Recurring concern

Inadequate competence of personnel conducting safety audits and reviews

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First reported 16 Sep 2013•Latest report 19 Jul 2022

Definition

What this concern includes

Includes failures to ensure appropriately qualified and competent personnel conduct audits or formal reviews of safety-critical care, risk assessments, service changes or comparable arrangements, including the anchor's unqualified audit of service changes and reviews of care plans or risk assessments by unsuitable personnel.

Not included

  • Excludes generic audit, governance or documentation deficiencies where reviewer competence is not the unsafe condition.
  • Excludes routine clinical assessments, treatment decisions or operational reviews that are not formal safety audits or reviews.
  • Excludes failures to implement recommendations after a competent audit or review has been completed.
  • Excludes competence deficiencies in frontline care or management where the person was not responsible for conducting the relevant safety audit or review.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2013–2022

First to latest report issue date

Stated actions
3

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.

Bristol Prison1
Herefordshire and Worcestershire Health and Care NHS Trust1
Hewell Prison1
Radcliffe Manor House1
Richmond Companions International (RCI)1
Richmond Psychosocial Foundation International (RPFI)1

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. Nottinghamshire

    AI-generated summary

    Beryl Simcock · 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

    Beryl Simcock, who lived in a care home because of dementia, suffered several falls, including a fall on 10 June 2021 that caused an impacted fractured neck of femur and led to a severe deterioration in her health. The concerns included inadequate care-plan and risk-assessment reviews, potentially inaccurate records, insufficient oversight, and inadequate information for her family when she was deprived of her liberty.

    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

    Care plan and risk assessment reviews conducted by unsuitable personnel

    Wider context from the report

    “I was concerned about the lack of written policies for care planning and review. I was concerned that reviews of care plans and risk assessments were either not done (and the records falsified to suggest that they were) or that they were done by someone unsuited to the task. This was not identified despite audit activity during the relevant period. I was also concerned that at times when Mrs Simcock was deprived of her liberty the care home did not ensure that her family were given adequate and timely information to enable them to provide independent scrutiny of the care and restrictions in place. ”

    Source location

    Beryl Simcock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West London

    AI-generated summary

    Sophie Bennett · 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

    Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

    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

    Use of an auditor without appropriate clinical or mental-health qualifications

    Wider context from the report

    “The governance of Lancaster Lodge, and of the staff, and others, working there during the material period, was inadequate in the following respects: 1. There was no “registered manager” who met the statutory criteria. 2. The staff were (despite RPFI’s assertions to the contrary), generally, untrained, unqualified and too few in number. 3. There were no, or no adequate, checks and controls by the staff, or by the acting manager, on the keeping of essential documents, including risk assessments and progress notes, which were, in consequence, themselves inadequate, unreliable and misleading - with corresponding risk to the safety of the residents. 4. The changes to which the determined circumstances refer were made following an audit by ████████ out: • ████████ was not qualified clinically, or in the field of mental health, to conduct that audit; • the audit conducted by him (which led to the proposals for change) took only a single day, which was grossly inadequate; • there was no, or no adequate, consultation with the staff, or by the staff with the residents, regarding the substantial changes introduced, and to be made; and • the changes were introduced at a “launch”, with no, or no adequate regard to the negative impact of their sudden introduction on the mental stability of the residents. 5. Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: • the need to have in place robust employment procedures; • the matters listed under paragraphs 1 to 4 above; • the appointments of the clinically unqualified ████████ and, later, the clinically unqualified art therapist as Clinical Lead, of a statutorily-approved registered manager, and of an adequate number of trained and qualified staff; • supervision and control of the changes introduced at ████████ instigation; • decisions made by the (unqualified) acting manager and staff in relation to the treatment to be given to the residents, and other steps required to meet their needs, and safety; • communication with other agencies involved in the care of the residents; • the keeping and production (including to the Court, for the purpose of the inquest) of the Board’s own records, communications and contracts; and • knowledge and performance of the Board’s fundamental obligations, including their duty of candour (not least in the Board having failed to fulfil its mandatory obligation to report to the CQC five instances of admission of Lancaster Lodge residents to hospital). 6. Advice to the acting manager was provided by ████████ - the founder of RPFI - and significant decisions regarding Lancaster Lodge and the residents, were made by her (in each case as a “consultant” to the Board, rather than by the Board of RPFI), and were followed by RPFI staff, when: • ████████ was neither a director, nor a Trustee, of RPFI (one Board member describing her role as “somewhat ambiguous”, and the evidence suggesting that she was a “shadow director”); and • ████████ had never visited Lancaster Lodge, and had never met (or had any knowledge, firsthand, knowledge of the residents). 7. The possibility of there being: • a conflict between the interests of ████████ (who, it appears, may have had a personal or family connection with the ownership of Lancaster Lodge) and those of RPFI itself; and • financial impropriety, in relation to the lease under which Lancaster Lodge was (it seems) held. 8. The post-death investigations carried out on behalf of RPFI: • were inadequate, verging on self-serving, and not objective; and • give rise to concerns as to their veracity and accuracy (the authorship of certain supposedly contemporaneous statements being denied by the staff member whose name appears on them as their maker). 9. The facts that: • a director and trustee of RPFI is also the Chairman of RCI; and • ████████ appears to have some family connection with the owner of RCI’s premises give rise to concerns in relation to RCI corresponding to those itemised under paragraphs 5 to 7 above. ”

    Source location

    Sophie Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Worcestershire

    AI-generated summary

    Reggie Johns · 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

    Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.

    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 involve appropriately qualified healthcare personnel in reviews

    Wider context from the report

    “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status. (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare. This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review. Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed. (3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view. Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel. Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents. ”

    Source location

    Reggie Johns · 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 Prison Service Instruction 64/2011 to identify and address areas of non-compliance at HMP Hewell.

    Verbatim wording from the response

    “I can also confirm that following the inquest into Mr Johns’ death ████████ and ████████ Prison Governor, HMP Hewell have reviewed Prison Service Instruction 64/2011 (updated) – in order to identify any areas of non-compliance and to address these.”

    Source location

    2013-0202-Response-by-Worcestershire-Health-Care-NHS
    Page 2 · response
    Published 16 September 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

    Issue Operational Orders requiring ACCT reviews to be multidisciplinary and obtain views from all appropriate departments.

    Verbatim wording from the response

    “Since Mr Johns' death, the enclosed Operational Orders have been issued entitled ‘Chairing ACCT Reviews’ and ‘ACCT Reviews’ which provide guidance for selecting appropriate ACCT case managers, and confirm that it is the case manager's responsibility to ensure that each review is multi-disciplinary with views from all appropriate departments being taken into consideration.”

    Source location

    2013-0202-Response-by-NOMS
    Page 2 · response
    Published 16 September 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

    Produce joint guidance for discipline and healthcare staff on working together and appropriately sharing information about prisoners in their care.

    Verbatim wording from the response

    “I am aware that you are now in receipt of Worcestershire Health and Care NHS Trust’s response to your report, which confirms that ACCT documents are now made available to nursing staff in reception in all cases when a prisoner arrives at HMP Hewell on an open ACCT. In addition to that response, I have enclosed a copy of a joint document which has been produced by HMP Hewell and Worcestershire Primary Care Trust which provides guidance to discipline and healthcare staff about the importance of working together and sharing information appropriately about the prisoners in their care.”

    Source location

    2013-0202-Response-by-NOMS
    Page 2 · response
    Published 16 September 2013

    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 healthcare representation in relevant ACCT reviews is considered sufficient to address concerns about healthcare involvement.

    Verbatim wording from the response

    “Healthcare provides representation into Assessment, Care in Custody and Teamwork (ACCT) reviews as follows:”

    Source location

    2013-0202-Response-by-Worcestershire-Health-Care-NHS
    Page 2 · response
    Published 16 September 2013

    Open published response
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Data last updated 7 September 2026