Recurring concern

Failure to reconcile conflicting information in safety assessments

First to latest report 17 Jan 2014 — 26 Apr 2023

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
9

What this concern includes

Includes failures within safety assessments to identify, compare, investigate and resolve material inconsistencies between referral information, historical records, observations, collateral reports, recent concerns or other relevant evidence before reaching or approving an assessment conclusion.

What is not included
  • Excludes generic clinical record, handover or communication deficiencies where no material conflict within a safety assessment is identified.
  • Excludes incomplete assessments where the issue is missing assessment content but not failure to reconcile conflicting information.
  • Excludes failures to act on a correctly reconciled assessment when the assessment process itself was reliable.
  • Excludes generic diagnostic disagreement or confirmation-bias concerns unless the report specifically identifies unreconciled conflicting information within a safety assessment.

Reports and published responses 5 reports

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

  1. Lincolnshire

    AI-generated summary

    Colin Robert GUMM · 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

    Colin Robert GUMM, a vulnerable adult receiving a care package, was found collapsed by his carers and died at Lincoln County Hospital on 27 November 2021 despite treatment. The concerns include gaps in Adult Social Care monitoring and safeguarding, the identification of apparent underweight and clinical dehydration only shortly before his death, conflicting evidence about alcohol provision, and the reported premature closure of a safeguarding enquiry before toxicology results were received.

    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 identify and assess conflicting evidence about alcohol provision

    Wider context from the report

    “6.Conflicting evidence was provided by bluebird care that : Registered Manager (02/02/2023) - "the only drink we pour for him is water, we never poured alcohol for him" "26th November 2021 14:24 from carer's log - "water and whiskey provided on top of ongoing medication" EMAS report (12/04/2022) - "bottles of alcohol were found by his bed and enquired with the carers ,however they believed he doesn't drink a lot as he was unable to pour on his own". If that is right somebody was pouring for him. Shouldn't all this have been picked up by the safeguarding assessment? ”

    Source location

    Colin Robert GUMM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.

    Verbatim wording from the response

    “Mr Gumm had sadly died and therefore this ended the Local Authority's legal duty to take steps to safeguard Mr Gumm under s.42. However, the Safeguarding Team did progress with a s.42 enquiry (although it should have been recorded as a non s.42 enquiry at that time) to seek wider assurance in relation to the care providers involved and any potential wider risks. (LCC’s processes in relation to s.42 enquiries and more generally is explored below in the section on action by LCC). Proportionate enquiries/fact-findings was undertaken (in so far as the council were able to do so given the circumstances) and no concerns were identified in relation to the services provided to the deceased.”

    Source location

    Response from Lincolnshire County Council
    Page 5 · response
    Published 3 May 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.

    Verbatim wording from the response

    “We can only reiterate that LCC was not providing care to Mr Gumm at the time. LCC are not therefore in a position to determine whose evidence can or should be believed”

    Source location

    Response from Lincolnshire County Council
    Page 5 · response
    Published 3 May 2023

    Open published response

  2. Inner North London

    AI-generated summary

    Jonathan Anthony MEANEY · 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

    Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.

    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 reconcile and challenge contradictory suicide-risk information

    Wider context from the report

    “2. When the mental nurse assessed Mr Meaney before discharge on Wednesday, 15 March, he did not question Mr Meaney’s assertion that he had not intended to take an overdose two days before. This was despite the fact that Mr Meaney had told the assessing doctor that he had been trying to kill himself and he had written notes of intent. ”

    Source location

    Jonathan Anthony MEANEY · 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

    Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.

    Verbatim wording from the response

    “It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 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

    CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.

    Verbatim wording from the response

    “We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 2017

    Open published response

  3. Inner South London

    AI-generated summary

    Richard Walsh · 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

    Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

    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 the whole person and reconcile or communicate missing and discordant information during proforma completion

    Wider context from the report

    “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person, or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened. ”

    Source location

    Richard Walsh · 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

    Publish AMHP guidance requiring direct scrutiny of police custody records and logs.

    Verbatim wording from the response

    “The Coroner has highlighted the fact that the MHA assessors did not directly examine the custody record or log.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    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

    Publish AMHP guidance requiring direct scrutiny of detained persons’ medical forms.

    Verbatim wording from the response

    “The Coroner has highlighted the fact that the MHA assessors did not directly examine the ‘Detained Persons Medical Forms’.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    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

    Publish AMHP guidance requiring direct discussion with police custody officers during each custody-centre assessment.

    Verbatim wording from the response

    “The Coroner has highlighted that the Custody Officers and the MHA assessors never spoke.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    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

    Require AMHPs to obtain written medical reports when assessments do not result in detention recommendations.

    Verbatim wording from the response

    “HCC/ PCC will be working with local NHS Provider Trusts and Hampshire Constabulary to review information sharing with the Police following joint assessment in Police Custody.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · 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

    Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.

    Verbatim wording from the response

    “The standard of mental health act assessments is brought into question by the Coroner in light of the findings from this inquest. Certainly the conduct of each of the practitioners involved in this case is referred to separately.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · 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

    Review professional development opportunities for AMHPs conducting police-custody assessments.

    Verbatim wording from the response

    “5.0 Training and Professional Development for AMHP staff when dealing with assessments in Police Custody”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 4 · response
    Published 26 February 2017

    Open published response

  4. Inner North London

    AI-generated summary

    Harold George de Mello · 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

    Harold George de Mello, who had multiple co-morbidities, limited mobility and incontinence, died in hospital on 13 April 2014 after collapsing at home and being treated for bronchopneumonia. The principal concerns were that social-care assessments did not adequately investigate or record the reported incontinence, hygiene problems, care arrangements and differing information, and lacked sufficiently comprehensive guidance and senior review.

    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 reconcile assessments with referral and historical information

    Wider context from the report

    “(3) that, given that a conclusion was made that there would be no social care provided, the assessment was made (and signed off by a senior colleague) without any reference to the rather different reports from the referrer and in the deceased’s historical record. There is an incongruence between the claimed observations of the First Response Officer and the information that led to the assessment that was not explored ”

    Source location

    Harold George de Mello · 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

    Disseminate the internal management review, action plan and lessons learned to managers and relevant frontline staff for discussion and implementation.

    Verbatim wording from the response

    “Immediate Practice Improvements | Disseminate internal management review and action plan to management team:”

    Source location

    2014-0449-Response-by-Tower-Hamlets-Local-Authority
    Page 3 · response
    Published 7 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver targeted Critical/Cumulative Analysis training to staff.

    Verbatim wording from the response

    “A programme of targeted Critical/Cumulative Analysis training with staff members has been scheduled for December 2014.”

    Source location

    2014-0449-Response-by-Tower-Hamlets-Local-Authority
    Page 5 · response
    Published 7 July 2014

    Open published response

  5. Cornwall

    AI-generated summary

    JULIA SHEEREN DELL · 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

    Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

    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 reconcile reassurance about mood stabilisation with recent concerns about wellbeing

    Wider context from the report

    “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”

    Source location

    JULIA SHEEREN DELL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026