Recurring concern

Unreliable adult safeguarding threshold assessment and response

First to latest report 6 Jul 2015 — 3 Apr 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
6

What this concern includes

Includes failures in the dedicated adult safeguarding threshold and response process, including Section 42 threshold training, triage, assessment, decisions about concerns below the threshold, guidance on when external intervention is warranted, and referral to proportionate safeguarding or support responses.

What is not included
  • Excludes safeguarding concerns involving children or probation offender-management checks unless the assertion explicitly concerns the adult safeguarding threshold and response process.
  • Excludes generic staff training, communication, resourcing or audit deficiencies that are not directly tied to adult safeguarding threshold decisions or resulting responses.
  • Excludes failures in multi-agency safeguarding coordination, referral follow-up or neglect investigation when the threshold assessment or response decision is not itself deficient.
  • Excludes clinical, mental-capacity or regulatory intervention thresholds that are not part of adult safeguarding decision-making.

Reports and published responses 5 reports

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

  1. County Durham and Darlington

    AI-generated summary

    Loraine Michelle CHEESMAN · 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

    Loraine Michelle CHEESMAN died in Darlington on 13 May 2023 as a consequence of a fire at the property. Her Hoarding Disorder and Executive Dysfunction made a more than minimal contribution to the fire, and concerns were raised about the lack of specific guidance on incorporating Executive Dysfunction into mental-capacity assessments and determining when external intervention should be triggered.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of guidance for assessing when external intervention can be triggered

    Wider context from the report

    “Department of Health and Social Care (2023), Care and Support Statutory Guidance, Section 14.17 states in relation to Self Neglect and Hoarding Disorder: “‘This covers a wide range of behaviour neglecting to care of one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.” During the course of the evidence I heard from social workers and safeguarding professionals than in relation to assessing whether “the point” had been reached in relation to an adult suffering from Hoarding Disorder and Executive Dysfunction there was no specific guidance and that such guidance would in future be welcome. Currently they are constrained by existing guidance for assessing mental capacity, which does not directly recognise Executive Dysfunction, or for assessing whether the adult’s behaviour constitutes a potentially chargeable criminal or regulatory offence, for example in relation to public nuisance, health hazard, or anti social behaviour, rather than the root cause of the behaviour - a mental disorder or disorders. So, the matter of concern consists of this request - for guidance to be provided as to how to incorporate consideration of Executive Dysfunction into the assessment of mental capacity and how to assess when the point when external intervention can be triggered has been reached. ”

    Source location

    Loraine Michelle CHEESMAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Cumbria

    AI-generated summary

    Gerald Goodwin · 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

    Gerald Goodwin, who had Alzheimer’s dementia and had consumed a significant amount of alcohol, was struck by a train while walking along a railway track on 10 November 2022; his death was confirmed at 00:17 on 11 November 2022. The principal concerns were that safeguarding and care-assessment referrals were rejected, closed, or not actioned, with multiple teams and systems failing to communicate effectively and potentially exposing other vulnerable adults to 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

    Triage failing to give sufficient regard to safeguarding concerns personally witnessed by practitioners

    Wider context from the report

    “(1) The Liaison and Diversion of Lancashire and South Cumbria NHS Foundation Trust had contact with Mr Goodwin in September and October 2022. Liaison and Diversion Team members visited Mr Goodwin at home and concluded that he was at risk of self-neglect. They noted his appearance, his living conditions and the fact that he was not taking prescribed medication. On any view Mr Goodwin was vulnerable: he suffered from Alzheimer's dementia, and was thought to misuse alcohol. The Liaison and Diversion Team considered that there were safeguarding concerns in respect of Mr Goodwin and referred him to the Adult Social Care team of Cumbria Council. I understand that the team in question now forms part of Westmorland and Furness Council. Despite this referral from practitioners who had personally visited Mr Goodwin, it was rejected at triage on 5th October 2022. I am concerned that this indicates that an approach to triage is being taken which pays insufficient regard to the concerns of practitioners who had personally witnessed apparent safeguarding concerns. ”

    Source location

    Gerald Goodwin · 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

    Implement the Self-Neglect Strategy requiring face-to-face visits, capacity consideration, dynamic risk assessment, professional challenge and supervisory support.

    Verbatim wording from the response

    “A Self-Neglect Strategy was put in place under the direction of the Westmorland and Furness Council Principal Social Worker and this was implemented on 1st July 2023. This strategy aims to strengthen Adult Social Care’s practice and response to people who are or may be self-neglecting.”

    Source location

    Response from Adult Social Services
    Page 1 · response
    Published 22 November 2023

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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

    Introduce decision-making guidance for Single Point of Access and practitioner teams, including timely collaborative decisions, multidisciplinary input and streamlined referral allocation.

    Verbatim wording from the response

    “In respect of making improvements to the triaging process new guidance on ‘Decision Making for Single Point of Access and Practitioner Teams’ has also been introduced under the direction of the Principal Social Worker. This guidance was introduced in September 2023.”

    Source location

    Response from Adult Social Services
    Page 2 · response
    Published 22 November 2023

    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 twice-daily multidisciplinary discussions to resolve concerns about incoming referrals and agree appropriate action promptly.

    Verbatim wording from the response

    “• All duty officers for the day must prioritise participation in the twice daily SPA Multidisciplinary calls unless they are out on a duty visit.”

