2 Oct 2025 Beatrice Smith · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Lack of effective internal investigation and organisational learning from safeguarding incidents View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Harbour Healthcare Ltd.
Complete a Serious Untoward Incident root cause analysis with Human Resources support.
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Harbour Healthcare Ltd.
Operate a governance process and tracker for new Serious Untoward Incidents, reviewing root-cause findings, learning, actions and trends.
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Harbour Healthcare Ltd.
Record actions in the Service Improvement Plan and share learning through Clinical Governance Meetings.
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Harbour Healthcare Ltd.
Operate a monthly Coroners Learning Forum to share inquest and serious-incident outcomes and associated lessons across the organisation.
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Harbour Healthcare Ltd.
Cascade Riverside Court’s inquest outcome and lessons learned across the company.
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AI-generated summary
Beatrice Smith · 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
Beatrice Smith, who was living at Riverside Court Care Home, developed seriously deteriorating leg and heel ulcers after 15 April 2025. Specialist attention was not sought and the ulcer was not always properly dressed; she developed sepsis, was admitted to hospital on 23 April 2025, and died that day. Concerns included the apparent absence of an effective internal investigation and of additional staff training or guidance, creating risks of missed learning and repeated inadequate care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of effective internal investigation and organisational learning from safeguarding incidents
Wider context from the report “(1) A safeguarding referral was made in respect of Mrs Smith's condition at the time. Despite this, and despite Mrs Smith's death, no effective internal investigation appears to have been conducted. I am concerned that the absence of such an investigation means that opportunities for learning are likely to be overlooked. In turn this risks residents being exposed to repeated practices that are inadequate. This is a risk to those residents.
2) I asked the Manager of Riverside Court whether any additional training or guidance had been provided to staff in the light of this incident and Mrs Smith's death. She replied that it had not. Given my concerns that Mrs Smith's condition was not well managed I am concerned that the absence of such training and guidance risks a repeat of these events.
” Source location Beatrice Smith · Prevention of Future Deaths report
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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 Complete a Serious Untoward Incident root cause analysis with Human Resources support.
Verbatim wording from the response “Following the inquest a Serious Untoward Incident Root Cause Analysis was completed by Harbour Healthcare Head of Safeguarding with support from Human Resources.” Source location Response from Harbour Healthcare Limited
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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 Operate a governance process and tracker for new Serious Untoward Incidents, reviewing root-cause findings, learning, actions and trends.
Verbatim wording from the response “10. There is a Governance Process in Place since June 2025 for all new Serious Untoward Incidents and we have a tracker monitored and reviewed by the Quality Team and Head of Safeguarding to look at detail in the RCA for lessons learned, actions, and trends in key areas” Source location Response from Harbour Healthcare Limited
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record actions in the Service Improvement Plan and share learning through Clinical Governance Meetings.
Verbatim wording from the response “11. When completing the home add any actions to their Service Improvement Plan and share learning through their Clinical Governance Meeting” Source location Response from Harbour Healthcare Limited
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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 Operate a monthly Coroners Learning Forum to share inquest and serious-incident outcomes and associated lessons across the organisation.
Verbatim wording from the response “As a company we have implemented a Coroners Lessons Learned forum which are held via teams every month. These commenced in October and offer a presentation of a coroners inquest relating to a home and then the associated lessons learned.” Source location Response from Harbour Healthcare Limited
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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 Cascade Riverside Court’s inquest outcome and lessons learned across the company.
