Recurring concern

Failure to make capacity-based decisions using relevant information and wishes

First to latest report 19 Nov 2021 — 17 Apr 2024

Reports that mention this concern: 3
Times this concern has been raised: 4
Stated actions linked to this concern: 16

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

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

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

17 Apr2024
Surrey
Concerns raised1
1. 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.
Linked response

Epsom and St Helier University Hospitals NHS Trust
Stated actions 3
1. Epsom and St Helier University Hospitals NHS Trust
  Review, update and approve the discharge policy to identify vulnerable patients, involve families and clarify safe-discharge responsibilities and escalation processes.
2. Epsom and St Helier University Hospitals NHS Trust
  Refresh safeguarding and Mental Capacity Act training into two sessions supported by dedicated e-learning modules.
3. Epsom and St Helier University Hospitals NHS Trust
  Provide additional safeguarding and Mental Capacity Act training, including individualised training for Trust discharge coordinators.
AI-generated summary

Mr Timothy Charles Clayton · 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

Mr Timothy Charles Clayton had alcohol-related brain damage, malnutrition, reduced mobility and fluctuating confusion, and was discharged to live alone despite concerns about his ability to care for himself. His flat was inadequately heated, and he was found profoundly hypothermic after self-neglecting; he died at Epsom General Hospital on 12 December 2022. The principal concerns were inadequate discharge planning, insufficient information sharing and investigation, failure to involve or heed his family, an erroneous reliance on his capacity, and pressure to vacate hospital beds.

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 provide requisite information before relying on decision-making capacity
Wider context from the report
“2. There was a misunderstanding by a clinician in relation to whether capacity to make a decision can be relied on to justify actions taken when the requisite information which needed to be considered by Mr Clayton in relation to that decision and its consequences had not been provided to him. Mr Clayton’s expressed wish to go home alone, without any care plan in place, was relied on, erroneously, to justify an unsafe discharge on the basis that he had capacity. ”
Source location
Mr Timothy Charles Clayton · 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
Review, update and approve the discharge policy to identify vulnerable patients, involve families and clarify safe-discharge responsibilities and escalation processes.

Verbatim wording from the response
“The Root Cause Analysis undertaken following this incident identified the fact that Mr Clayton was a vulnerable adult and so a complex discharge pathway should have been triggered as required within the Trust’s discharge policy. As a result of this investigation, the principles of effective discharge processes were reviewed, safe check lists embedded into practice and clinical practice reviewed. Subsequent to the Inquest the Hospital Discharge and Criteria to Reside Policy (ESTH/POL/64521) has been reviewed, updated and approved and shared with staff in the organisation. This policy provides clarity on the identification of vulnerable patients for discharge and outlines the responsibilities of patients, family and carers to be included in the discharge planning. The policy encourages families to raise concerns and, where concerns are raised, supports how these are managed.”

Source location
Response from St George's, Epsom and St Helier
Page 3 · response
Published 29 April 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
Refresh safeguarding and Mental Capacity Act training into two sessions supported by dedicated e-learning modules.

Verbatim wording from the response
“Following the investigation, the safeguarding training at the Trust has been reviewed and training has been updated include Mr Claytons case anonymised to support training. Following the inquest, further actions have been taken to strengthen the training. Whilst currently Mental Capacity Act training is included as part of Safeguarding Training, the Trust has reviewed the safeguarding training, and will deliver the training in 2 separate sessions with eLearning modules which are being imported from St George’s Hospital to support the face-to-face offering. This will further allow staff to have further developed their understanding and responsibilities and duties under the Mental Capacity Act than currently in one single session. The specific Mental Capacity Act training objectives are;”

Source location
Response from St George's, Epsom and St Helier
Page 6 · response
Published 29 April 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
Provide additional safeguarding and Mental Capacity Act training, including individualised training for Trust discharge coordinators.

