Recurring concern

Unreliable access to required social-worker support

First to latest report 28 Dec 2014 — 29 Jan 2025

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
11

What this concern includes

Includes failures of social-worker support provision or access for people who require it, including unavailable or unreachable allocated workers without an effective alternative contact and delayed or absent appointment or allocation of a social worker.

What is not included
  • Excludes community-care assessments, care-package provision and other downstream social-care processes unless the asserted unsafe condition is specifically lack of access to required social-worker support.
  • Excludes generic telephone, communication or escalation failures where no social-worker support or allocation function is involved.
  • Excludes general shortages or service-capacity concerns without a direct failure to provide access to a required social worker.
  • Excludes failures concerning non-social-work advisers or specialist services unless the report explicitly connects them to the same social-worker support arrangement.

Reports and published responses 6 reports

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

  1. Inner South London

    AI-generated summary

    Naomi SULEYMAN · 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

    Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.

    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 an out-of-hours social worker welfare check on the day of discharge

    Wider context from the report

    “(3) On the day of discharge, Ms Suleyman should have received a welfare check from the LBL out of hours social worker which did not happen. ”

    Source location

    Naomi SULEYMAN · Prevention of Future Deaths report
    Page 2 · concerns

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    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 same-day Enablement Care Officer visits after discharge to assess care suitability and escalate changes.

    Verbatim wording from the response

    “• Any client in receipt of Enablement or brokered out care provision now receives a visit from an Enablement Care Officer, this visit happens the same day that the patient is discharged from hospital and reviews the suitability of care provision once the patient is in their own environment. Any changes are fed back to the Discharge to Assess Team (occupational therapist, physiotherapist or social worker) and patient, carer or other family members.”

    Source location

    Response from Lewisham and Greenwich NHS Trust and Lewisham Council
    Page 3 · response
    Published 29 January 2025

    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 next-day out-of-hours welfare calls by a therapist or social worker for patients discharged between 5pm and 8pm.

    Verbatim wording from the response

    “• For those patients discharged out of hours between 5pm-8pm) the out of hours social worker ensures that a welfare call is carried out the next day by a therapist and/or social worker”

    Source location

    Response from Lewisham and Greenwich NHS Trust and Lewisham Council
    Page 3 · response
    Published 29 January 2025

    Open published response

  2. Essex

    AI-generated summary

    Molly Ann Sergeant · 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

    Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic 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

    Delayed appointment of a social worker

    Wider context from the report

    “(5) Essex County Council did not: a. act on appropriate referrals to social care by Essex Partnership NHS Trust b. conduct required assessments of Molly during her detention c. did not appoint a social worker until after Molly was discharged There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act. ”

    Source location

    Molly Ann Sergeant · 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

    Require Child and Family Assessments and continued Social Care involvement for every young person admitted to a Tier 4 inpatient bed.

    Verbatim wording from the response

    “There is now agreement that there will be a Child and Family Assessment for every young person admitted to an in-patient Tier 4 bed. This has been in place since January 2022 but has been re-emphasised to the Children and Families Hub and all operational social work teams since the Inquest. The initial communication stated that any young person admitted to a psychiatric in-patient unit is a child in need (by definition) and will receive a Child and Family Assessment. There is a specific audit being undertaken this Spring 2023 by our Professional Standards Unit to ensure that these are always taking place. The expectation is that the Young Person will have an allocated social worker throughout their stay as an in-patient.”

    Source location

    Response from Essex County Council
    Page 3 · response
    Published 10 March 2023

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    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 acknowledged shortcomings were not causation or contributory factors in Molly’s death.

    Verbatim wording from the response

    “It is not our view that these shortcomings, which we have fully acknowledged and have taken significant steps to ensure do not happen again, were causation factors or contributory factors which led to Molly’s very sad death.”

    Source location

    Response from Essex County Council
    Page 2 · response
    Published 10 March 2023

    Open published response

  3. Inner North London

    AI-generated summary

    Max TURBUTT · 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

    Max Turbutt had experienced mental ill health for several years and had been supported by Kent County Council services as a care leaver. The report states that he died by suicide, with the medical cause of death recorded as hanging. Concerns were raised that attempts by Max and his father to contact his personal adviser were unsuccessful, with no phone redirect or email out-of-office message, and that a crisis number led only to an answerphone.

    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 an accessible alternative contact when a personal advisor or social worker is unavailable

    Wider context from the report

    “Max’s father told me at inquest that in March and April 2022, Max tried to contact his personal advisor at the 18+ Service at Thistley Hill in Dover on several occasions over a number of weeks, but found her phone always to be switched off. There was no redirect and no out of office on her email. Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick. A crisis number was given and Mr Turbutt called it, but it was simply an answerphone. This arrangement does not seem adequate for a vulnerable person in need. ”

    Source location

    Max TURBUTT · 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

    Advise young adults immediately when their allocated Personal Advisor is off long-term sick, providing the Team Manager’s name and Duty contact number.

    Verbatim wording from the response

    “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

    Source location

    Response from Kent County Council
    Page 3 · response
    Published 20 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

    Require the relevant staff member to add a mobile-phone voice message identifying whom to contact during their absence.

    Verbatim wording from the response

    “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

    Source location

    Response from Kent County Council
    Page 3 · response
    Published 20 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

    Ensure an out-of-office email reply is added when a staff member is absent on a long-term basis.

