Recurring concern

Unreliable communication of placement arrangements before release

First to latest report 29 Sep 2015 — 21 Jul 2025

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
1

What this concern includes

Includes failures in the placement-information process to communicate intended placement, placement conditions, supervision coverage, timing and other material arrangements clearly and sufficiently before release or admission.

What is not included
  • Excludes failures to secure, fund or provide a suitable placement where the information communicated about the placement is not itself deficient.
  • Excludes generic communication, discharge or care-planning failures that do not concern information about a specific placement arrangement.
  • Excludes clinical care, supervision or accommodation-quality failures occurring after the person has been placed when the placement information was accurate and adequately communicated.
  • Excludes placement-suitability inspection and provider-approval failures unless the asserted deficiency is specifically the communication of placement arrangements.

Reports and published responses 2 reports

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

  1. Avon

    AI-generated summary

    Melissa Louise Mathieson · 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

    Melissa Louise Mathieson, an 18-year-old autistic woman with ADHD and a diagnosis of Asperger’s, was attacked by another resident at Alexandra Homes on 12 October 2014 and died a few days later from her injuries. Concerns included misleading descriptions of supervision, the absence of a formal induction and weekly review process, and inadequate review of support plans and risk assessments.

    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

    Misleading placement and supervision offers lacking clarification of coverage

    Wider context from the report

    “(1) the offer of placement and the level of supervision i.e. 1:1 was misleading, there was no clarification for example, 24hrs cover, 8hrs cover during the day only, or when carrying out activities or when outside the home only. ”

    Source location

    Melissa Louise Mathieson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. 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 provide timely information about intended placement

    Wider context from the report

    “(1) That the deceased was not informed of his intended placement in Milton Keynes until the day before his release. ”

    Source location

    Lee Anthony Boden · 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

    Address timely release planning and communication learning with managers and staff across the Buckinghamshire and Oxfordshire Local Delivery Unit.

    Verbatim wording from the response

    “In addition, rather than relying on the prison to inform Mr Boden of the change of plan, it would have been preferable for his offender manager to make contact with him to explain the circumstances and to ensure he was aware what could be done to help him on his return to the community. Timeliness in developing release plans, and ensuring that service users are kept informed of changes, are learning points for the team and this will be addressed with managers and staff across the Buckinghamshire and Oxfordshire Local Delivery Unit.”

    Source location

    2015-0394-Response-by-NOMS
    Page 1 · response
    Published 29 September 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