Verbatim wording from the response
“As well as the existing scheduled safeguarding training sessions during 2024/2025, an additional member of the Safeguarding team has been employed to facilitate increased training sessions to provide additional training within areas where there are high numbers of medical discharges including Buckley Ward and provide additional sessions above previously scheduled sessions. The discharge coordinators across the Trust will additionally receive individualised training on safeguarding and mental capacity assessments. Compliance with safeguarding and mental capacity assessment training will be monitored through the statutory and mandatory training dash boards for each division in the Senior Leadership Team Meetings.”

Source location
Response from St George's, Epsom and St Helier
Page 6 · response
Published 29 April 2024
Open published response
18 Aug2022
South Yorkshire (Western)
Concerns raised2
1. Inadequate assessment and clarification of capacity-based information-sharing wishes
2. 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.
Linked responses

Cygnet Health Care Limited
NHS England - North East and Yorkshire
Stated actions 4
1. NHS England - North East and Yorkshire
  Revise the NHSE Case Management Standard Operating Procedure using learning from quality concerns in CAMHS inpatient services.
2. NHS England - North East and Yorkshire
  Implement the revised NHSE Case Management Standard Operating Procedure.
3. Cygnet Health Care Limited
  Implement specific communication care plans for every young person, with fortnightly review and documentation of information-sharing decisions and their reconsideration.
1. Cygnet Health Care Limited
  Document consideration of young people’s individual needs, priorities, understanding and associated risks in ward-round summaries.
Respondent positions 1
1. NHS England - North East and Yorkshire
  Existing discussions, ward-round reviews and capacity assessment were considered sufficient assurance regarding Chelsea’s decision not to share information with family.
  Existing arrangements considered sufficient
AI-generated summary

Chelsea Blue Louise Mooney · 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

Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.

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 assessment and clarification of capacity-based information-sharing wishes
Wider context from the report
“3. The decision not to share information with family was made based on one capacity assessment. This did not fully address the issues with Chelsea of understanding the consequences of that decision and neither does it adequately break down the information which Cygnет may wish to share with family. This appears to have been a blanket decision and once a capacity assessment determined that Chelsea had the capacity to make that decision there is not evidence available to me of conversations with Chelsea to establish exactly what she would and would not share with family and that the consequences of those decisions were adequately explored with her. I would have expected; at Chelsea's age, that a social worker would be involved in supporting her with this decision and reviewing it regularly. This decision about her capacity and information sharing were also not revisited which they ought to have been regularly. Not least because Chelsea's mother was responsible for supporting her with s17 leave and was entitled to fully understand the risks to Chelsea or herself through this. ”
Source location
Chelsea Blue Louise Mooney · 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 regularly revisit capacity and information-sharing decisions
Wider context from the report
“3. The decision not to share information with family was made based on one capacity assessment. This did not fully address the issues with Chelsea of understanding the consequences of that decision and neither does it adequately break down the information which Cygnет may wish to share with family. This appears to have been a blanket decision and once a capacity assessment determined that Chelsea had the capacity to make that decision there is not evidence available to me of conversations with Chelsea to establish exactly what she would and would not share with family and that the consequences of those decisions were adequately explored with her. I would have expected; at Chelsea's age, that a social worker would be involved in supporting her with this decision and reviewing it regularly. This decision about her capacity and information sharing were also not revisited which they ought to have been regularly. Not least because Chelsea's mother was responsible for supporting her with s17 leave and was entitled to fully understand the risks to Chelsea or herself through this. ”
Source location
Chelsea Blue Louise Mooney · 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
Revise the NHSE Case Management Standard Operating Procedure using learning from quality concerns in CAMHS inpatient services.

Verbatim wording from the response
“The learning from quality concerns in the CAMHS In-patient services including relevant aspects of this regulation 28, is informing the revised NHSE Case Management Standard Operating Procedure. It is expected that this will be implemented before the end of the year.”

Source location
Response from NHS England
Page 2 · response
Published 3 October 2022
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
Implement the revised NHSE Case Management Standard Operating Procedure.

Verbatim wording from the response
“The learning from quality concerns in the CAMHS In-patient services including relevant aspects of this regulation 28, is informing the revised NHSE Case Management Standard Operating Procedure. It is expected that this will be implemented before the end of the year.”

