered with us. As the individual is not registered with us, these concerns do not fall within our remit for further investigation.”

    Source location

    Response from Health and Care Profession Council
    Page 1 · response
    Published 22 November 2023

    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

    An employer referral was not considered necessary under HCPC guidance following the serious incident investigation.

    Verbatim wording from the response

    “Response The Trust follows the guidance provided by the HCPC in relation to circumstances in which a referral by an employer should be made. This guidance can be found on the HCPC website (https://www.hcpc-uk.org/employers/managing-concerns/refer-an-employee-to-us/). Reference the section ‘When to refer’, the Trust did not believe that a referral was required following the serious incident investigation. Accepting that a referral has now been made, the Trust will review its practices to ensure appropriate referrals are made.”

    Source location

    Response from West Midlands Ambulance Service
    Page 9 · response
    Published 22 November 2023

    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

    A fitness-to-practise referral was considered unlikely to meet referral criteria given the employment context, remaining training and registered-paramedic supervision.

    Verbatim wording from the response

    “At the time of the incident, ████████ was working as an employee of WMAS and not in her capacity as a student on placement. As such, WMAS did not notify the University of the incident and we remained unaware of it until two days prior to the receipt of the Regulation 28 report. Had we known earlier, we may have considered whether a referral to an FtP panel was appropriate, but it seems unlikely that the event would have met the criteria for referral. ████████ still had over 15-months of her programme remaining (including the sessions on ECGs), and she was working with a registered paramedic who held overall responsibility and accountability for the decisions made.”

    Source location

    Response from University of Wolverhampton
    Page 4 · response
    Published 22 November 2023

    Open published response
  4. Inner South London

    AI-generated summary

    Thomas Warren · 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

    Thomas Warren, a child with cerebral palsy, died after receiving a 25 microgram fentanyl patch for pain and subsequently developing symptoms before suffering a cardiac arrest. The report identified concerns about prescribing an opiate to an opiate-naïve child without hospital admission, missed opportunities to stop dispensing the drug and provide parents with adequate monitoring information, and gaps in checks on the fitness to practise of a locum doctor.

    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 secure complete employment histories, references and fitness to practise information for long-term locum doctors

    Wider context from the report

    “(2) There are particular difficulties with securing a complete sequence of employment and the associated references and confirmation about concerns for fitness to practice of long term locum doctors who may have gaps between jobs or worked abroad. Thus serious concerns about practice may have existed but not come to notice of the Agency or prospective employing NHS Trust. ”

    Source location

    Thomas Warren · Prevention of Future Deaths report
    Page 1 · 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

    Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers

    Wider context from the report

    “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance. ”

    Source location

    Thomas Warren · Prevention of Future Deaths report
    Page 1 · 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 place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete

    Wider context from the report

    “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance. ”

    Source location

    Thomas Warren · Prevention of Future Deaths report
    Page 1 · 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

    Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors

    Wider context from the report

    “(1) There does not appear to be clarity as to who or which organization should enquire into previous fitness to practice concerns and referrals to NCAS (or successor organization) which have not led to restrictions or conditions of registration by the GMC when locum doctors are being recruited by an Agency at short notice by prospective NHS Trusts. In this case it appears that neither the Recruitment Agency nor Trust nor consultant asked the doctor before his employment began. ”

    Source location

    Thomas Warren · 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

    Complete employment and professional registration checks for recruited staff, including verifying GMC registration, restrictions and fitness-to-practise investigations.

    Verbatim wording from the response

    “All staff recruitment at the Trust including engagement of agency medical staff is completed in line with these requirements. The six checks required are:”

    Source location

    2014-0378-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 1 · response
    Published 14 August 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review temporary-staff employment-check processes, including medical agency staff, through an internal audit in January 2015.

    Verbatim wording from the response

    “We also review both policy and practice in relation to employment checks on a regular basis and as changes to the national requirements are introduced. Our internal audit team will be reviewing the processes for temporary staff, including medical agency staff, in January 2015, and any recommendations from this audit will of course will be implemented.”

    Source location

    2014-0378-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 2 · response
    Published 14 August 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish a high-level Secondary Care Locum Doctor Working Group and obtain recommendations to strengthen locum-doctor recruitment and quality assurance.

    Verbatim wording from the response

    “In November 2013, I established a high level Secondary Care Locum Doctor Working Group. This made a series of recommendations to Government to strengthen the existing arrangements:”

    Source location

    2014-0378-Response-by-Department-of-Health
    Page 2 · response
    Published 14 August 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing recruitment and revalidation arrangements provide sufficient assurance, so further enquiry into locum doctors’ previous fitness-to-practise concerns is not necessary.

    Verbatim wording from the response

    “As part of the professional registration and qualification check, the Trust verifies on line with the Registered Body, in this case the GMC, whether the candidate:”

    Source location

    2014-0378-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 2 · response
    Published 14 August 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Locum agencies and healthcare providers are responsible for checking doctors’ fitness and suitability, with ultimate responsibility resting with the employer.

