First reported 19 Nov 2021•Latest report 17 Apr 2024
Definition
What this concern includes
Includes failures in capacity-related decision processes to provide or clarify relevant information, establish the person's understanding and wishes, consider the consequences of the decision, and revisit the decision when circumstances or risks change; include capacity-based information-sharing decisions and other consequential care decisions where the person's capacity is relied upon.
Not included
Excludes generic failures to assess mental capacity where the unsafe condition is not that the decision lacked relevant information, wishes or consequence-based clarification.
Excludes ordinary disagreements with a capacity-based decision when the person's understanding, wishes and relevant consequences were adequately established and considered.
Excludes failures limited to communicating with families or carers after a capacity-based decision was properly made.
Excludes Mental Capacity Act authorisation, best-interests, deprivation-of-liberty and advocacy-process failures where the specific statutory process, rather than informed capacity-based decision-making, is the supported concern.
Reports
3
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2021–2024
First to latest report issue date
Stated actions
16
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.
NHS England2
Cygnet Health Care Limited1
Pennine Care NHS Foundation Trust1
St George's, Epsom and St Helier Hospital Group1
Executive non-departmental public body2
NHS provider group1
NHS trust1
Private limited company1
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.
Surrey
Concerns raised1
Failure to provide requisite information before relying on decision-making capacity
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review, update and approve the discharge policy to identify vulnerable patients, involve families and clarify safe-discharge responsibilities and escalation processes.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Refresh safeguarding and Mental Capacity Act training into two sessions supported by dedicated e-learning modules.
Stated by Epsom and St Helier University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
Action
Provide additional safeguarding and Mental Capacity Act training, including individualised training for Trust discharge coordinators.
Stated by Epsom and St Helier University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
South Yorkshire (Western)
Concerns raised2
Inadequate assessment and clarification of capacity-based information-sharing wishes
Failure to regularly revisit capacity and information-sharing decisions
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Revise the NHSE Case Management Standard Operating Procedure using learning from quality concerns in CAMHS inpatient services.
Stated by NHS England - North East and YorkshireStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.
Action
Implement the revised NHSE Case Management Standard Operating Procedure.
Stated by NHS England - North East and YorkshireStated plannedThe respondent said that this action was planned when they made their response on 3 October 2022.
Action
Implement specific communication care plans for every young person, with fortnightly review and documentation of information-sharing decisions and their reconsideration.
Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Document consideration of young people’s individual needs, priorities, understanding and associated risks in ward-round summaries.
Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing discussions, ward-round reviews and capacity assessment were considered sufficient assurance regarding Chelsea’s decision not to share information with family.
Stated by NHS England - North East and YorkshireExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
Concerns raised1
Failure to conduct capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2022.
Action
Commission Mental Capacity Act training for all clinicians.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Deliver mental-capacity lunch-and-learn sessions in Oldham.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Design a Mental Capacity Act audit.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 October 2022.
Action
Implement PARIS across inpatient mental health wards, including a mental-capacity assessment documentation template.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Share inquest learning about longitudinal mental-capacity assessment with senior Oldham consultant psychiatrists.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2022.
Action
Escalate the need for additional longitudinal mental-capacity education to the Safeguarding Team and Mental Health Law and Scrutiny Group.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2022.
Action
Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures in capacity-related decision processes to provide or clarify relevant information, establish the person's understanding and wishes, consider the consequences of the decision, and revisit the decision when circumstances or risks change; include capacity-based information-sharing decisions and other consequential care decisions where the person's capacity is relied upon.