Source location
Response from NHS England
Page 2 · response
Published 3 October 2022
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
Implement specific communication care plans for every young person, with fortnightly review and documentation of information-sharing decisions and their reconsideration.

Verbatim wording from the response
“Changes implemented following Chelsea’s death”

Source location
Response from Cygnet Health Care
Page 5 · response
Published 3 October 2022
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
Document consideration of young people’s individual needs, priorities, understanding and associated risks in ward-round summaries.

Verbatim wording from the response
“19. The GMC provides guidance on the type of information that patients may need to know before making a decision, and recommends that doctors should do their best to find out about a young person’s individual needs and priorities when providing information about treatment options. It advises that discussions should focus on the young person’s ‘individual situation and risk to them’ and sets out the importance of providing the information about the procedure and associated risks in a balanced way and checking that young person has understood the information given.”

Source location
Response from Cygnet Health Care
Page 6 · response
Published 3 October 2022
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 discussions, ward-round reviews and capacity assessment were considered sufficient assurance regarding Chelsea’s decision not to share information with family.

Verbatim wording from the response
“Chelsea was aware that she could change her mind about sharing information with her family and that she could see her family whenever she wanted. The Case Manager discussed this with Chelsea, for example on 18 November 2020 where it was noted that Chelsea had started contact with her mother again. The Ward supported Chelsea in rebuilding her relationship with her mother and contact resuming.”

Source location
Response from NHS England
Page 2 · response
Published 3 October 2022
Open published response
19 Nov2021
Manchester North
Concerns raised1
1. 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.
Linked response

Pennine Care NHS Foundation Trust
Stated actions 9
1. Pennine Care NHS Foundation Trust
  Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
2. Pennine Care NHS Foundation Trust
  Commission Mental Capacity Act training for all clinicians.
3. Pennine Care NHS Foundation Trust
  Deliver mental-capacity lunch-and-learn sessions in Oldham.
1. Pennine Care NHS Foundation Trust
  Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
2. Pennine Care NHS Foundation Trust
  Design a Mental Capacity Act audit.
3. Pennine Care NHS Foundation Trust
  Implement PARIS across inpatient mental health wards, including a mental-capacity assessment documentation template.
4. Pennine Care NHS Foundation Trust
  Share inquest learning about longitudinal mental-capacity assessment with senior Oldham consultant psychiatrists.
5. Pennine Care NHS Foundation Trust
  Escalate the need for additional longitudinal mental-capacity education to the Safeguarding Team and Mental Health Law and Scrutiny Group.
6. Pennine Care NHS Foundation Trust
  Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
Respondent positions 1
1. Pennine Care NHS Foundation Trust
  The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
  Disputes the concern
AI-generated summary

Sarah McGarrigle · 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

Sarah McGarrigle, aged 23, was found deceased at home on 1 March 2020. She died from catastrophic internal haemorrhage caused by spontaneous rupture of oesophageal varices associated with chronic alcohol use, in the context of trauma, mental disorder and self-neglect. The principal concerns were that relevant information about her history and community behaviours was not properly considered on Aspen Ward, and that a requested assessment of her mental disorder and capacity did not take place.

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 capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks
Wider context from the report
“(2) That the Consultant Psychiatrists who reviewed the Deceased on Aspen Ward made the assumption that concern about the Deceased’s capacity was raised in the context of her withdrawal from alcohol. Consideration of the information that had been communicated to Aspen Ward (which included the specific limb of the capacity test that was in doubt) and a more longitudinal approach to the assessment would have shown that the concern related to the far more complex picture that the Deceased presented in the community and management of risks associated with self-neglect. This was not addressed by those responsible for assessing the Deceased on Aspen Ward. ”
Source location
Sarah McGarrigle · 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
Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.

Verbatim wording from the response
“• The concerns identified during the inquest have been reviewed by Professor Nihal Fernando, PCFT’s Executive Medical Director. Professor Fernando will share a copy of PCFT’s Regulation 28 response with the Aspen ward consultant Psychiatrists Responsible Officer, in his new Trust.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 2 · response
Published 6 October 2022
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
Commission Mental Capacity Act training for all clinicians.

