17 Jan 2020 Shneur Zalman Kaye · Prevention of Future Deaths report Manchester North
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Concerns raised 2 Failure to contact parents before closing a referral where no safeguarding or legal reason prevents contact View source Failure to share safeguarding referral information and reasons with relevant third parties, services or agencies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Shneur Zalman Kaye · 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
Shneur Zalman Kaye died at home on 24 August 2018, aged 14, from suffocation caused by inhalation of helium. The report raises concerns that a safeguarding referral was closed without contacting Shneur or his parents and that the referral and reasons for it were not shared with relevant third parties or agencies, potentially limiting assessment and protective action.
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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. The report was sent to Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to contact parents before closing a referral where no safeguarding or legal reason prevents contact
Wider context from the report “1. The decision to close a referral without prior contact with parents (where there is no safeguarding or legal reason why such contact should not be made) potentially deprives the Social Worker of the opportunity to contextualise the event or concern which has triggered the referral, and of forming an informed view of the welfare of the child to whom the referral relates;
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share safeguarding referral information and reasons with relevant third parties, services or agencies
Wider context from the report “2...The evidence received by the Court indicates that the closure of the safeguarding referral marks an end to social services involvement. Despite this no attempt is made to share the fact of the referral or the reasons for it with any third party, service or agency . This may have the unintended result of depriving third parties (including parents) and agencies already participating in the care and welfare of a child from being alerted to the concern and taking appropriate action (including accessing other services) in response to it. The submissions made on behalf of the council indicate these practices are driven by considerations of data protection compliance The practice imperils the precedence to be given to the paramountcy principle and has the potential to undermine the protection of children who are the subject of referral.
” 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 Make speaking with parents or carers part of MASH referral practice unless a safeguarding or legal reason prevents contact.
Verbatim wording from the response “Strength based practice within the MASH, working alongside parents/carers and seeing them as an expert in their own right is standard practice and unless there is a safeguarding or legal reason not to, it is an expectation that parents/carers are spoken with as part of the process.” Source location Response from Bury Council
Open published response
8 Aug 2018 Dr Donald Clegg · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 9 Inadequate and unsafe medicine administration training, supervision and audit processes View source Inadequate and unsafe medicines policy View source Inadequate and incomplete record keeping View source Inadequate pre-admission assessment of care needs View source Lack of a policy or protocol for observation and monitoring of service users View source Failure to recognise deteriorating service users View source Inadequate pre-admission risk assessment View source Delays in seeking medical attention when service users deteriorate View source Insufficient communication and handover during transfers of care View source See 6 more concerns
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.
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AI-generated summary
Dr Donald Clegg · 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
Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.
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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unsafe medicine administration training, supervision and audit processes
Wider context from the report “3. The evidence indicated that the:
i) Medicine Policy
&/or
ii)Medicine administration training, supervision and audit processes
at Persona were inadequate and unsafe (indeed, the audit process was perfunctory ).
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unsafe medicines policy
Wider context from the report “3. The evidence indicated that the:
i) Medicine Policy
&/or
ii)Medicine administration training, supervision and audit processes
at Persona were inadequate and unsafe (indeed, the audit process was perfunctory).
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incomplete record keeping
Wider context from the report “5. Record keeping was inadequate and in parts, incomplete . Record keeping is vital in keeping service users safe.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate pre-admission assessment of care needs
Wider context from the report “Persona Only:
2. The process of assessment of care needs prior to admission was inadequate . Assessment is critical in establishing the suitability and safety of a placement – in this case, capable of meeting complex physical and mental health needs of the individual. Assessment of risk, in particular, was inadequate.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy or protocol for observation and monitoring of service users
Wider context from the report “6. There is no policy/protocol for the observation/monitoring of service users e.g. when directed to do so by a medical practitioner. Staff are left to interpret for themselves what this means .
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deteriorating service users
Wider context from the report “4. Staff were unable to recognise the deteriorating adult and did not seek medical attention in a timely manner when signs of change became apparent. This potentially puts service users at risk of harm/death.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate pre-admission risk assessment
Wider context from the report “Persona Only:
2. The process of assessment of care needs prior to admission was inadequate. Assessment is critical in establishing the suitability and safety of a placement – in this case, capable of meeting complex physical and mental health needs of the individual. Assessment of risk, in particular, was inadequate .
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking medical attention when service users deteriorate
Wider context from the report “4. Staff were unable to recognise the deteriorating adult and did not seek medical attention in a timely manner when signs of change became apparent . This potentially puts service users at risk of harm/death.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and handover during transfers of care
Wider context from the report “Persona and Bury MBC:
1. Communication/transfer of care/handover between social services, the first placement and/or the final placement was insufficient , given the complexities of the deceased’s case.
