Recurring concern

Unsafe home-visit policies for clinical and personal-safety decisions

First to latest report 18 Aug 2014 — 29 Aug 2019

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

What this concern includes

Includes deficiencies in explicitly identified policies or formal guidance governing home visits where they fail to support safe clinical decisions, patient access, visit adaptation or staff personal-safety decisions, including the anchor's absence of criteria for declining unsafe visits and omissions concerning complex chronic conditions in residential settings.

What is not included
  • Excludes failures in carrying out, documenting or following up individual home visits when no deficiency in the home-visit policy or formal guidance is identified.
  • Excludes generic clinician safety, staffing, training or risk-assessment deficiencies not specifically tied to home-visit policy or guidance.
  • Excludes hospital, community-treatment or welfare-visit processes unless the assertion explicitly concerns a policy governing clinical home visits.
  • Excludes physical examination or treatment failures during a home visit where the policy or guidance itself is not deficient.

Reports and published responses 3 reports

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

  1. Nottinghamshire

    AI-generated summary

    Evelyn Ann Swift · 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

    Evelyn Ann Swift became increasingly unwell over several days and contacted her GP surgery repeatedly on 3 January 2019, but a home visit was not arranged until that evening. The assessment was incomplete, her condition was not recognised as severe, and she was not admitted to hospital; she was found deceased at home the following morning. The principal concerns related to unsafe procedures for triage, home-visit allocation, urgent clinical advice, documentation, clinical cover, and review of significant events.

    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 safe procedures for allocating home visits

    Wider context from the report

    “2. The Beechdale group did not have safe procedures in place for the allocation of home visits. ”

    Source location

    Evelyn Ann Swift · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Birmingham and Solihull

    AI-generated summary

    Timothy Simon Jones · 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

    Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

    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 the home visit policy to address complex chronic conditions in care or residential facilities

    Wider context from the report

    “4. The GP’s policy for home visits (copy attached) did not contain any reference to those with complex chronic conditions who were residents in care or residential facilities. The policy actively seeks to avoid home visits which may have influenced decision making in this case. ”

    Source location

    Timothy Simon Jones · 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

    Issue a learning alert to all Solihull member practices covering home-visit requests, policies, care-home requests and administrative-task classifications.

    Verbatim wording from the response

    “• In addition a ‘learning alert’ will be issued to all Solihull member practices to highlight concerns and learning in relation to: ○ Recording of requests for home visits ○ GP home visit policies ○ Nursing/residential home requests for GP home visits ○ Classifications of administrative tasks”

    Source location

    2016-0421-Response-by-Solihull-Clinical-Commissioning-Group
    Page 1 · response
    Published 19 February 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

    Ask the Local Medical Committee to discuss consideration of a Solihull-wide home-visiting policy with its members.

    Verbatim wording from the response

    “• The CCG will ask the Local Medical Committee to discuss with its members the consideration of a Solihull wide home visiting policy;”

    Source location

    2016-0421-Response-by-Solihull-Clinical-Commissioning-Group
    Page 1 · response
    Published 19 February 2017

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Jeffrey Gash · 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

    Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.

    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

    Absence of a clear policy for declining home visits on personal safety and security grounds

    Wider context from the report

    “2. No evidence was provided at the inquest to indicate a formal Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision. The absence of a clear policy and a policy for recording decisions made or understanding and training thereon is an area of concern ”

    Source location

    Jeffrey Gash · 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

    Review relevant policies against the findings and produce an implementation plan.

    Verbatim wording from the response

    “The Trust also has a Lone Working Procedure which should be completed for all staff who may in the course of their duties have periods where they are working alone including in the context of a high risk visit. This is to some extent addressed within the SUI report where it is documented that a more assertive approach may have helped with the engagement findings. The policy for these areas will be asked to review the relevant policy against your findings and ensure that these are fully taken into account and an implementation plan produced accordingly.”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 2 · response
    Published 18 August 2014

    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