Recurring concern

Unreliable escalation of assessed safety risk levels

First to latest report 25 Jul 2014 — 26 Jul 2024

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
3

What this concern includes

Includes failures of controls governing the escalation, updating or consistent assignment of assessed safety risk levels, including inhibiting policy wording, approval barriers, inconsistent level-setting and failure to maintain current risk-level information when these directly affect risk recognition.

What is not included
  • Excludes generic risk-assessment deficiencies where the specific issue is not escalation, updating or consistent assignment of risk levels.
  • Excludes failures to communicate or record risk information where the underlying risk level was reliably assessed and escalated.
  • Excludes failures of a separately named hazard-specific risk system unless that system is the supported parent boundary.
  • Excludes generic staffing, training or senior-oversight deficiencies unless they directly prevent appropriate escalation or updating of assessed risk levels.

Reports and published responses 4 reports

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

  1. East London

    AI-generated summary

    Zara Natasha Aleena · 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

    Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.

    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

    Obstacles inhibiting increases in assessed risk levels

    Wider context from the report

    “(9) There may be obstacles to increasing risk levels. The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team. The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase risk. ”

    Source location

    Zara Natasha Aleena · Prevention of Future Deaths report
    Page 4 · 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

    Remove the statement discouraging risk-level inflation during the next risk-assessment policy review.

    Verbatim wording from the response

    “9.1. We do not have any evidence of a widespread problem of Probation Officers being reluctant to ask SPOs to approve formal increases in assessed risk, or that this particular statement in policy is inhibiting staff from raising their assessment of an offender’s risk level, where that would be justified based on the available evidence. The percentage of those assessed as ‘high risk of serious harm’ has increased in recent years from 19.9% in 2018 to 25% in 2022. PARG’s annual sentence management audit confirms agreement with the risk level in most assessments. To avoid any misinterpretation, this statement will be removed in the next review, due by November.”

    Source location

    Response from HMPPS and MoJ
    Page 8 · response
    Published 2 August 2024

    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

    There is no evidence of a widespread reluctance to seek approval for increased risk or that the policy statement inhibits justified risk escalation.

    Verbatim wording from the response

    “9.1. We do not have any evidence of a widespread problem of Probation Officers being reluctant to ask SPOs to approve formal increases in assessed risk, or that this particular statement in policy is inhibiting staff from raising their assessment of an offender’s risk level, where that would be justified based on the available evidence. The percentage of those assessed as ‘high risk of serious harm’ has increased in recent years from 19.9% in 2018 to 25% in 2022. PARG’s annual sentence management audit confirms agreement with the risk level in most assessments. To avoid any misinterpretation, this statement will be removed in the next review, due by November.”

    Source location

    Response from HMPPS and MoJ
    Page 8 · response
    Published 2 August 2024

    Open published response

  2. Milton Keynes

    AI-generated summary

    Nicholas Rousseau · 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

    Nicholas Rousseau attended Milton Keynes University Hospital on 3 and 5 October 2019 and died at home on 9 October 2019, aged 47. During his first attendance, his lactate level was 3.9 and he was discharged. The report identified conflicting views among senior Accident and Emergency staff about the significance of elevated lactate and whether it should be repeated, with concern that disregarding the NICE guidelines posed a threat to patients with sepsis and elevated lactate levels.

    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 follow NICE sepsis risk stratification guidance for lactate levels above 2

    Wider context from the report

    “(1) In the course of oral evidence Dr ████████ and ████████ ████████, both Consultants in Accident and Emergency Medicine at the hospital gave conflicting accounts of how much importance they would ascribe to the lactate level which was nearly twice the upper limit of normal and whether they would repeat it before discharge. ████████ told me he would not repeat it because he saw lots of patients with elevated lactate and with the resources he had available he would be spending a disproportionate amount of time checking lactate levels in patients who ultimately would be fine. We spent some time on the point and with reference to the NICE Sepsis Risk Stratification Tools. The Guideline is clear that if a lactate is above 2 then the patient should be escalated to high risk. ████████ was challenged several times on his position that irrespective of the guidelines he would not routinely repeat the lactate level dismissing it as an unnecessary burden. He maintained that position. Dr ███ took a flatly contrary view and said that she would repeat it irrespective of the burden of work it may generate. These contrasting opinions indicate a degree of confusion amongst the senior staff at Milton Keynes University Hospital Accident and Emergency Department which in my view poses a threat to patients with sepsis and with elevated lactate levels. The disregarding of the NICE Guidelines simply because it is inconvenient is disturbing. ”

    Source location

    Nicholas Rousseau · 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

    Update the MKUH sepsis policy at its scheduled November 2021 review.

    Verbatim wording from the response

    “• Maintains a local MKUH policy that is consistent with national guidance (including NG51). The current policy is due for scheduled review in November 2021.”

    Source location

    2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
    Page 3 · response
    Published 30 March 2021

    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

    The patient was not suspected of sepsis and lacked high-risk criteria, so guidelines did not mandate repeat lactate measurement or imply likely clinical benefit.

    Verbatim wording from the response

    “Before coming to the substantive matter of blood lactate levels, I would like to take this opportunity to extend my condolences and sympathies to Mr Rousseau’s family. I am conscious that any sense of divergence in view, at Inquest, between HM Coroner and attending physicians will have added to the family’s distress. I am not clear from the Regulation 28 report whether you consider that an alternative course of action regarding the measurement of blood lactate might have afforded an opportunity to alter the subsequent clinical course and Mr Rousseau’s ultimately death. For avoidance of doubt, we do not consider this likely.”

    Source location

    2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
    Page 1 · response
    Published 30 March 2021

    Open published response

  3. East London

    AI-generated summary

    Trinder Kaur Birdi · 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

    Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.

    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 consult the referring general practitioner before downgrading suicide risk

    Wider context from the report

    “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional. It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor. ”

    Source location

    Trinder Kaur Birdi · 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

    Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.

    Verbatim wording from the response

    “1. A requirement will be introduced for a referral to the on-call psychiatrist to be completed where the presenting risk is significantly different to that of another clinician (including GP) who has reviewed the patient on the same day.”

    Source location

    2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    Open published response

  4. West Yorkshire (Western)

    AI-generated summary

    Edna Bulmer · 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

    Edna Bulmer, who had a history of falls, suffered an unwitnessed fall on 10 September 2013 and was later found unconscious in bed. She died in hospital on 15 September 2013 after sustaining a serious intracranial haemorrhage. The concerns identified were inconsistent recording of her falls risk, delays in providing the identified pressure mat and pendant, and the apparent absence of a clear process for reviewing her risk assessment after further falls.

    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

    Lack of clear and consistent identification of falling risk levels in records

    Wider context from the report

    “(1) There did not appear to be a clear identification of the level of risk of Mrs. Bulmer falling made within Dovecote Lodge records. In one section Mrs. Bulmer is described as very high risk, elsewhere she is described as high risk. ”

    Source location

    Edna Bulmer · 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.

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Data last updated 7 September 2026