” Open source report
21 Aug 2017 Mr Roger Hamer · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 7 Failure to document carriageway defect condition during inspections View source Lack of a duty-of-candour procedure for significant incidents View source Unmarked potholes lacking paint markings View source Failure to investigate carriageway defects below the 40mm threshold View source Inconsistent application of the current highway-management procedure View source Lack of an effective significant-incident investigation and learning procedure View source Failure to repair carriageway defects at or above the 40mm threshold View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Roger Hamer · 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 Roger Hamer fell from his bicycle on Bury New Road, suffering a traumatic brain injury and multiple fractures, and died in hospital from those injuries on 2 April 2016. The inquest jury found that a pothole probably caused his fall. Concerns included inadequate recording and monitoring of carriageway deterioration, a lack of paint markings around potholes, the absence of a duty-of-candour procedure for investigating significant incidents, and proposed highway-management thresholds that might increase risks to cyclists.
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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document carriageway defect condition during inspections
Wider context from the report “(1) When he inspected the carriageway in January 2016 and February 2016 the highway inspector did not photograph, measure and/or record any details as to the condition of the carriageway where the Pothole developed despite it having started to deteriorate, wear and crack by October 2015.
This prevented the Highway Authority from effectively assessing the rate of deterioration of this part of the carriageway which may have helped to inform it as to the need for earlier repair.
Also, the lack of images and/or measurements of the Pothole as at the date of the inspections restricted the Highway Authority’s ability to effectively supervise and monitor the highway inspector and it hindered the jury’s ability to make more detailed findings as to the circumstances of Mr Hamer’s death.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a duty-of-candour procedure for significant incidents
Wider context from the report “(3) The Highway Authority does not have a procedure with a duty of candour for the effective investigation of, and learning lessons from, significant incidents comparable to those adopted by other public bodies (for example within the National Health Service).
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unmarked potholes lacking paint markings
Wider context from the report “(2) The jury recorded its concern as to the lack of paint markings around the potholes which may have highlighted their presence to Mr Hamer thereby enabling him to avoid them.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate carriageway defects below the 40mm threshold
Wider context from the report “(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016.
With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired.
Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed.
If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired.
Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent application of the current highway-management procedure
Wider context from the report “(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016.
With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired.
Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed.
If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired.
Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective significant-incident investigation and learning procedure
Wider context from the report “(3) The Highway Authority does not have a procedure with a duty of candour for the effective investigation of, and learning lessons from, significant incidents comparable to those adopted by other public bodies (for example within the National Health Service).
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to repair carriageway defects at or above the 40mm threshold
Wider context from the report “(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016.
With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired.
Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed.
If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired .
Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
” 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 Take routine photographs of dangerous defects before repair and of repairs afterward.
Verbatim wording from the response “Due to investment in the highway maintenance procedures and IT systems, highway inspectors now routinely take photographs of defects giving rise to a real source of danger. Repair crews also take photographs prior to and post repair.” Source location 2017-0259-Response-by-Bury-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 Provide specific training and competency checks for highway inspectors under the new Code of Practice.
Verbatim wording from the response “All Highway Inspectors are scheduled to undergo specific training and competency checks to ensure that they understand how to undertake their role under the new Code of Practice.” Source location 2017-0259-Response-by-Bury-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 Maintain highway inspection procedures and systems in accordance with best-practice guidance.
Verbatim wording from the response “1) Bury Council, as Highway Authority, ensured that their procedures and systems of inspection were in accordance with best practice guidance as set out within the Well Maintained Highways – A Code of Practice for Highway Maintenance Management 2009.” Source location 2017-0259-Response-by-Bury-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 Conduct regular evidence-based reviews and monitoring of the new Code of Practice.
Verbatim wording from the response “The Highway Authority aim is to ensure consistency of approach in application of both the current and the new Code of Practice. The new risk based approach and specific training of inspectors on their role in accordance with the WMHI Code of Practice should allow the Highway Authority to apply a consistent risk based approach where the reasons for taking specific decisions will be evidenced. There will be regular evidence based reviews of the new Code of Practice and monitoring.” Source location 2017-0259-Response-by-Bury-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 Agree an overarching framework with Greater Manchester highway authorities for consistent risk-based inspection, repair and investigation approaches.
Verbatim wording from the response “Bury Council in collaboration with the other 9 Greater Manchester Highway Authorities, are seeking to agree an “Overarching Framework of Agreed Principles” which would provide consistency of approach across the boundaries on the following matters: frequency and classification of highways, the risk based approach to safety inspections, the risk based approach to repair timescales, the investigative levels which would trigger the Highway inspector to apply the risk based matrix for assessing the risk.” Source location 2017-0259-Response-by-Bury-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 Develop and implement a formal follow-up investigation procedure for highway incidents reported by Greater Manchester Police.