Verbatim wording from the response “15. Harbour Healthcare have introduced a Coroners Learning Forum in October 2025 where a team’s call is open to all interested individuals to share outcomes from Coroners Courts or potentially serious incidents along with any associated lessons learned for the wider organisation. The outcome of Riverside Courts inquest was cascaded to the company on Wednesday 3rd November 2025” Source location Response from Harbour Healthcare Limited
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4 Nov 2024 Janet Brown Townend · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 7
Failure to provide Safeguarding Adult Review outcomes and recommendations to review subjects View source Failure to appropriately probe responses during Safeguarding Adult Reviews View source Failure to document the full Safeguarding Adult Review process properly View source
Lack of adequate Safeguarding Adult Review quality View source Failure to record family input in Safeguarding Adult Reviews View source Failure to follow the full Safeguarding Adult Review process View source Hasty Safeguarding Adult Review processes View source See 4 more concerns
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
East Riding of Yorkshire Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
East Riding of Yorkshire Council
Implemented new forms guiding practitioners to undertake and record safeguarding concerns and Section 42 enquiries, including person and family voices and outcome-sharing records.
View source
East Riding of Yorkshire Council
Disseminated lessons learned from the identified enquiry practice issues across the safeguarding team.
View source
East Riding of Yorkshire Council
Delivered training, learning and guidance to strengthen practitioners’ completion of safeguarding forms, professional curiosity and thorough enquiry practice.
View source
East Riding of Yorkshire Council
Implemented practice workshops and a weekly safeguarding hub forum providing case discussion and leadership guidance.
View source See 1 more action
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AI-generated summary
Janet Brown Townend · 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
Janet Brown Townend developed an infected foot wound that progressed to sepsis after an injury, and she died in hospital on 15 October 2023 despite antibiotics, surgery and other treatment. Concerns were raised about the care she received and about the subsequent Safeguarding Adult Review, which was described as lacking professional curiosity, family input, appropriate scrutiny and proper documentation.
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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 Failure to provide Safeguarding Adult Review outcomes and recommendations to review subjects
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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 Failure to appropriately probe responses during Safeguarding Adult Reviews
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way .
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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 Failure to document the full Safeguarding Adult Review process properly
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly .
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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 adequate Safeguarding Adult Review quality
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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 Failure to record family input in Safeguarding Adult Reviews
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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 Failure to follow the full Safeguarding Adult Review process
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
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 Hasty Safeguarding Adult Review processes
Wider context from the report “There was a referral to Adults Safeguarding from both Yorkshire Ambulance Service and Hull Royal Infirmary regarding concerns as to the care Ms Townend had received.
As a result of the referrals there was a review that was deemed necessary.
However, the quality of that review was lacking.
The Safeguarding Adult Review that took place did not probe the responses received appropriately from the care company and the Community Nurses in any way.
In evidence it was heard that the procedure adopted did not record how the responses had been obtained. The family's input was not recorded. The process happened hastily and the review not to the appropriate standards that would have been of any benefit.
The outcomes of the review and recommendations were not provided to the subjects of the review.
In evidence it was heard that there was a lack of professional curiosity and the full review process not followed or documented properly.
The importance of Safeguarding reviews must not be underestimated. They are in place to identify concerns and prevent any such issues occurring in the future. The procedure conducted needs to be looked at to avoid any impact on anyone else.
” Source location Janet Brown Townend · Prevention of Future Deaths report
Open source report
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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 Implemented new forms guiding practitioners to undertake and record safeguarding concerns and Section 42 enquiries, including person and family voices and outcome-sharing records.
Verbatim wording from the response “In November 2023 (after this enquiry took place), as part of the implementation of a new service and practice model for safeguarding adults, the service launched a new set of forms to record safeguarding adult concerns and section 42 enquiries. These forms lead the practitioner through a much more succinct process for undertaking and recording their intervention with the voice of the person and their family/representative at the heart of the enquiry record.” Source location Response from East Riding of Yorkshire Council
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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 Disseminated lessons learned from the identified enquiry practice issues across the safeguarding team.
Verbatim wording from the response “The record of the enquiry also lacked analysis of the information that was received from both services approached for information and it was not fully triangulated with other information gathered from both Janet Brown Townend herself and members of her family within the record of the section 42 enquiry. It is difficult to say whether the outcome of the enquiry would have been different had these issues been addressed, however, it is acknowledged that the recorded evidence for decision making and subsequent actions in this case could have been improved. The practice issues identified in this enquiry have been addressed with the individual practitioner and lessons learned disseminated within the team.” Source location Response from East Riding of Yorkshire Council
Open published response
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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 Delivered training, learning and guidance to strengthen practitioners’ completion of safeguarding forms, professional curiosity and thorough enquiry practice.
Verbatim wording from the response “The roll out of the forms was accompanied by training and learning for those who are completing them, refreshing practitioners understanding about the expectations for their completion, what good looks like and encouraging professional curiosity. There is also accompanying guidance for practitioners within and external to the form to support them to undertake and record a thorough section 42 enquiry.” Source location Response from East Riding of Yorkshire Council
Open published response
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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 Implemented practice workshops and a weekly safeguarding hub forum providing case discussion and leadership guidance.
Verbatim wording from the response “To support high quality safeguarding adults enquiry practice, the services practice development team has implemented a training programme of practice workshops accompanied by a weekly practice forum with the safeguarding adults hub where cases can be discussed and practitioners obtain clear guidance from the safeguarding adults leadership team. The service also leads a safeguarding champions programme bringing professionals from within and external to the local authority together to share good practice and develop consistent responses to safeguarding across the sector.” Source location Response from East Riding of Yorkshire Council
Open published response
2 Feb 2024 Susan Wendy Bracegirdle · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to obtain input from key people involved in care during safeguarding reviews View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Susan Wendy Bracegirdle · 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
Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain input from key people involved in care during safeguarding reviews
Wider context from the report “4. There had been a safeguarding review undertaken. However key people involved in her care had not provided input to the review which meant there was no clear holistic assessment of what lessons could be learnt to reduce the risk of deaths from pressure ulcers in the future . It was unclear why such an approach had been taken
” Source location Susan Wendy Bracegirdle · Prevention of Future Deaths report
Open source report
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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 Complete the Safeguarding Adult Review, including a multi-agency practitioner learning event and production of the review report.
Verbatim wording from the response “I can confirm that following initial review of Ms Bracegirdle’s case it was confirmed that the circumstances of the case met the criteria for a Safeguarding Adult Review (SAR) as set out in Section 44 of The Care Act 2014.” Source location Response from Greater Manchester Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC previously had no remit over local authorities’ safeguarding reviews, although it now assesses local authorities’ safety duties.
Verbatim wording from the response “4. There had been a safeguarding review undertaken. However key people involved in her care had not provided input to the review which meant there was no clear holistic assessment of what lessons could be learnt to reduce the risk of deaths from pressure ulcers in the future. It was unclear why such an approach had been taken.” Source location Response from Care Quality Commission
Open published response
1 Apr 2022 Name not published · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Lack of appropriate safeguarding review View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Name not published · 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
The deceased had chronic mental health problems, serious self-neglect and infected wounds, and was detained in hospital under the Mental Health Act. After readmission, a VTE risk assessment, monitoring, records, management plan and further capacity assessments were not undertaken; she suffered a pulmonary thromboembolism and died following a cardio-respiratory arrest on 23 February 2020. The principal concerns included inadequate safeguarding and clinical oversight, failures to implement and audit the VTE policy, and insufficient staff training.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of appropriate safeguarding review
Wider context from the report “1. There was a lack of appropriate safeguarding review , Senior clinical oversight as well as necessary MDT meetings and actions to be completed.
” Source location Name not published · Prevention of Future Deaths report
Open source report
19 Nov 2019 Katie Croft · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Unclear dissemination of safeguarding investigation lessons beyond the local area View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Katie Croft · 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
Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear dissemination of safeguarding investigation lessons beyond the local area
Wider context from the report “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations. They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or nationally ;
” Source location Katie Croft · Prevention of Future Deaths report
Open source report
22 Dec 2017 Ronald Arthur Farrington · Prevention of Future Deaths report Surrey
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Concerns raised 3
Failure to conduct an adequate safeguarding enquiry View source Failure to involve family in safeguarding review View source Failure to produce an adequate s42 report View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Surrey County Council
Improve systems to identify long-running adult safeguarding enquiries and bring them to satisfactory conclusions.
View source
Surrey County Council
Implement a revised quality assurance auditing programme for adult safeguarding work.
View source
Surrey County Council
Revise adult safeguarding policies and procedures with clearer expectations for planning, family involvement, organisational contributions, responsibility and timeliness.
View source
Surrey County Council
Deliver a learning and development programme to help staff meet revised adult safeguarding expectations.
View source
Surrey County Council
Review systems to support expected adult safeguarding practice and produce better management information for oversight.
View source See 2 more actions
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AI-generated summary
Ronald Arthur Farrington · 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
Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct an adequate safeguarding enquiry
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” Source location Ronald Arthur Farrington · Prevention of Future Deaths report
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 Failure to involve family in safeguarding review
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” Source location Ronald Arthur Farrington · Prevention of Future Deaths report
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 Failure to produce an adequate s42 report
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” Source location Ronald Arthur Farrington · Prevention of Future Deaths report
Open source report
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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 Improve systems to identify long-running adult safeguarding enquiries and bring them to satisfactory conclusions.
Verbatim wording from the response “We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period. We are confident we can sustain this improved performance.” Source location 2017-0494-Response
Open published response
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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 Implement a revised quality assurance auditing programme for adult safeguarding work.
Verbatim wording from the response “We have also put in place a revised quality assurance auditing programme of our adult safeguarding work so that we can more readily identify when our adult safeguarding work is falling short of expectations and take action to address this.” Source location 2017-0494-Response
Open published response
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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 Revise adult safeguarding policies and procedures with clearer expectations for planning, family involvement, organisational contributions, responsibility and timeliness.
Verbatim wording from the response “We are in the process of revising our adult safeguarding policies and procedures, and working with our colleagues on Surrey Safeguarding Adults Board to guide the Board’s policies and procedures, so that” Source location 2017-0494-Response
Open published response
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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 Deliver a learning and development programme to help staff meet revised adult safeguarding expectations.
Verbatim wording from the response “We expect these policies and procedures to be in place by April 2018, when they will be followed by a learning and development programme to support our staff to understand and be able to meet the expectations on them. We will also review our systems to ensure they are able to support the practice we expect and produce better management information to help oversee the work. We expect this work to be completed by October 2018.” Source location 2017-0494-Response
Open published response
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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 Review systems to support expected adult safeguarding practice and produce better management information for oversight.
Verbatim wording from the response “We expect these policies and procedures to be in place by April 2018, when they will be followed by a learning and development programme to support our staff to understand and be able to meet the expectations on them. We will also review our systems to ensure they are able to support the practice we expect and produce better management information to help oversee the work. We expect this work to be completed by October 2018.” Source location 2017-0494-Response
Open published response
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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 employing provider had first responsibility to complete the safeguarding enquiry, subject to the Council assuring its sufficiency and following up if necessary.
Verbatim wording from the response ““It is important that all partners are clear where responsibility lies where abuse or neglect is carried out by employees or in a regulated setting, such as a care home, hospital, or college. The first responsibility to act must be with the employing organisation as provider of the service … However, a local authority would have to satisfy itself that an employer’s response has been sufficient to deal with the safeguarding issue and, if not, to undertake any enquiry of its own and any appropriate follow up action”” Source location 2017-0494-Response
Open published response
22 May 2017 Kevin George Morgan · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure to refer incidents for safeguarding review and learning View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kevin George Morgan · 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
Kevin George Morgan, who had poorly controlled type 1 diabetes, was found deceased in his flat after family contacted police when they had not heard from him for several weeks. His body was heavily decomposed, and there were no suspicious circumstances. The principal concerns were the lack of effective follow-up by social services and housing, inadequate responses to safeguarding and safety concerns, and the absence of a post-death serious incident or safeguarding review.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer incidents for safeguarding review and learning
Wider context from the report “(6) Following the death of Kevin Morgan there was no Serious Incident Review conducted by social services and it was not referred for a safeguarding review so that lessons have not been learned from this incident . Without such a review a similar incident could occur in the future .
” Source location Kevin George Morgan · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a multi-agency learning review to identify lessons, improve practice and reduce the likelihood of similar cases.
Verbatim wording from the response “My decision is that the case does not meet the criteria for a Safeguarding Adult Review, but as I share many of the concerns you expressed in your Regulation 28 report, I have commissioned another more flexible but no less rigorous form of review called a learning review in order to establish what can be learnt from the case to improve practice and reduce the likelihood of similar cases occurring. I am happy to send you my full decision should you wish to see it, but have set out below the decision and the commission for a learning review for your information.” Source location 2017-0165-Response-by-Milton-Keynes-Safeguarding-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake the multi-agency learning review, including practitioner engagement, case-report analysis, concern analysis and a practice-improvement report with dissemination recommendations.
Verbatim wording from the response “• Mr M’s mother and other family members of her choice (through the opportunity to meet and speak to the review chair and a review group member)” Source location 2017-0165-Response-by-Milton-Keynes-Safeguarding-Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The case did not meet statutory criteria for a Safeguarding Adults Review, so that review could not be conducted.
Verbatim wording from the response “My decision is that the case does not meet the criteria for a Safeguarding Adult Review, but as I share many of the concerns you expressed in your Regulation 28 report, I have commissioned another more flexible but no less rigorous form of review called a learning review in order to establish what can be learnt from the case to improve practice and reduce the likelihood of similar cases occurring. I am happy to send you my full decision should you wish to see it, but have set out below the decision and the commission for a learning review for your information.” Source location 2017-0165-Response-by-Milton-Keynes-Safeguarding-Board
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4 Aug 2015 Mr Warren · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Lack of formal review of safeguarding-related deaths View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Warren · 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 Warren, an elderly and deaf tenant with no known family or friends, was found deceased at home on 29 January 2015 after apparently falling around 24 January and suffering broken ribs, bronchopneumonia and signs of hypothermia. Concerns included the failure to address a hazardous electric heater, the use of a non-urgent police welfare check, insufficient guidance and training for social-work staff, and the absence of a formal review by the relevant councils.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of formal review of safeguarding-related deaths
Wider context from the report “(1) That neither CBC nor WSCC have a yet undertaken any formal review of this case despite the death of someone known to both organisation and subject to a safeguarding alert at the time of his death. An opportunity to learn lessons from the above events has hence been delayed and potentially been lost.
” Source location Mr Warren · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Follow and report safeguarding alerts to senior managers and immediately review future deaths involving such alerts.
Verbatim wording from the response “6. Finally, the Council did not have a procedure for immediately reviewing a death where a safeguarding alert had been made. The Council’s review was prompted by being contacted by the Coroner’s office on 11 February 2015. Safeguarding alerts will be followed and reported to senior managers and any future deaths where a safeguarding alert has been made will immediately be subject to review. This has been actioned.” Source location Crawley-Borough-Council-Response-1
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a detailed review of the circumstances surrounding Mr Warren’s involvement with the Council.
Verbatim wording from the response “I can confirm that we have now completed a detailed review (copy attached) of the circumstances relating to our involvement with Mr Warren. We involved Crawley Borough Council in the review process.” Source location 2015-0307-West-Sussex-County-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Council disputes that its review and recommendations were absent, stating they arose from an earlier case review.
Verbatim wording from the response “• At the time of the Inquest the Council had carried out a Review, had spoken to the staff involved and reviewed all of the case notes. The manager of the housing management team initially carried out this review as part of the preparation of the report for the Inquest and this was then reviewed by the Head of Service with the service recommendations coming from further discussions. The recommendations were not contained in the report for the Inquest. Recommendations 1 and 2 below had come out of this Review. We are of the view that the line out of the Housing of the Council witness TSO1 meant that she thought there was something other than the discussion she had had with her line manager.” Source location Crawley-Borough-Council-Response-1
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.