    Source location

    Response from Adult Social Services
    Page 2 · response
    Published 22 November 2023

    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

    Conduct a quality assurance and process-mapping review of reablement referrals to identify required improvements, including triage and delay reduction.

    Verbatim wording from the response

    “Adult Social Care and Cumbria Care Services (who operate the reablement service) have set up a task and finish group to undertake a quality assurance review and to identify required process changes.”

    Source location

    Response from Adult Social Services
    Page 3 · response
    Published 22 November 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

    Adult Social Care says the referral was not rejected; it was triaged below the statutory safeguarding-enquiry threshold, with social work support considered appropriate.

    Verbatim wording from the response

    “The referral in question was received by Adult Social Care on 5th October 2022. The referral identified potential safeguarding concerns and was therefore considered initially by the Safeguarding Team which sits within Adult Social Care. It was decided at that stage that the threshold for a statutory safeguarding enquiry was not met and the provision of social work support was considered to be more appropriate. The fact that the initial triage concluded that the threshold for a statutory safeguarding enquiry was not met does not mean that any safeguarding issues would not be addressed. The approach would generally be that the individual should be given the opportunity to engage with a Care Act assessment and potentially treatment but that any safeguarding issues would also be addressed if they emerged during the process.”

    Source location

    Response from Adult Social Services
    Page 1 · response
    Published 22 November 2023

    Open published response

  3. Berkshire

    AI-generated summary

    Lucy Anne Walles · 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

    Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient training on Section 42 thresholds and options for concerns below the threshold

    Wider context from the report

    “Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. ”

    Source location

    Lucy Anne Walles · 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

    Provide tailored safeguarding training for managers on consistent handling of safeguarding contacts, referrals and enquiries.

    Verbatim wording from the response

    “In addition to the core training offer outlined above Assistant Directors in Adult Social Care and the Safeguarding Lead are now providing tailored safeguarding training for Managers to ensure that all senior staff have a consistent approach to safeguarding contacts, referrals and enquiries and are appraised of best practice guidance. All Social Care practitioners have access to the training materials and briefing notes produced by the Safeguarding Adults Board following Safeguarding Adult Reviews (SAR) reports and are given opportunities to attend learning events for SAR recommendations. The SAR findings for Ms Lucy Anne Walles (under the title “Bree” SAR) and the recommendations therein will be the subject of learning events.”

    Source location

    Response from Reading Borough Council
    Page 3 · response
    Published 23 June 2023

    Open published response

  4. 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

    Premature closure of section 42 safeguarding enquiries without gathering material information

    Wider context from the report

    “7.Instead the s.42 reporter according to the live evidence of the principal practitioner of the Adult Safeguarding team of the day, appears to have collated only limited information and closed the inquiry down prematurely without looking at material documents or even awaiting the toxicology report. At the very least it should be reopened to see if there was any missed opportunities from which lessons could be learnt and future deaths prevented and to embody the whole purpose of a s.42 assessment in deciding what action to take to support and protect the person in question. It being reiterated that this assessment was only commissioned after the deceased had passed away. ”

    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 statutory safeguarding duty did not apply to a deceased individual, so a section 42 enquiry was inappropriate in these circumstances.

    Verbatim wording from the response

    “Pursuant to LCC’s duties under s.42, a Local Authority is not required by law to carry out enquiries for those individuals who do not meet the criteria for safeguarding as set out in this section of the Act. In particular, the care act duty can have no application to a deceased individual as the purpose of the enquiry is to decide what action is to be taken in relation to the individual and by whom. In some cases, LCC may have had a safeguarding referral during the individual’s life and appropriate information about LCC’s safeguarding actions will be provided to the coroner.”

    Source location

    Response from Lincolnshire County Council
    Page 6 · response
    Published 3 May 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 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

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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

    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

  5. South Yorkshire (Eastern)

    AI-generated summary

    Phyllis Broomhead · 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

    Phyllis Broomhead, who had dementia and lived at Lord Hardy Court EMI Residential Home, suffered repeated falls, including three significant falls requiring hospitalisation. On 9 June 2013 she fell from her bed while trying to reach the toilet, sustained a head injury and died later that day from a traumatic left-sided subdural haemorrhage. Concerns included incomplete implementation of measures, staff training and record keeping, safeguarding screening, and the lack of closer monitoring or alternative placement for residents at high risk of serious injury.

    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 of initial safeguarding referral screening to be sufficiently detailed and objective

    Wider context from the report

    “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to: i. the head injury protocol, how this should be followed and the importance of doing so. ii. record keeping. iii. indicators and triggers to seek social worker input. (2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home. ”

    Source location

    Phyllis Broomhead · 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

    Re-engineer safeguarding documentation to capture the customer journey and provide detailed screening guidance for informed exit decisions.

    Verbatim wording from the response

    “Work Completed Safeguarding documentation has been re-engineered to be Care Act compliant and to ensure the customer journey is captured and recorded. More detailed guidance and standard practice to confirm what documents have been screened, dates spoken to during the screening stage to enable the decision maker to make informed decisions before exiting.”

    Source location

    2015-0290-Response-by-Rotherham-Borough-Council
    Page 4 · response
    Published 6 July 2015

    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