Recipient

Adullam Homes Housing Association Limited

First report 19 May 2021•Latest report 19 May 2021

Recipient record

Reports, concerns and published responses

Housing · Registered provider of social housing. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Adullam Homes Housing Association Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

19 May2021
Manchester North
Concerns raised8
1. Deficient and ineffective Serious Incident Review process
2. Failure to conduct a two-person physical welfare check after no response
3. Insufficient weekend staffing capacity to cover all sites and conduct hourly checks
1. Failure to update risk assessments after a suspected overdose
2. Failure to conduct agreed hourly welfare checks
3. Failure to follow the procedure for requesting a drug check of a resident’s room
4. Failure to escalate operational problems to the on-call manager
5. Lack of clarity about the scope of care and monitoring responsibilities in supported housing
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Liam Kenyon · 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

Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.

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. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Deficient and ineffective Serious Incident Review process
Wider context from the report
“7. Finally the Serious Incident Review process which is in place to learn lessons from such incidents was deficient and ineffective. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct a two-person physical welfare check after no response
Wider context from the report
“5. The Court heard that on the 18th July a staff member went to Liams room on three occasions (from 10am) and knocked on the door receiving no response. The Court heard that where no response was received a physical welfare check involving 2 members of staff entering the room using the master key should have occurred. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Insufficient weekend staffing capacity to cover all sites and conduct hourly checks
Wider context from the report
“6. The Court heard that at a weekend there are less staff to cover all the sites and on the 18th July the staff were dealing with a number of incidents involving residents, meaning to conduct hourly checks would have been difficult. However no member of staff escalated to the on call manager the fact that there were problems. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to update risk assessments after a suspected overdose
Wider context from the report
“4. In addition following him being found unconscious due to a suspected overdose the Court heard his risk assessment should have been updated and this was not done. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct agreed hourly welfare checks
Wider context from the report
“2. Having agreed with the support plan and this being confirmed in an email to staff, hourly checks were not conducted on Liam. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow the procedure for requesting a drug check of a resident’s room
Wider context from the report
“3. The Court heard following the incident on the 17th July the procedure of asking Liam if a drug check of his room could be conducted was not done. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate operational problems to the on-call manager
Wider context from the report
“6. The Court heard that at a weekend there are less staff to cover all the sites and on the 18th July the staff were dealing with a number of incidents involving residents, meaning to conduct hourly checks would have been difficult. However no member of staff escalated to the on call manager the fact that there were problems. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adullam Homes Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity about the scope of care and monitoring responsibilities in supported housing
Wider context from the report
“1. The evidence highlighted a lack of clarity as to the extent of the care provided by the supported housing association and how staff interpret this. The Court was informed that the housing association have a “duty of care to its residents” and that this included “safeguarding residents” and the “risk management of residents”. However when the situation arose on the 17th July 2020 the Court was advised the housing association are not care providers and should not have become involved in the plan to monitor Liam. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised8

Deficient and ineffective Serious Incident Review process

Failure to conduct a two-person physical welfare check after no response

Insufficient weekend staffing capacity to cover all sites and conduct hourly checks

Failure to update risk assessments after a suspected overdose

Failure to conduct agreed hourly welfare checks

Failure to follow the procedure for requesting a drug check of a resident’s room

Failure to escalate operational problems to the on-call manager

Lack of clarity about the scope of care and monitoring responsibilities in supported housing