19 May 2021 Liam Kenyon · Prevention of Future Deaths report Manchester North
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Concerns raised 8 Deficient and ineffective Serious Incident Review process View source Failure to conduct a two-person physical welfare check after no response View source Insufficient weekend staffing capacity to cover all sites and conduct hourly checks View source Failure to update risk assessments after a suspected overdose View source Failure to conduct agreed hourly welfare checks View source Failure to follow the procedure for requesting a drug check of a resident’s room View source Failure to escalate operational problems to the on-call manager View source Lack of clarity about the scope of care and monitoring responsibilities in supported housing View source See 5 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations