Recurring concern

Unreliable funding responsibility and referral arrangements for required care

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First reported 27 Sep 2017•Latest report 28 May 2026

Definition

What this concern includes

Includes failures in arrangements for identifying the responsible funding authority or commissioning body and making or progressing the funding referral needed for additional, urgent or otherwise required care, including the anchor's failure to refer urgent 1:1 care funding applications and confusion between ICBs about responsibility for additional care or safer placements.

Not included

  • Excludes general funding shortages or refusals where the funding-responsibility or referral process itself is not deficient.
  • Excludes delays in delivering care packages or placements after funding responsibility and the required referral have been reliably established.
  • Excludes funding pathways for unrelated specialist treatment, such as psychological therapy, unless the assertion concerns responsibility for funding required care provision.
  • Excludes generic inter-agency communication or administrative failures that do not concern determining funding responsibility or making the necessary care-funding referral.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2017–2026

First to latest report issue date

Stated actions
4

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.

NHS England2
Advinia Health Care Limited1
HCRG Care Group1
Lancashire County Council1
Lodge Care Home1
London Borough of Hounslow1
Mid and South Essex NHS Foundation Trust1
NHS Essex Integrated Care Board1

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. Essex

    AI-generated summary

    Lacey Carole Anne HEATH · 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

    Lacey Carole Anne HEATH died on 16 February 2025 after collapsing at home and suffering cardiac arrest en route to hospital. The death followed thrombosis and complete stenosis of her mechanical aortic valve in the context of sub-therapeutic anticoagulation. Concerns included difficulty maintaining therapeutic anticoagulation, lack of access to affordable at-home monitoring, absence of a funding application, insufficient medical review or haematology referral, and inadequate clinical records.

    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 apply for funding for at-home anticoagulation monitoring

    Wider context from the report

    “5. No application for funding was made on behalf of Ms Heath by the Trust nor was this explained to Ms Heath who a very quiet, shy lady who always relied on her very loving family to assist her with appointments and could not advocate for herself. There was no consideration if Ms Heath had any learning difficulties and it was noted that there was a developmental delay in her medical records. Evidence at the inquest was Ms Heath experienced this as clinicians not caring about her and she became very despondent about the failure to achieve a therapeutic range. ”

    Source location

    Lacey Carole Anne HEATH · 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

    Establish an escalation process for clinically required anticoagulation monitoring equipment or consumables when financial barriers arise, including funding guidance, staff communication and application audits.

    Verbatim wording from the response

    “By the end of September 2026 we will have a process for escalating cases where recommended anticoagulation monitoring equipment or consumables may be clinically required but financial barriers are identified. This will include signposting to available funding routes, individual funding consideration, charitable support or commissioner discussion where applicable.”

    Source location

    Response from Mid & South Essex NHS Foundation Trust
    Page 3 · response
    Published 6 August 2026

    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 responsible anticoagulation service or specialist clinician must submit funding requests for exceptional at-home INR monitoring to the Integrated Care Board.

    Verbatim wording from the response

    “This case is exceptional, however, as there was a clear clinical need for an INR home testing machine. As such an approach for funding should have been made by the anticoagulation service to the ICB for this individual, if not routinely included in the service specification.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 August 2026

    Open published response

  2. Lancashire and Blackburn with Darwen

    AI-generated summary

    John Graham ALSTON · 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

    Mr Alston, a 70-year-old man with dementia living in a specialist care home, was punched by another resident on 2 November 2022, suffered an unsurvivable brain bleed, and died in a hospice on 8 November 2022. The concerns relate to confusion over which commissioning body was responsible for the other resident, delays in finding a safer placement, and difficulties sharing discharge information; the report warns that similar delays could contribute to future deaths.

    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

    Reactive determination of the funding ICB when additional care or changes are required

    Wider context from the report

    “1. ████████ had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. ████████ remained in hospital for some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred. It was quickly apparent that care home two could not meet ████████ needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for ████████. There were also difficulties in sharing information for discharge processes because it was unclear which area or from where ████████ had come. This inquest concluded that due to the complexity of ████████ presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements. I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident. I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue causes necessary care or changes when proactive determination of the issue before problems arise ought to be possible. ”

    Source location

    John Graham ALSTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 accessing increased funding, support, services or suitable placements