    Verbatim wording from the response

    “It is the responsibility of both the locum agency and the healthcare provider to check a doctor is up to date, fit to practise and suitable for a specific post. Ultimately, the employer is responsible for the staff it employs, but if an agency is involved, the agency should apply the same checks as the Trust itself would if employing directly.”

    Source location

    2014-0378-Response-by-Department-of-Health
    Page 3 · response
    Published 14 August 2014

    Open published response
  5. South and East Cumbria

    AI-generated summary

    Helena Kathleen Farrell · 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

    Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.

    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 verify school counsellor updating, training and professional registration

    Wider context from the report

    “(5) The school’s counsellor had been in post for many years and there was no proof of her qualifications or her competence nor of update and training or registration with any professional body. The County Council needs to be more thorough with checking credentials. ”

    Source location

    Helena Kathleen Farrell · 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

    Remind schools to ensure school counsellors are appropriately qualified and receive appropriate clinical supervision.

    Verbatim wording from the response

    “The Council has in the past reminded schools of their duty to ensure that counsellors are appropriately qualified with appropriate clinical supervision. Following your report we shall do so again by the end of September and will also undertake a sample audit later in the school year to ascertain from schools whether they have complied with their duty. The results of this audit will be presented to the Local Safeguarding Children’s Board.”

    Source location

    2014-0309-Response-by-Cumbria-County-Council
    Page 2 · response
    Published 3 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Audit a sample of schools’ compliance with counsellor qualification and clinical supervision duties, and present the results to the Local Safeguarding Children Board.

    Verbatim wording from the response

    “The Council has in the past reminded schools of their duty to ensure that counsellors are appropriately qualified with appropriate clinical supervision. Following your report we shall do so again by the end of September and will also undertake a sample audit later in the school year to ascertain from schools whether they have complied with their duty. The results of this audit will be presented to the Local Safeguarding Children’s Board.”

    Source location

    2014-0309-Response-by-Cumbria-County-Council
    Page 2 · response
    Published 3 July 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Academies and foundation or voluntary aided schools appoint and employ their counsellors, so responsibility for relevant checks rests with their governing bodies or academies.

    Verbatim wording from the response

    “The Council is not the employer of counsellors at Academies such as Kirkbie Kendal School or in Foundation or Voluntary Aided Schools. The Governing Body or the Academy appoints and employs all staff in these schools.”

    Source location

    2014-0309-Response-by-Cumbria-County-Council
    Page 2 · response
    Published 3 July 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Individual community and voluntary controlled schools are legally responsible for deciding appointments and completing relevant employment checks for counsellors.

    Verbatim wording from the response

    “The Council does employ counsellors at Community and Voluntary Controlled Schools however deciding which staff are appointed and ensuring the relevant employment checks are completed is the legal responsibility of the individual school. The school must adhere to relevant safeguarding guidance and employment law.”

    Source location

    2014-0309-Response-by-Cumbria-County-Council
    Page 2 · response
    Published 3 July 2014

    Open published response
  6. North Wales (East and Central)

    AI-generated summary

    Kate Louise PIERCE · 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

    Kate Louise PIERCE died on 14 March 2013, aged 7, following complications associated with meningitis, including acquired cerebral palsy, epilepsy and chronic lung disease. The report raised concerns about the handling of her diagnosis at Wrexham Maelor Hospital and whether a doctor misled her parents about obtaining a second opinion. It also raised concerns about that doctor's fitness to practise and continued work as a GP, identifying a risk of future deaths.

    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

    Continued practice by a GP whose fitness to practice is in doubt

    Wider context from the report

    “On the 29th of March 2006 Kate was taken into the Wrexham Maelor Hospital where she was examined by a Dr ████████. It appears from the evidence available that he failed to deal correctly with the diagnosis of Kate's condition and furthermore there is a belief that he may have misled the parents of Kate by indicating that he had sought a second opinion from a colleague before discharging her when this was not in fact the case. I understand that enquiries were made previously by the GMC following a complaint against Dr ████████ but that no action has been taken due to legal action by the Dr in view of the elapse of a relevant time limit. In the course of my current investigation following Kate’s death, a statement has been obtained from a witness namely Dr ████████ and a copy of this is annexed hereto. My view is that this statement casts doubt on Dr ████████ fitness to practice and this is of grave concern as my understanding is that he currently continues to practice as a GP within my Corner Area. In view of this I consider that there is a risk of future deaths. ”

    Source location

    Kate Louise PIERCE · Prevention of Future Deaths report
    Page 1 · 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

    Responsible Officer oversight, complaint reporting and periodic revalidation were considered sufficient to address concerns about current fitness to practise.

    Verbatim wording from the response

    “In terms of Dr ████████ current fitness to practise, we have not received any further complaints about Dr ████████ since 2007. Additionally, as part of the process of revalidation of a doctor’s licence to practise, doctors must have a Responsible Officer whose statutory duties include reporting concerns to us, if they call into question a doctor’s current fitness to practise. Our Employer Liaison Advisor who is a senior member”

    Source location

    2013-0363-Response-by-General-Medical-Council
    Page 1 · response
    Published 20 December 2013

    Open published response
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Data last updated 7 September 2026