25 Jun 2018 William Lugg · Prevention of Future Deaths report London Inner (North)
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Concerns raised 8 Failure to understand and follow the prescribed failed visits procedure View source Dissemination of inaccurate information about client welfare View source Failure of failed visits policies to give sufficient prominence to police involvement View source Absence of a clear system for assessing and deciding referral priority View source Failure to clearly record keyholder identity and contact details View source Failure of the provider’s failed visits procedure to reflect the prescribed procedure View source Failure to adequately record carer calls about failed visits View source Failure to record referral priority decision-making View source See 5 more concerns
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
Action
Update keyholder details for all service users and implement scheduling software to maintain accurate, accessible records.
View source
Action
Retrain all office staff and care workers on the revised Failed Visits policy and adult safeguarding principles.
View source
Action
Update the Failed Visits policy to align with relevant local-authority procedures and strengthen escalation, communication recording and police involvement.
View source
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AI-generated summary
William Lugg · 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
William Lugg lived alone and received daily care visits, but after an unwitnessed fall on or by the morning of 3 March 2018, carers received no answer and he was not found until 6 March 2018, when he was discovered deceased at his residence. The concerns included failures to follow and coordinate failed-visit procedures, inaccurate information about his welfare, inadequate recording of keyholder and call details, insufficient prominence given to contacting police, and the absence of a clear Monday-morning referral-prioritisation system.
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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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and follow the prescribed failed visits procedure
Wider context from the report “(1) Tower Hamlet’s Failed Visits Procedure was poorly understood and not followed by Careworld staff , in particular (though not limited to): (a) the appropriate means of alerting Tower Hamlets to failed care visits that occurred during a weekend ; and (b) use of the Tower Hamlet’s pro forma Failed Visit Record ;
” 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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Dissemination of inaccurate information about client welfare
Wider context from the report “(4) No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made, leading, in turn, to inaccurate information regarding the client’s welfare being disseminated to Tower Hamlets by another member of Careworld staff ;
” 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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of failed visits policies to give sufficient prominence to police involvement
Wider context from the report “(5) Neither Tower Hamlets or Careworld’s Failed Visits policy gives any / any sufficient prominence to the possibility of involving the police if other attempts to confirm the individual’s welfare following a failed visit have proved unsuccessful;
” 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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear system for assessing and deciding referral priority
Wider context from the report “(6) The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making).
” 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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record keyholder identity and contact details
Wider context from the report “(3) Vital information regarding the identity of and contact details for the only other keyholder to the premises in this instance was not clearly recorded by either Tower Hamlets or Careworld;
” 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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the provider’s failed visits procedure to reflect the prescribed procedure
Wider context from the report “(2) Careworld’s own Failed Visits Procedure does not mirror or reflect aspects of Tower Hamlet’s prescribed procedure ;
” 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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record carer calls about failed visits
Wider context from the report “(4) No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made , leading, in turn, to inaccurate information regarding the client’s welfare being disseminated to Tower Hamlets by another member of Careworld staff;
” 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 Careworld London Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record referral priority decision-making
Wider context from the report “(6) The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making) .
” 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 Update keyholder details for all service users and implement scheduling software to maintain accurate, accessible records.
Verbatim wording from the response “been addressed. It will be seen from the Action Plan that such details in respect of all 664 service users have now been updated. Dedicated scheduling software has now been put in place to ensure that such information is accurately recorded, up-to-date and accessible to all those who have need of it. Without wishing to descend into too great particularity, we append to this letter as Appendix E screenshots from the software used, that we hope give an indication of the way in which such records are now maintained;” Source location 2018-0200-Response-by-Careworld-London-Ltd
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 Retrain all office staff and care workers on the revised Failed Visits policy and adult safeguarding principles.
Verbatim wording from the response “(ii) The Failed Visits policy itself has been updated - a copy is at Appendix B - and all Careworld London staff (both office staff and care workers) have been re-trained in respect of the content of the revised policy and in respect of the fundamental principles involved in safeguarding adults. All such training was completed by 3 August 2018.” Source location 2018-0200-Response-by-Careworld-London-Ltd
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 Update the Failed Visits policy to align with relevant local-authority procedures and strengthen escalation, communication recording and police involvement.
Verbatim wording from the response “(ii) The Failed Visits policy itself has been updated - a copy is at Appendix B - and all Careworld London staff (both office staff and care workers) have been re-trained in respect of the content of the revised policy and in respect of the fundamental principles involved in safeguarding adults. All such training was completed by 3 August 2018.” Source location 2018-0200-Response-by-Careworld-London-Ltd
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations