3 Mar 2025 JAVED IQBAL · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 8 Failure of staff to take appropriate action on serious acute mental health issues View source Failure to communicate serious concerns to the GP in writing View source Absence of a formal internal post-death investigation report View source Failure of staff to understand service users' best interests View source Failure of staff to recognise serious acute mental health issues View source Failure of post-death training to address identified concerns View source Outstanding post-death internal training View source Failure to maintain accurate contemporaneous records of behaviour and mood View source See 5 more concerns
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AI-generated summary
JAVED IQBAL · 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
Javed died on 1 June 2024 after deliberately igniting his room with flammable liquid and sustaining major burn injuries and smoke inhalation, followed by multi-organ failure. The report identified concerns that staff did not recognise and appropriately act on serious acute mental health issues, including not escalating worsening mood and irrational behaviour to the GP in writing. It also identified the absence of a formal internal post-death investigation and outstanding internal training that had not addressed these concerns.
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 All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to take appropriate action on serious acute mental health issues
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues . For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate serious concerns to the GP in writing
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing .
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Absence of a formal internal post-death investigation report
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report .
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand service users' best interests
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user :
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to recognise serious acute mental health issues
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues . For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of post-death training to address identified concerns
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Outstanding post-death internal training
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death . However, I was not satisfied this training has recognised the above 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. The report was sent to All Care In One Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate contemporaneous records of behaviour and mood
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above concerns.
” 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