Recurring concern

Failure to recognise vulnerability in safeguarding decisions

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First reported 1 Oct 2013•Latest report 30 May 2024

Definition

What this concern includes

Includes failures in safeguarding, police or comparable protective decision-making to recognise, assess or act on a person's vulnerability, including treating capacity as negating vulnerability or misclassifying a vulnerable person despite relevant indicators.

Not included

  • Excludes generic safeguarding failures where recognition or assessment of vulnerability is not the deficient control.
  • Excludes mental-capacity assessment or best-interests failures where vulnerability recognition is not materially involved.
  • Excludes failures concerning a separately named hazard, statutory pathway or specialist risk-assessment system when that system provides the more specific supported boundary.
  • Excludes general service-access, communication or support failures where vulnerability was recognised and the deficiency arose at a later stage.
Reports
10

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
24

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
College of Policing2
Greater Manchester Police2
Home Office2
Energy UK1
Greater Manchester Mental Health NHS Foundation Trust1
Ministry of Housing, Communities and Local Government1
Ministry of Justice1
National Probation Service1
NHS England1
NHS Greater Manchester Integrated Care Board1
NHS Norfolk and Suffolk Integrated Care Board1
NHS Norfolk and Waveney Integrated Care Board1
Norfolk and Suffolk NHS Foundation Trust1
North Cumbria Integrated Care 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. Suffolk

    AI-generated summary

    Katie MADDEN · 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

    Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.

    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 assess additional risks to vulnerable parents in safeguarding referrals concerning their children

    Wider context from the report

    “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation, with no system in place to assess any additional risks posed to Kate herself. There were no additional steps, or risk assessments undertaken in relation to Kate, even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable. ”

    Source location

    Katie MADDEN · 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

    Add guidance to the MASH practice note and Standard Operating Procedure to identify vulnerable adults in safeguarding referrals concerning children.

    Verbatim wording from the response

    “Any referrals related to safeguarding concerns for a parent would be passed to the MASH who will consider any safeguarding actions required in accordance with Section 42 of the Care Act. A practice note and addition to the Standard Operating Procedure for the MASH will be made to remind MASH practitioners of the need to identify the vulnerabilities of any adults involved in safeguarding referrals in respect of children.”

    Source location

    Response from SCC
    Page 2 · response
    Published 6 June 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

    Implement prompts across children’s and adults’ multi-agency referral forms to identify and route related concerns about adults or children.

    Verbatim wording from the response

    “Action is already underway following a Serious Case Review in respect of MANDY for a process of prompts in both children’s and adult Multi Agency Referral Forms. This is for the practitioner to consider, when putting in a referral related to a child, whether there is an adult involved for whom there are also concerns. The practitioner will be prompted at the end of the referral form to direct the practitioner to submit the additional concerns in relation to the adult to the relevant portal for triaging. This process will also be implemented when referrals are received in respect of adults where the practitioner will be prompted to refer any concerns identified in relation to a child to the relevant portal.”

    Source location

    Response from SCC
    Page 2 · response
    Published 6 June 2024

    Open published response
  2. Cumbria

    AI-generated summary

    Karen THOMASON · 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

    Karen Thomason, aged 52, collapsed at home on 31 October 2023, was discharged from hospital without Cumbria Housing staff being notified, and was found unresponsive at home the following day. Her death was confirmed on 1 November 2023 after she had consumed a substantial amount of alcohol. The concerns included errors in safeguarding documentation, failures to notify housing staff about discharge, and the risk of conflating capacity with an absence of vulnerability or safeguarding concerns.

    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 distinguish mental capacity from vulnerability in safeguarding decisions

    Wider context from the report

    “(3)The evidence I received places an emphasis on the fact that Ms Thomason had capacity and indicated that she felt safe. It is certainly correct that this meant that there could be no question of her being held in hospital. It is also correct that her view of her situation was of relevance. However, it does not mean that obvious vulnerability or safeguarding concerns could not be addressed. Regardless of what Ms Thomason said, her vulnerability was obvious. I am concerned that the concepts of 'having capacity' and 'not being vulnerable' are being elided. ”

    Source location

    Karen THOMASON · 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

    Develop an Emergency Department safeguarding supervision programme for adult patients, supported by the Trust Safeguarding Team.

