Concerns raised 3 Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English View source Failure to establish the contents of an infant’s bottle feed View source Lack of culturally informed professional curiosity in infant feeding assessment 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
Izzah Fatima Ali · 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
Izzah Fatima Ali, a nine-month-old infant, died after developing profound iron-deficiency anaemia associated with consumption of cow’s milk. The report identified concerns about healthcare professionals failing to establish what was in her bottles, insufficient consideration of cultural practices, and the repeated absence of an interpreter during ante- and post-natal 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved , contrary to guidance .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the contents of an infant’s bottle feed
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry . In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle . It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact .
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle .
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of culturally informed professional curiosity in infant feeding assessment
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices : while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries , for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity .
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” 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 Add targeted quality-assurance checks on bottle-content recording and interpreter use.
Verbatim wording from the response “1-3 months (embed)” Source location Response from Cornwall 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 Deliver mandatory infant-feeding training covering cultural practices, professional curiosity, interpreters and safe formula guidance, including recorded catch-up.
Verbatim wording from the response “Staff training and mandatory webinar” Source location Response from Cornwall 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 Secure funding to update infant-feeding guidance and strengthen interpreter and translation solutions.
Verbatim wording from the response “Funding secured for rapid mitigations” Source location Response from Cornwall 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 Confirm interpreter pathways and procurement or enablement options using the draft interpretation procedure.
Verbatim wording from the response “• A meeting has taken place with the resettlement team within Cornwall Council on January 23, 2026. Within this meeting we discussed how we can make any improvements and work closely together to ensure we are meeting the needs of families where English is not their first language. Draft Standard Operating Procedure (SOP) on Interpretation and Translation has been updated to reinforce professional use of interpreters and safeguard practice which also includes the importance of documenting need in record.” Source location Response from Cornwall 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 Horizon-scan national interpreter-service practice and share relevant examples for incorporation into the updated SOP.
Verbatim wording from the response “External best practice initiated” Source location Response from Cornwall 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 Update infant-feeding training materials to reflect guidance on terminology, professional curiosity and bottle feeding.
Verbatim wording from the response “• We have met with the Senior Clinical Lead from the 0-19 Clinical Programme Unit from the Department of Health and Social Care to discuss terminology and advice regarding bottle feeding, and there has been no change nationally to the term bottle feeding. We will be providing further guidance and training to staff through the webinars arranged regarding professional curiosity in relation to formula/bottle feeding and we have updated all training that is provided in relation to infant feeding.” Source location Response from Cornwall 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 Finalise and publish the organisation-wide Interpretation and Translation SOP and provide service-wide staff training.
Verbatim wording from the response “Policy/Standard Operating Procedure alignment on interpreter/translator services across the organisation” Source location Response from Cornwall Council
Open published response
Concerns raised 1 Absence of speed enforcement on the A3083 between RNAS Culdrose and Helston 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
SAMUEL GEORGE VASS · 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
Samuel George Vass, a Royal Navy serviceman, died after the car he was driving crossed the carriageway and collided with an oncoming vehicle. The principal concern was the absence of speed enforcement on the A3083 between RNAS Culdrose and Helston, where there had been a number of collisions and previous deaths.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Absence of speed enforcement on the A3083 between RNAS Culdrose and Helston
Wider context from the report “The concern is the absence of speed enforcement on the stretch of the A3083 road between RNAS Culdrose and Helston.
There have been a number of road traffic collisions on this stretch of the A3083. Mr Vass is the fourth person to be killed on this stretch of road in the last six years. In 2022 two serviceman were killed after a road traffic collision in which the cause of the collision was found to be grossly excessive speed by the deceased driver. In Mr Vass’ death, excessive speeding was found to have caused him to lose control of his car and cross the carriageway, contributed to by Mr Vass driving with excessive alcohol.
On this stretch of road the court heard that there are options for the installation of speed enforcement either by way of an average speed camera system or a fixed camera system.
” Open source report
Concerns raised 1 Failure of infant-feeding guidance to advise against giving cow’s milk to infants under one 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
Izzah Fatima Ali · 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
Izzah Fatima Ali was a nine-month-old infant who consumed cow’s milk after her parents were not informed of the risks, and the milk was not identified during multiple healthcare interactions. She was later found to be profoundly anaemic, suffered cardiac arrests during treatment, and was verified deceased on 7 September 2024. The principal concerns were the lack of appropriate interpreting support and the failure of feeding guidance to explain the risks of cow’s milk for infants under one year.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure of infant-feeding guidance to advise against giving cow’s milk to infants under one
Wider context from the report “I wanted to ensure that the authors of the Essential Guide to feeding your Baby that I was told was being re-produced were aware of the facts of this case. I wanted them to reflect on whether the revised Guide needed to state that giving cow’s milk to an infant under the age of one was not advised because it ran the risk of preventing the absorption of iron from other sources and causing anaemia .
” Open source report
Concerns raised 3 Failure to complete Nearest Relative details on the MH 1 form View source Failure to record the rationale for decisions not to detain following mental health assessments View source Failure to further explore a patient's decision not to involve a relevant family member in discharge notification View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Callum James Hargreaves · 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
Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Nearest Relative details on the MH 1 form
Wider context from the report “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024.
1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes.
2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so.
The Nearest Relative details on the MH 1 form were not completed.
The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further.
You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record the rationale for decisions not to detain following mental health assessments
Wider context from the report “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024.
1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes.
2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so.
The Nearest Relative details on the MH 1 form were not completed.
The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further.