Verbatim wording from the response
“There is evidence the Aspen Ward MDT considered Sarah’s mental capacity to make decisions about drinking alcohol, the risks associated with, however the Aspen Ward MDT did not complete and document a formal mental capacity assessment. This area of practice that required improvement had been identified in a PCFT investigation completed after Sarah’s death (but before Sarah’s inquest). Several actions have been taken since the time of Sarah’s admission to Aspen Ward which improve how inpatient wards consider and apply the mental capacity act in practice:”

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
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
Deliver mental-capacity lunch-and-learn sessions in Oldham.

Verbatim wording from the response
“████████commissioned Mental Capacity Act training for all clinicians. ████████arding team have delivered lunch and learn sessions on mental capacity in Oldham.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
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 Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.

Verbatim wording from the response
“• Oldham's mental health services now have a route to refer patients to the Oldham multi-agency Adults with Multiple Complex Needs Meeting. This ████████to support professionals to work with complex patients who present with high levels of risk but are assessed as having the mental capacity to make unwise decisions or do not engage with their care and treatment.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
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
Design a Mental Capacity Act audit.

Verbatim wording from the response
“• The PCFT safeguarding team are designing a Mental Capacity Act audit.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
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
Implement PARIS across inpatient mental health wards, including a mental-capacity assessment documentation template.

Verbatim wording from the response
“• PCFT has successfully implemented PARIS in all its inpatient mental health wards. This electronic patient record system includes a mental capacity assessment template that clinicians can use to document their assessments.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
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
Share inquest learning about longitudinal mental-capacity assessment with senior Oldham consultant psychiatrists.

Verbatim wording from the response
“• The learning from Sarah s Inquest regarding a potential missed opportunity for clinicians to consider a more longitudinal approach to assessing mental capacity assessments has been shared with senior Consultant Psychiatrists in Oldham. There was some agreement that additional education in this area could be beneficial. This will be escalated to the PCFT Safeguarding Team and the Mental Health Law and Scrutiny Group.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
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
Escalate the need for additional longitudinal mental-capacity education to the Safeguarding Team and Mental Health Law and Scrutiny Group.

Verbatim wording from the response
“• The learning from Sarah s Inquest regarding a potential missed opportunity for clinicians to consider a more longitudinal approach to assessing mental capacity assessments has been shared with senior Consultant Psychiatrists in Oldham. There was some agreement that additional education in this area could be beneficial. This will be escalated to the PCFT Safeguarding Team and the Mental Health Law and Scrutiny Group.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
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
Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.

Verbatim wording from the response
“• PCFT’s Head of Safeguarding and the Named Professional for Safeguarding Adults will make a recommendation to the Oldham Safeguarding Adult Partnership Board that a multi-agency protocol be developed. The recommended protocol would outline the roles and responsibilities of each agency when assessing mental capacity for complex patients with a mixture of health and social care needs. The guidance would also outline how multi-agency partners can request specialist mental health input for a mental capacity assessment.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 4 · response
Published 6 October 2022
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 MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.

Verbatim wording from the response
“physical symptoms of withdrawal. On admission to Aspen Ward, she was not experiencing any alcohol-related behavioural issues. It is widely accepted that alcohol use can cause or increase symptoms of behavioural and/or mental illness. For some patients, when they stop alcohol, their symptoms can significantly improve or stop all together. Sarah’s overall presentation from the time she was assessed and detained under the MHA in the Royal Oldham Acute Hospital, compared to while an inpatient on Aspen was significantly better. Sarah appeared to improve in the time between being detained under Section 2 and being transferred to Aspen Ward (which was a period of several days). Sarah had been safely using leave off the medical wards for a cigarette break. While on Aspen Ward, she also used leave off the ward for cigarettes.”

Source location
Response from NHS Pennine Care Foundation Trust
Page 2 · response
Published 6 October 2022
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to provide requisite information before relying on decision-making capacity

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Inadequate assessment and clarification of capacity-based information-sharing wishes

Failure to regularly revisit capacity and information-sharing decisions

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to conduct capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Stated actions 3

Stated actions 4

Respondent positions 1

Stated actions 9

Respondent positions 1