    Verbatim wording from the response

    “Safeguarding supervision for staff working with children is mandated within the Intercollegiate Document. Staff working with children are offered Safeguarding Children’s supervision which is attended quarterly. Safeguarding adults supervision is not mandated or recommended as best practice. Safeguarding supervision sessions can help staff explore their own experiences as well as support colleagues to understand, change, and improve their approach collectively. The ED Team recognise that engaging with this approach for all ages of patients would ensure our staff regularly discuss this and debate patient vulnerability, options for managing them safely, improve professional understanding, provide peer to peer support through professional conversations, and potentially offer suggestions around improvements to systems and processes.”

    Source location

    Response from North Cumbria Integrated Care
    Page 4 · response
    Published 14 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

    Ensure relevant staff attend mandated safeguarding training at the appropriate level and review attendance through governance meetings.

    Verbatim wording from the response

    “Currently our mandatory Safeguarding Adults Level 3 Training for all clinicians is completed every 3 years and stands at 80% completion across our Emergency Care Collaborative (88% for the organisation overall and 80.5% for our individual EDs). This needs to improve in order that all our staff have an understanding of vulnerability and how to recognise it and act accordingly. We also recognise that while this training is important, there needs to be some additional supplementary means of ensuring that staff are continually learning and using safeguarding best practice.”

    Source location

    Response from North Cumbria Integrated Care
    Page 4 · response
    Published 14 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

    A capacitous adult’s liberty and choice limited the Trust’s ability to intervene despite risky behaviours or an unsafe lifestyle.

    Verbatim wording from the response

    “We do recognise however that this case highlights how vulnerable adults such as Ms Thomason could be better supported and safeguarded in particular when leaving the department and even in the knowledge of them being known to support services. Notwithstanding that even if people have what we regard as risky behaviours or unsafe lifestyles they do have the capacity and choice (freedom of liberty) to do as they wish.”

    Source location

    Response from North Cumbria Integrated Care
    Page 3 · response
    Published 14 May 2024

    Open published response
  3. Manchester South

    AI-generated summary

    Tobias Ryse Mannering-Jones · 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

    Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.

    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 recognise sexual exploitation and vulnerability among homeless LGBTQIA young people

    Wider context from the report

    “4. The inquest was told that young adults who are homeless are often sexually exploited and that those who identify as LGBTQIA can be particularly vulnerable and that the underlying vulnerability and risk was not always appreciated by those dealing with young homeless people and that it could be mistaken by agencies as a lifestyle choice rather than what it actually was, i.e., exploitation by an older adult. ”

    Source location

    Tobias Ryse Mannering-Jones · 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

    Work with the adult safeguarding board to embed tiered risk assessment in team practice and train staff to recognise sexuality-based discrimination as potential abuse.

    Verbatim wording from the response

    “We are also working with the adult safeguarding board to embed the tiered risk assessment process for adults into the teams working practices alongside training around how discrimination due to sexuality should be recognised as potential abuse and therefore a safeguarding issue.”

    Source location

    Response from Greater Mnachester Integrated Care
    Page 3 · response
    Published 20 March 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

    Fund sector training and resources on safeguarding and safe service delivery for night shelters.

    Verbatim wording from the response

    “DLUHC is also providing funding to Housing Justice (a national membership charity for homeless shelters) to deliver training to the night shelter sector, including online resources, webinars and briefings on safeguarding and how to deliver a safe service for all. Housing Justice operates a night shelter accreditation system, which is designed to help night shelters deliver the best possible service and provides independent external validation by issuing a Quality Mark. I will continue work with Housing Justice and other partner organisations to support high-quality night shelter provision, including through the current NSTF and wider homelessness and rough sleeping funding.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 3 · response
    Published 20 March 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

    Work with Homeless Link to develop training covering safeguarding support for people whose protected characteristics, particularly sexuality, increase vulnerability.