Verbatim wording from the response “3) GMP investigates highway incidents and reports these to Bury Council by the STATS 19 process. Any incidents linked to road defects (either condition or layout) are acted upon as soon as possible.” Source location 2017-0259-Response-by-Bury-Council
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 Highway Authority does not paint carriageway potholes because doing so would expose highway inspectors to danger from traffic.
Verbatim wording from the response “2) The Highway Authority does not paint markings around potholes especially in the carriageway. As identified above this is for reasons of safety of the highway inspector who would otherwise place himself in a position of danger caused by traffic.” Source location 2017-0259-Response-by-Bury-Council
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 Given traffic speeds, paint markings alone would not have sufficiently highlighted the pothole to road users.
Verbatim wording from the response “Given the speed at which vehicular traffic uses Bury New Road, Ramsbottom, the Highway Authority contend that markings alone would not have been sufficient to highlight the presence of the pothole to Mr Hamer.” Source location 2017-0259-Response-by-Bury-Council
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 Paint markings are unnecessary because handheld GPS identifies defects precisely and risk-based repair timescales ensure responsive repair.
Verbatim wording from the response “Paint markings are not used to highlight defects to users of the highway. If they were historically used then this would have been to allow a pothole raised for repair to be identified by the repair team. The need to mark defects is no longer” Source location 2017-0259-Response-by-Bury-Council
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 lack of pothole images or measurements did not restrict effective supervision or compliance with the statutory highway safety duty.
Verbatim wording from the response “It is not accepted that the lack of images or measurements of the pothole restricted the Highway Authority’s ability to effectively supervise and monitor the highway inspector or did not allow it to comply with its statutory duty under the Highways Act 1980 to ensure that they had taken such care as in all the circumstances was reasonably required to secure that part of the highway was not dangerous for traffic.” Source location 2017-0259-Response-by-Bury-Council
Open published response
11 Feb 2015 Anne Horner · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Failure of toilet cubicle doors to permit safe access when an occupant is slumped forward View source
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
Anne Horner · 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
Anne Horner was a resident at Oak Lodge Nursing Home when she sustained head injuries in two incidents involving a toilet cubicle door. Following the second incident on 25 March 2014, she was found unresponsive and died at Salford Royal Hospital from a traumatic head injury. The principal concern was that the toilet cubicle door and available clearance may not have adequately accommodated a resident who had fallen or was slumped forward.
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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of toilet cubicle doors to permit safe access when an occupant is slumped forward
Wider context from the report “4. The evidence at Inquest confirmed that the bathroom facility which included the toilet cubicle was constructed in or about 1988 in compliance with the relevant Planning Permission and Building Regulations. I accept that the facility had been used on many previous occasions without incident. The fact however that a resident sustained injury on two separate occasions within a period of 6 weeks gives rise to concern. I anticipate that there are many establishments within England and Wales where toilet facilities are not dissimilar to those at Oak Lodge Nursing Home. I understand that separate guidance in relation to disabled toilet design suggests doors that open outwards to facilitate access if someone falls behind the door. Whilst photographic images produced at Inquest suggested adequate door clearance for a resident sitting normally on the toilet, that would not be so for an individual resident who sat / was slumped forward.
” Open source report
26 Dec 2014 Anthony Maurice Huggan · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Delays in follow-up and welfare checks after self-discharge following a life-threatening drugs overdose View source Lack of a suitable out-of-hours service for people with drug addiction problems View source
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
Anthony Maurice Huggan · 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
Anthony Maurice Huggan, who had a longstanding drug problem, was admitted to hospital after an accidental opiate overdose but self-discharged against medical advice on 3 June 2014. He was found deceased at home the following day after taking excessive amounts of prescribed and illicit substances; post-mortem examination and toxicology identified combined drugs toxicity involving Pregabalin, Morphine and Methadone. Concerns included the lack of an out-of-hours community drugs service and the timeliness of follow-up or welfare checks after a life-threatening overdose and self-discharge.
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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in follow-up and welfare checks after self-discharge following a life-threatening drugs overdose
Wider context from the report “2. Where a patient takes self-discharge following a life threatening drugs overdose, concerns arise around the timeliness of follow up/welfare checks , given the limitations of the service commissioned by the Local Authority .
” 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 Bury Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a suitable out-of-hours service for people with drug addiction problems
Wider context from the report “1. The lack of a suitable out of hours service , resulting in an undue burden being placed upon the emergency services and the NHS (none of whom are best placed to deal with and support those with drug addiction problems).
” 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