Recipient

Cardiff Council

First report 22 Oct 2017•Latest report 4 Jul 2023

Recipient record

Reports, concerns and published responses

Local government · Welsh county council. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 67%
Concerns addressed: 3
Stated actions: 20

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.

67%published responses found

20stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Cardiff Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

4 Jul2023
South Wales Central
Concerns raised1
1. Lack of a mechanism for Social Services to become aware of adults at risk of neglect
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review current multi-agency referral and monitoring arrangements for vulnerable adults.
  Stated completed
Respondent positions 2
1. Position
  A separate vulnerable-adults register was considered unnecessary because existing multi-agency monitoring and referral arrangements were sufficient and clearer.
  Existing arrangements considered sufficient
1. Position
  The decision not to refer for social work involvement was considered correct because existing referral processes were clear and appropriate.
  Disputes the concern
AI-generated summary

Stella Ann JAMES · 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

Stella Ann James, aged 40, died at the Royal Glamorgan Hospital on 20 January 2021 after being admitted with severe pneumonia and sepsis following severe food restriction, malnutrition and very low body weight. The principal concerns were that she appeared to meet the criteria for an adult at risk of neglect, without an apparent mechanism for Social Services to be aware of her status, and whether a register or anonymous referral mechanism could support unannounced social-work visits.

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 Cardiff Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of a mechanism for Social Services to become aware of adults at risk of neglect
Wider context from the report
“(1) Stella appeared to meet the criteria as an ‘adult at risk of neglect’ due to her food avoidance and very low body weight, yet there was no apparent mechanism for Social Services to be aware of Stella’s status. Stella was very secretive and formally had capacity when assessed months before her death, although it is noted that this can fluctuate. (2) Could there be a register to include a person in Stella’s position, whereby unannounced house visits from a social worker can be an option? Perhaps involving a mechanism for anonymous referral? ”
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 current multi-agency referral and monitoring arrangements for vulnerable adults.

Verbatim wording from the response
“In this case the decision not to refer for social worker involvement was the correct one and, having reviewed current arrangements, all partners are confident that should such a referral be assessed as needed in a future case then the process is clear and unambiguous. There is also the potential that the creation of a much wider vulnerable adults list would give the misguided impression to someone referring an individual onto the register, that the individual would be safeguarded.”

Source location
Response from Cardiff Council
Page 3 · response
Published 2 July 2026
Open published response
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
A separate vulnerable-adults register was considered unnecessary because existing multi-agency monitoring and referral arrangements were sufficient and clearer.

Verbatim wording from the response
“In terms of holding a register of vulnerable adults more generally, we think that this could potentially negatively impact on the existing arrangements in place for appropriate multi agency involvement in future complex cases.”

Source location
Response from Cardiff Council
Page 3 · response
Published 2 July 2026
Open published response
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 decision not to refer for social work involvement was considered correct because existing referral processes were clear and appropriate.

Verbatim wording from the response
“In this case the decision not to refer for social worker involvement was the correct one and, having reviewed current arrangements, all partners are confident that should such a referral be assessed as needed in a future case then the process is clear and unambiguous. There is also the potential that the creation of a much wider vulnerable adults list would give the misguided impression to someone referring an individual onto the register, that the individual would be safeguarded.”

Source location
Response from Cardiff Council
Page 3 · response
Published 2 July 2026
Open published response
17 Dec2019
South Wales Central
Concerns raised1
1. Unfettered motorcycle racing in Trelai Park endangering the general public
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

Mr. Mark Anthony Anderson · 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 Mark Anthony Anderson suffered fatal head injuries in a collision between motorcycles travelling in opposite directions on a narrow path in Trelai Park, Cardiff, on 28 May 2019. The report raises concern that motorcyclists were using the park for unrestricted racing and off-road activities, putting members of the public, particularly children and elderly people, at risk.

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 Cardiff Council; that does not assign responsibility.
PFD Monitor interpretation
Unfettered motorcycle racing in Trelai Park endangering the general public
Wider context from the report
“The safety of the general public, in particular children and the elderly, is at risk while motorcyclists continue to use Trelai Park as an unfettered area for racing their motorcycles. ”
Open source report
22 Oct2017
South Wales Central
Concerns raised2
1. Lack of clear responsibility for the environment and resident safety control measures
2. Failure of care and risk assessments to consider stair-gate and locking-mechanism risks
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement and maintain an agreed referral pathway clarifying responsibilities for environmental-control assessments, including joint occupational-therapy assessment of stairgate requests.
  Stated completed
2. Action
  Develop and consult staff on stairgate assessment guidance and an assessment tool for evaluating stairgate risks.
  Stated completed
3. Action
  Enhance monthly health-and-safety checklists and prescribed safety logs with prompts covering stairs, stairgates and related risks.
  Stated completed
Respondent positions 1
1. Position
  Council policies, processes and partner arrangements adequately address recommended reviews of stair suitability and supported-living risk, supervision and control.
  Existing arrangements considered sufficient
AI-generated summary