    Verbatim wording from the response

    “• Training: DLUHC’s Voluntary and Community Frontline Sector Grant is a three-year £7.3 million investment which funds sector experts to provide co-ordination, training and capacity building within the homelessness workforce. As part of our plans for 2024/25, our partner Homeless Link are developing training and online content exploring the role of safeguarding adult boards and partnerships when supporting vulnerable people sleeping rough. In response to the Report, DLUHC will work closely with Homeless Link to ensure that training material for 2024/25 covers supporting people whose protected characteristics may make them vulnerable, particularly sexuality.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 4 · response
    Published 20 March 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

    Share NICE homelessness guidance across housing, homelessness and health sectors to promote person-centred, trauma-informed support.

    Verbatim wording from the response

    “• Trauma-Informed Approach: In March 2022, the National Institute for Health and Care Excellence (NICE) published guidelines on ‘integrated health and social care for people experiencing homelessness’⁵. This guidance has been widely shared with LAs and across housing, homelessness and health sectors, to promote best practice guidance in supporting someone experiencing homelessness. The guidance sets out how services and staff should be person-centred, empathic, non-judgemental and trauma-informed, with specific references to specialist support for a person who identifies as LGBT.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 4 · response
    Published 20 March 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 Department for Levelling Up, Housing and Communities will provide further context on exploitation risks affecting vulnerable homeless young people.

    Verbatim wording from the response

    “I appreciate that a number of your concerns relate to issues around the impact of Mr Mannering-Jones’ homelessness. DHSC has recently published updated guidance for ICPs on the development of integrated care strategies, with specific reference to inclusion health groups and those suffering multiple disadvantage. The updated guidance provides greater clarity on the opportunity for integrated care strategies to consider the wider determinants of”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 20 March 2024

    Open published response
  4. South Yorkshire (Eastern)

    AI-generated summary

    Lee Bowman · 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

    Lee Bowman was last seen on 31 October 2021 after being reported as having injuries consistent with an assault, and his body was found on 3 January 2022. The medical cause of death was unascertained. The principal concerns were assumptions about his whereabouts and reasons for not contacting family, insufficient weight given to information from his family, and shortcomings in the police handling and risk assessment of the missing-person reports.

    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 assess missing-person vulnerability without relying on assumptions about addiction

    Wider context from the report

    “1. There were significant assumptions made about the whereabouts of Lee and the reasons for his failure to contact family. The assumptions were based on the facts of Lee's addiction which on one view ought to have been identified as a vulnerability, on another view were wholly irrelevant in the context of his family confirming he was in day contact until 31 October 2021. ”

    Source location

    Lee Bowman · 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

    Update Missing Persons APP to warn against imprecise, value-laden terminology and require clear descriptions relevant to risk assessment.

    Verbatim wording from the response

    “In reading your report, our subject matter expert was troubled by the term ‘chaotic lifestyle’ that appeared to have been used in some of the risk assessments. Terminology such as this is imprecise and invites readers of such comments to assign their own assumptions to what the term means. We will update our Missing Persons APP to alert police officers and staff to the need to avoid such value laden but imprecise terms. Instead, they should set out clearly and simply what matters and issues have been identified that have a bearing on the assessment of risk.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 28 February 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

    Publish Evidence Based Guidelines on vulnerability-related risk assessment, including gathering information from multiple sources to inform professional risk judgements.

    Verbatim wording from the response

    “Your second matter of concern refers to reliance on PNC and intelligence records. Unfortunately, the report to us contains no detail of what was in these records or any commentary on why investigators gave them greater weight. It is, therefore, difficult for us to respond to these particular circumstances. However, the College has recently published Evidence Based Guidelines on Risk Assessment Vulnerability-related risks | College of Policing. This document is based on a broad range of research and sets out clear guidance on how to carry out risk assessment and is based on risk principles Risk | College of Policing. It emphasises the importance of gathering information from a range of sources to inform a decision maker’s professional judgement about the level of risk and what action should be taken to address that risk.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 28 February 2024

    Open published response
  5. Manchester City

    AI-generated summary

    Name not published · 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 had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.

    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 consider safeguarding referral and assessment for vulnerable adults with serious mental disorder

    Wider context from the report

    “6. A significant failure to consider a safeguarding referral and assessment for a vulnerable adult suffering from serious mental disorder. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  6. Manchester South

    AI-generated summary

    Dane Lee Pearson · 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

    Dane Lee Pearson, who had a history of mental health problems and amphetamine use, was found suspended from a ligature at his home on 13 December 2017. The investigation concluded that the death was suicide, with the medical cause recorded as hanging. Concerns included failures in the issuing and documentation of a Child Abduction Warning Notice, failure to assess or account for his vulnerability, inadequate recording of vulnerability markers, and failure to communicate that criminal proceedings had been discontinued.