    Verbatim wording from the response

    “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

    Source location

    Response from Kent County Council
    Page 3 · response
    Published 20 October 2022

    Open published response

  4. East London

    AI-generated summary

    Mrs Helena Opoku · 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

    Mrs Helena Opoku was pronounced deceased at home on 4 April 2021 after dying from carbon monoxide toxicity associated with using charcoal braziers for cooking and heating after her gas and electricity had been disconnected. The report raised concerns about social services’ failure to investigate safeguarding referrals, appoint social workers within a reasonable timeframe, and assess vulnerable residents’ homes during January to March 2021.

    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

    Delays in appointing social workers to vulnerable persons

    Wider context from the report

    “2. During the same period the team was unable to appoint social workers to vulnerable persons within a reasonable timeframe or carry out assessments of the suitability of the homes of vulnerable residents. ”

    Source location

    Mrs Helena Opoku · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Lewis Victor Mendelson · 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

    Lewis Victor Mendelson, who had profound learning and physical disabilities, became unwell after vomiting on 8 May 2019, was taken to hospital, later received end-of-life care, and died at home on 16 May 2019. The concerns included the absence of a DoLS authorisation, statutory care review and allocated social worker, as well as hospital treatment and end-of-life decisions without a formal best interests meeting or IMCA involvement.

    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

    Absence of a designated social worker overseeing care

    Wider context from the report

    “1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death. He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages. There was no designated Social worker overseeing his care due to staffing shortages; ”

    Source location

    Lewis Victor Mendelson · 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

    Local authorities are accountable for meeting statutory Care Act duties, including conducting regular care-plan reviews.

    Verbatim wording from the response

    “I am deeply concerned to read in your report that Mr Mendelson was not assigned a social worker and an annual review of his care was not conducted by the Stockport Metropolitan Borough Council. This is the second Prevention of Future Deaths report received by the Department where Manchester South coroners have raised concerns that annual care reviews have not been conducted by Stockport Council as required by law. This is clearly unacceptable and I expect Stockport Council to look into this matter thoroughly.”

    Source location

    2019-0434-Response-from-the-Department-of-Health-and-Pensions-1
    Page 1 · response
    Published 31 December 2019

    Open published response

  6. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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

    Delays in allocating a named social worker and escalating allocation difficulties

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · 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

    Maintain social-worker staffing levels and smaller caseloads to support allocation of a worker to every looked-after child.

    Verbatim wording from the response

    “6. Children’s Social Care Services in Tower Hamlets has a clear expectation that all children and young people looked after by the council will have an allocated social worker. The number of social workers in the teams providing this service have been maintained despite a reduction in the number of looked after children and this has been reflected in smaller case loads. Managers within the service are clear that ensuring that all looked after children have an allocated social worker is one of their primary responsibilities.”

    Source location

    2014-0555-Response-by-Tower-Hamlets
    Page 1 · response
    Published 28 December 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

    Monitor worker allocation through monthly management reports and require urgent investigation when vulnerable children appear unallocated.

    Verbatim wording from the response

    “7. The Children’s Social Care Management Team receives a monthly report providing information about all children and young people receiving a service. This includes confirmation of the allocation of looked after children (and children subject to a protection plan); if the performance report shows that any of these vulnerable children appears to be without an allocated worker, then the responsible senior manager is required to investigate this as a matter of urgency. There have not been any unallocated looked after children over the course of the last 3 years, other than the brief period in which they are being transferred between social work staff / social work teams.”

    Source location

    2014-0555-Response-by-Tower-Hamlets
    Page 2 · response
    Published 28 December 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

    Remind managers to complete case transfers efficiently and maintain an identified key worker for every case.

    Verbatim wording from the response

    “8. Since the completion of the organisational restructure in January 2012, Service and Team Managers have been reminded of the need to ensure that case transfer is undertaken in an efficient and timely manner and that there is always an identified key worker for each case.”

    Source location

    2014-0555-Response-by-Tower-Hamlets
    Page 2 · response
    Published 28 December 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

    Operate an escalation policy using management alerts for failures to implement looked-after children’s plans, including social-worker allocation.

    Verbatim wording from the response

    “9. The Head of Service has written to all of the Independent Reviewing Officers to remind them of their responsibility to raise any concerns about case allocation and planning to Team and Service Managers and ultimately to the Head of Service via an escalation policy. This escalation policy is based upon the use of alerts to draw to the attention of first line, middle and senior managers the failure to implement any part of the plan for a looked after child, including allocation to a social worker. The escalation policy was reviewed and updated in 2013 and has been used to highlight concerns about the lack of progress in the implementation of plans for some looked after children.”

    Source location

    2014-0555-Response-by-Tower-Hamlets
    Page 2 · response
    Published 28 December 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

    Operate a YOT escalation policy for reporting shortcomings in other agencies to management, with annual management review and monitoring.

    Verbatim wording from the response

    “Point 1,a; this issue was identified within the IMR and SCR. As a result of these publications a YOT escalation policy was formulated and has operated successfully since March 2013. A copy of the escalation policy is attached at Annex 2. The policy will be reviewed and its implementation monitored by YOT management on an annual basis.”

    Source location

    2014-0555-Response-by-Medway-Youth-Offending-Service
    Page 3 · response
    Published 28 December 2014

    Open published response

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

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Data last updated 7 September 2026