Lesley Hanson · 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

Lesley Hanson, who had severe learning disabilities and poor stability, gained access to stairs at her supported accommodation on 11 March 2017 and fell, sustaining injuries that led to her death. The concerns were that care and risk assessments did not address the gate being left open, the type of stair-gate or locking mechanism, and that responsibility for environmental safety controls was unclear. The inquest jury found the arrangements inadequate, including failure to follow the service plan and repeated occasions when the stair-gate had been left open.

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 Cardiff Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear responsibility for the environment and resident safety control measures
Wider context from the report
“(2) It was unclear from the evidence who had the responsibility for the environment and control measures to ensure residents safety at the property. ”
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 Cardiff Council; that does not assign responsibility.
PFD Monitor interpretation
Failure of care and risk assessments to consider stair-gate and locking-mechanism risks
Wider context from the report
“(1) The evidence revealed that the care and risk assessments did not appear to consider the impact of the gate being left open by other residents, the type of stair-gate and the suitability of the locking mechanism. ”
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
Implement and maintain an agreed referral pathway clarifying responsibilities for environmental-control assessments, including joint occupational-therapy assessment of stairgate requests.

Verbatim wording from the response
“1.3 Where assessments for environmental controls are required, the Senior Support Worker (or delegated member of staff) will complete a referral form and forward to ABMU Learning Disability Health Team or the Cardiff Communities Occupational Therapy Team (CCOT) depending on the nature/size of the work requested. A ‘Referral Pathway’ flowchart has been designed to ensure consistency of process. This flowchart has been subject to consultation with the ISL Manager Supported Living Coordinator, Learning Disability Social Services Team Managers, ABMU Health Team Manager and Cardiff Occupational Therapists.”

Source location
2017-0303-Response
Page 2 · response
Published 27 November 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
Develop and consult staff on stairgate assessment guidance and an assessment tool for evaluating stairgate risks.

Verbatim wording from the response
“1.7 As a result of the fatal incident ABMU Learning Disability Occupational Therapist has developed a Stairgate Factsheet and an Assessment Tool. These documents identify that as far as can be ascertained (after extensive searches) there is no specific guidance (from an appropriate Statutory Regulator) on use of stairgates for adults. They have therefore been developed having regard to good practice and advice provided by professional bodies in order to provide a thorough checklist for staff that are undertaking assessments. These documents have been consulted with Cardiff Communities Occupational Therapy colleagues, the Supported Living Co-ordinator and Cardiff Council’s Operational Manager for Health and Safety.”

Source location
2017-0303-Response
Page 2 · response
Published 27 November 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
Enhance monthly health-and-safety checklists and prescribed safety logs with prompts covering stairs, stairgates and related risks.

Verbatim wording from the response
“3.1 The Internal Supported Living Service (ISL) has a prescribed system of checks for which all senior support staff are trained by the Compliance Officer, Housing and Neighbourhood Team. These are recorded in the ‘Fire, Health and Safety and General Maintenance Log Book’. In addition to this, a comprehensive monthly ‘Health and Safety Checklist’ has been enhanced in collaboration with Cardiff Council’s Operational Manager for Health and Safety. This includes reference to stairs and stair gates with additional prompts to staff regarding specific issues to consider.”

Source location
2017-0303-Response
Page 4 · response
Published 27 November 2017
Open published response
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
Council policies, processes and partner arrangements adequately address recommended reviews of stair suitability and supported-living risk, supervision and control.

Verbatim wording from the response
“Since the tragic death of Lesley Hanson on the 13 March 2016, there has been an extensive review undertaken by the Council which has resulted in improvements to policy and processes involving council staff, services and our partners in Abertawe Bro Morgannwg University Health Board (ABMU). The improvements made have been communicated to the Health and Safety Executive and address the following actions raised in your Regulation 28 Report:-”

Source location
2017-0303-Response
Page 1 · response
Published 27 November 2017
Open published response

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 raised1

Lack of a mechanism for Social Services to become aware of adults at risk of neglect

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Concerns raised1

Unfettered motorcycle racing in Trelai Park endangering the general public

Concerns raised2

Lack of clear responsibility for the environment and resident safety control measures

Failure of care and risk assessments to consider stair-gate and locking-mechanism risks

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 1

Respondent positions 2

Actions described in response 3

Respondent positions 1