    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 assess known vulnerability when issuing CAWNs

    Wider context from the report

    “2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out. In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it. The inquest heard evidence that he was deeply worried about it and the impact of it on his life. ”

    Source location

    Dane Lee Pearson · 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

    Release updated Child Abduction Warning Notice guidance requiring vulnerability risk assessment, links to suicide-prevention guidance, and clear explanation of events to recipients.

    Verbatim wording from the response

    “The College is about to release updated APP on issuing CAWNs and this will reflect the need to carry out a risk assessment. There is existing guidance on suicide prevention in our Mental Health APP. The new CAWNs APP will link to that document so that those dealing with these issues are easily able to access the best advice. It will also make clear that a description of the events leading up to the issue of the CAWN must be carefully explained to the recipient.”

    Source location

    2019-0056-Responses
    Page 1 · response
    Published 6 June 2019

    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

    Strengthen PACE Code C to require proactive identification and recording of vulnerability factors and sharing those records with personnel communicating with the individual.

    Verbatim wording from the response

    “The treatment of those arrested and under investigation for alleged criminal offences is governed by Part 4 of the Police and Criminal Evidence Act 1984 (PACE) and by PACE Code of Practice C. While, at the time of Mr Pearson’s contact with the police in 2017, there was existing guidance in place relating to the handling of investigations and the treatment of potentially vulnerable individuals, this has subsequently been strengthened.”

    Source location

    2019-0056-Responses
    Page 3 · response
    Published 6 June 2019

    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

    Require pre-service vulnerability risk assessments, documenting the rationale and potential impact on the suspect in Child Abduction Warning Notice records.

    Verbatim wording from the response

    “2) Carry out a risk assessment prior to the service of a CAWN to ensure that consideration is given to a suspect’s history, particularly relating to any intelligence about vulnerability or threats, and include the outcome of the risk assessment in the CAWN service forms.”

    Source location

    2019-0056-Responses
    Page 6 · response
    Published 6 June 2019

    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

    Operational and procedural concerns about police practice are for the police to address.

    Verbatim wording from the response

    “The matters of concern that you raised are primarily operational and procedural matters for the police who, I understand, will be responding to you separately.”

    Source location

    2019-0056-Responses
    Page 3 · response
    Published 6 June 2019

    Open published response
  7. Shropshire, Telford and Wrekin

    AI-generated summary

    Tyrone Lock · 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

    Tyrone Lock left a hotel wearing only boxer shorts and socks on a cold, windy night and was found deceased two days later in a pond. The jury concluded that he should have been classified as a vulnerable person rather than an absconder, and that a second helicopter request should have been made; it identified police failings contributing to his death.

    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 classify people presenting indicators of vulnerability as vulnerable persons rather than absconding suspects

    Wider context from the report

    “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding. (2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state. (3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person. (4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm. (5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm. (6) As NPAS serves all police forces in England and Wales they are included in this report so that: a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other. b. To review whether any other police force may also have a similar lack of understanding. ”

    Source location

    Tyrone Lock · 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

    Finalize a vulnerability strategy incorporating nationally recognized effective practice.

    Verbatim wording from the response

    “I can confirm that in terms of supporting officers and staff West Mercia Police has already embarked on an extensive programme of work to raise awareness and understanding of vulnerability. We are keen that our people are professionally curious and recognise where those who cannot help themselves may require our help, support and intervention.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 1 · response
    Published 26 February 2017

    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

    Roll out the piloted “see beyond the obvious” vulnerability programme across West Mercia in 2017.

    Verbatim wording from the response

    “We have piloted a programme within the Telford area which encourages officers and staff to see beyond the obvious and think wider. This will be rolled out across West Mercia in 2017.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 2 · response
    Published 26 February 2017

    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

    Maintain an organisation-wide programme developing officers and staff to identify and manage vulnerability and protect people from harm.