    Wider context from the report

    “1. ████████ had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. ████████ remained in hospital for some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred. It was quickly apparent that care home two could not meet ████████ needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for ████████. There were also difficulties in sharing information for discharge processes because it was unclear which area or from where ████████ had come. This inquest concluded that due to the complexity of ████████ presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements. I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident. I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue causes necessary care or changes when proactive determination of the issue before problems arise ought to be possible. ”

    Source location

    John Graham ALSTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Sefton, St Helens and Knowsley

    AI-generated summary

    Julia MURPHY · 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

    Julia Murphy, known as Sheila, died in hospital on 9 April 2023 after a fall in her care home caused a hip fracture and her condition deteriorated. The report raises concerns about repeated falls, incomplete or inaccurate referrals to the falls prevention team, inadequate escalation, and failure to formally seek one-to-one supervision funding where appropriate.

    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 formally request one-to-one supervision funding when necessary

    Wider context from the report

    “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia; 1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team . 2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment. 4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis. 5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation. The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia. ”

    Source location

    Julia MURPHY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. West London

    AI-generated summary

    Mrs Pamela Craigie · 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 Pamela Craigie died on 19 March 2017 after falling at Cloisters Nursing Home on 24 February 2017 and sustaining an acute subdural haematoma and head injury. The report raised concerns about inconsistent supervision and adherence to her care plan, unclear criteria and processes for referring residents for urgent 1:1 care, delays in urgent assessments, and how residents’ safety was managed while awaiting additional care.

    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 make urgent 1:1 care funding referrals when criteria are met

    Wider context from the report

    “2. That it is 'very difficult' to get funding from the local authority for 1:1 care. I am concerned that applications to the local authority for urgent 1:1 care are not being made, because the Home feel that they have been refused before and that a future application will not be successful. The Home should ensure that where the criteria for 1:1 care is met, that a referral for funding is always made. ”

    Source location

    Mrs Pamela Craigie · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 criteria and timing for referrals for 1:1 care funding

    Wider context from the report

    “1. A resident would only be likely to warrant funding for 1:1 care if they were falling "almost every day, or every week". There is no set number of times they would be required to fall. However, it is not clear from the staff who gave evidence, when a referral for funding for 1:1 care should be made to the local authority, and based on what criteria. The Home should ensure that the criteria for 1:1 care is clear to staff. ”

    Source location

    Mrs Pamela Craigie · 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

    Ensure staff refer residents for 1:1 care when the policy criteria are met.

    Verbatim wording from the response

    “The revised Falls Prevention Policy was issued to all homes within the Company, including Cloisters, in October 2017 and all Registered Managers will ensure that the policy is followed and will refer residents for 1:1 care when the criteria is met.”

    Source location

    2017-0279-Response-by-Advinia-Health-Care
    Page 1 · response
    Published 27 November 2017

    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

    Update the Falls Prevention Policy and resident risk assessments to define the protocol for providing 1:1 care.

    Verbatim wording from the response

    “The Company has reviewed its Falls Prevention Policy and has updated its risk assessments in line with that amended Policy. The Policy now clearly states the protocol that staff are to follow should a resident require 1:1 care: Falls Prevention Policy, page 11, section 14”

    Source location

    2017-0279-Response-by-Advinia-Health-Care
    Page 1 · response
    Published 27 November 2017

    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 the revised Falls Prevention Policy to all company homes, including Cloisters.

    Verbatim wording from the response

    “The revised Falls Prevention Policy was issued to all homes within the Company, including Cloisters, in October 2017 and all Registered Managers will ensure that the policy is followed and will refer residents for 1:1 care when the criteria is met.”

    Source location

    2017-0279-Response-by-Advinia-Health-Care
    Page 1 · response
    Published 27 November 2017

    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

    Commissioners decide whether funding for additional 1:1 support is provided following reassessment of the resident’s needs.

    Verbatim wording from the response

    “However, if a Resident continues to have frequent falls, defined as 2 or more per month, and all equipment is in place to manage this risk and there has been input from the local falls team and/or G.P, and the Resident still continues to experience a high number of falls, then the Home Manager will liaise with the Commissioners to request a re-assessment of needs. This may result in 1:1 support for that person to manage the risk. In these cases, the Home Manager will liaise with the Operations Manager to request a re-assessment or specific funding.”

    Source location

    2017-0279-Response-by-Advinia-Health-Care
    Page 1 · response
    Published 27 November 2017

    Open published response
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Data last updated 7 September 2026