    Verbatim wording from the response

    “I can confirm that in terms of supporting officers and staff West Mercia Police has already embarked on an extensive programme of work to raise awareness and understanding of vulnerability. We are keen that our people are professionally curious and recognise where those who cannot help themselves may require our help, support and intervention.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 1 · response
    Published 26 February 2017

    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

    Introduce the THRIVE model across the force to support information gathering, risk assessment and public protection decisions.

    Verbatim wording from the response

    “We have complemented the NDM by introducing the THRIVE model, (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) across the Force. NDM and THRIVE both provide a framework for officers and staff to seek out as much information that they can and make sound rational decisions to protect the public.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 2 · response
    Published 26 February 2017

    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 vulnerability-related training, online learning and knowledge checks across public-protection disciplines.

    Verbatim wording from the response

    “To increase our professionalism further, officers and staff have been provided with an ongoing programme of development built around protecting people from harm. Officers and staff with specialist knowledge have provided training across the 13 strands of public protection, including high harm areas such as mental health and missing persons. These sessions are also supported by an extensive programme of on-line learning and knowledge checks provided by the College of Policing.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 2 · response
    Published 26 February 2017

    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 vulnerability training and improvements with NPAS are considered sufficient; the force has done all it can to prevent recurrence.

    Verbatim wording from the response

    “I am satisfied that with the extensive programme of vulnerability training already underway, coupled with the ongoing improvements already put in place with NPAS colleagues, the force has done all it can to prevent such a circumstance arising again.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 4 · response
    Published 26 February 2017

    Open published response
  8. Manchester South

    AI-generated summary

    Christopher Philip Fields · 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

    Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red 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

    Failure to safeguard an injured or intoxicated vulnerable person before police departure

    Wider context from the report

    “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death. Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found? Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE) ”

    Source location

    Christopher Philip Fields · 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 wider vulnerability work incorporating lessons learned from this case.

    Verbatim wording from the response

    “It is proposed that we will be able to report back to the Coroners. In October 2016 in terms of the wider work we are completing around vulnerability, including the lessons learnt from this case.”

    Source location

    2016-0194-Response-by-Greater-Manchester-Police
    Page 3 · response
    Published 18 May 2016

    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

    Specific waiting times cannot be formalised because circumstances vary and fixed timescales would be impractical.

    Verbatim wording from the response

    “No policy or guidance exists that formalises how long officers should wait in such cases and it would be impractical to set down specific timescales for officers to adhere to. Officers are given guidance in the use of the National Decision Making Model (‘NDMM’). The NDMM allows officers to make decisions based on the following principles:”

    Source location

    2016-0194-Response-by-Greater-Manchester-Police
    Page 1 · response
    Published 18 May 2016

    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 National Decision Making Model is considered sufficient for officers to assess risks and decide whether to remain at a scene.

    Verbatim wording from the response

    “No policy or guidance exists that formalises how long officers should wait in such cases and it would be impractical to set down specific timescales for officers to adhere to. Officers are given guidance in the use of the National Decision Making Model (‘NDMM’). The NDMM allows officers to make decisions based on the following principles:”

    Source location

    2016-0194-Response-by-Greater-Manchester-Police
    Page 1 · response
    Published 18 May 2016

    Open published response
  9. Milton Keynes

    AI-generated summary

    Lee Anthony Boden · 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

    Lee Anthony Boden was released from prison to an approved premises in Milton Keynes on 13 February 2015 and was found unresponsive in a bathroom later that night, where drugs and drug paraphernalia were found. He was confirmed dead at 12.10am on 14 February 2015; the stated cause of death was central respiratory depression associated with illicit heroin use. Concerns included limited advance notice of his placement, lack of forward planning, insufficient recognition of his vulnerability, the length of time before he was discovered, and an apparent absence of a protocol for monitoring vulnerable new arrivals.

    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 recognise vulnerable residents

    Wider context from the report

    “(4) Having just been released from prison and being unable to return to his home, he should have been recognised as a vulnerable resident. ”

    Source location

    Lee Anthony Boden · 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

    The Approved Premises had protocols for monitoring vulnerable residents, including ACCT assessments and additional checks where required.

    Verbatim wording from the response

    “The AP has a policy and procedures for assessing risk of self-harm and suicide and a system based on the Assessment, Care in Custody and Teamwork process (ACCT) for identifying those who require additional monitoring. In Mr Boden’s case, an ACCT assessment was undertaken and overnight welfare checks were established as a result.”

    Source location

    2015-0394-Response-by-NOMS
    Page 2 · response
    Published 29 September 2015

    Open published response
  10. Leicester City and South Leicestershire

    AI-generated summary

    Michael Joseph Hirrell · 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

    Michael Joseph Hirrell died from carbon monoxide poisoning between 18 and 25 January 2013 after using a borrowed generator at his home following disconnection of the electricity supply. The principal concerns were that his vulnerability was not recognised or protected during the disconnection, staff did not feel empowered to halt it, and wider consumer-protection arrangements may not prevent similar 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

    Failure to recognise vulnerable consumers

    Wider context from the report

    “1. Mr Hirrell’s presence was recognised by npower representatives before the power supply was disconnected, and he was noted to look unwell, be in receipt of welfare benefits, have no credit on his mobile telephone and to have no gas supply (and therefore no source of heat or light to his home). Notwithstanding this, he was not recognised to be a “vulnerable person”. ”

    Source location

    Michael Joseph Hirrell · 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

    Issue guidance to non-domestic suppliers on good practice for debt management and disconnection, including shared occupancy and vulnerable customers.

    Verbatim wording from the response

    “Open letter: Non-domestic debt and disconnection – suppliers’ approaches and good practice expected”

    Source location

    Response from OFGEM
    Page 5 · response
    Published 30 December 2013

    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 and publish the Safety Net to protect vulnerable domestic consumers using non-domestic supplies from uncontrolled disconnection.

    Verbatim wording from the response

    “Working with suppliers, Energy UK has undertaken a review of the relevant Safety Net section regarding domestic consumers with a non-domestic supply. The matter was discussed in detail at a meeting of Energy UK members on the 11th December 2013. It was agreed that the Safety Net should be amended to clarify that where the supplier determines that a member of a domestic household, which takes its energy through a non-domestic supply, is, for reasons of age, health, disability or severe financial insecurity, unable to safeguard their personal welfare or the personal welfare of other members of the domestic household, the non-domestic supply will not knowingly be disconnected for reasons outside the domestic household’s control.”

    Source location

    2013-0247-Response
    Page 1 · response
    Published 30 December 2013

    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

    Keep the Safety Net’s operation, including its new protections, under constant review through independent audits of suppliers’ systems and processes.

    Verbatim wording from the response

    “As you are aware, suppliers are responsible for putting the principles of the Safety Net into practice and may do this in different ways, depending on how their businesses are structured. All signatories, however, aim to have implemented the required systems and processes to deliver the new protections for domestic consumers with a non-domestic supply as soon as practicable and will have done so by the end of 2014. Energy UK is also committed to keeping the operation of the Safety Net, including the new provisions, under constant review. This includes audits of suppliers’ systems and processes by an independent auditor.”

    Source location

    2013-0247-Response
    Page 2 · response
    Published 30 December 2013

    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

    Add mandatory vulnerability and shared-supply checks, standardize recording through a checklist, and investigate reported risks before disconnection.

    Verbatim wording from the response

    “Following our review of Mr Hirrell's case, which was carried out at a senior level within the organisation, we agreed a number of further enhancements to our procedures within npower's non-domestic division. These enhancements, which are all now in place, are as follows:”

    Source location

    Response from NPOWER
    Page 3 · response
    Published 30 December 2013

    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

    Brief internal and external debt-collection agencies on amended shared-supply and vulnerability procedures, with further written guidance and annual repetition.

    Verbatim wording from the response

    “• In July 2013 we carried out a face to face briefing with all of our debt collection agencies (internal and external), setting out our amended policy and procedures for dealing with shared supplies and vulnerable customers, and clearly explaining the part they have to play in this. Further details were then provided to the agencies in writing, to ensure clarity and consistency, and we intend to repeat this at least annually;”

    Source location

    Response from NPOWER
    Page 4 · response
    Published 30 December 2013

    Open published response
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Data last updated 7 September 2026