You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to further explore a patient's decision not to involve a relevant family member in discharge notification
Wider context from the report “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024.
1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes.
2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so.
The Nearest Relative details on the MH 1 form were not completed.
The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further.
You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded.
” 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 Transfer Mental Health Act assessment recording from RIO to Mosaic to enable inclusion in the audit programme.
Verbatim wording from the response “From the 14th of May 2025, the local authority has been proactively implementing a change in where Mental Health Act (MHA) assessments are recorded. This is a departure from the current practice of recording on the health database (RIO) to recording on the Adult Social Care database (Mosaic). This change will allow us to incorporate MHA assessments into our audit programme, thereby supporting improved quality and consistency in documentation and recording.” Source location Response from Cornwall Council (Care and Wellbeing)
Open published response
Concerns raised 2 Failure to rapidly resolve responsibility for housing cuckooed tenants who become effectively homeless View source Inconsistent approaches by Council staff to homelessness applications from social tenants View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Callum James Hargreaves · 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
Callum James Hargreaves died after his body was recovered from the sea in Newquay on 20 January 2024, following multiple injuries consistent with a fall from height; the report recorded a conclusion of suicide. Concerns included unresolved responsibility between the Council and a social housing provider for addressing safeguarding alerts about cuckooing and housing Callum, despite seven safeguarding conferences, as well as conflicting views about whether a social tenancy disqualified someone from making a homelessness application.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to rapidly resolve responsibility for housing cuckooed tenants who become effectively homeless
Wider context from the report “1) On the facts of this case, Callum had a social tenancy with Sanctuary Housing but it is recognised the Council will have professional relationships with a number of housing providers. Safeguarding alerts were raised that Callum was being cuckooed. There was then a “stand-off” between Sanctuary and the Council as to who had responsibility for housing Callum. This was not resolved even though there were seven Safeguarding conferences held over half a year. It was felt by the Chair of the Safeguarding conferences that Callum had been failed and that the question of who was responsible for his accommodation should have been resolved much more quickly. Going forward, the Council may wish to reflect upon:
- How it would like social housing providers with whom it has professional relationships to resolve concerns about the cuckooing of tenants. A separate Preventing Future Deaths report has been written to Sanctuary in this regard (with a copy sent to the Council);
- How disagreements about who has responsibility for housing a cuckooed tenant who becomes effectively homeless may be resolved more rapidly;
- Council witnesses held conflicting views as to whether a social tenancy disqualified a tenant from making a homelessness application. It is for the Council to decide how to ensure a consistent approach is taken by its staff.
The situation generally is considered in greater detail at paragraphs 150-160 of the attached judgement.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent approaches by Council staff to homelessness applications from social tenants
Wider context from the report “1) On the facts of this case, Callum had a social tenancy with Sanctuary Housing but it is recognised the Council will have professional relationships with a number of housing providers. Safeguarding alerts were raised that Callum was being cuckooed. There was then a “stand-off” between Sanctuary and the Council as to who had responsibility for housing Callum. This was not resolved even though there were seven Safeguarding conferences held over half a year. It was felt by the Chair of the Safeguarding conferences that Callum had been failed and that the question of who was responsible for his accommodation should have been resolved much more quickly. Going forward, the Council may wish to reflect upon:
- How it would like social housing providers with whom it has professional relationships to resolve concerns about the cuckooing of tenants. A separate Preventing Future Deaths report has been written to Sanctuary in this regard (with a copy sent to the Council);
- How disagreements about who has responsibility for housing a cuckooed tenant who becomes effectively homeless may be resolved more rapidly;
- Council witnesses held conflicting views as to whether a social tenancy disqualified a tenant from making a homelessness application. It is for the Council to decide how to ensure a consistent approach is taken by its staff.
The situation generally is considered in greater detail at paragraphs 150-160 of the attached judgement.
” 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 Ensure all managers and supervisors demonstrate understanding and application of the escalation procedure by August 2025.
Verbatim wording from the response “In order to ensure this, managers and supervisors will be directed to the Council's ‘Escalation of Professional Differences Procedure and Guidance’ (- cios sab-escalation-procedure-october-2020.pdf). This document provides clear guidance on steps to resolve professional differences and strategic steps for the escalation of concerns.” Source location Response from Cornwall Council (Housing)
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 Require staff to access, read and understand the Homelessness Code of Guidance through caseworker supervision.
Verbatim wording from the response “All staff to have access to, and be required to read and understand, the ‘Homelessness Code of Guidance’. This will be referred to in case worker supervision to ensure compliance and understanding.” Source location Response from Cornwall Council (Housing)
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 Direct managers and supervisors to use the Escalation of Professional Differences Procedure and Guidance.
Verbatim wording from the response “2. An escalation of Callum’s situation following the safeguarding/MDT meetings did not occur. Had the difficulties encountered triggered an escalation, then there may have been further opportunities to explore and potentially resolve the housing issue.” Source location Response from Cornwall Council (Housing)
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 Review the caseworker supervision framework to improve consistency and uniformity.
Verbatim wording from the response “Furthermore, it is accepted that Callum’s individual case was not sufficiently highlighted through caseworker supervision. In light of this, we are currently reviewing the framework under which” Source location Response from Cornwall Council (Housing)
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 robust caseworker supervision to ensure correct homelessness legal tests and thresholds are applied in every case.
Verbatim wording from the response “3. We accept that an opportunity to open a case based on existing homelessness triggers under Part 7 of the Housing Act 1996 existed and that this could have been explored further. Of relevance to this matter was the fact that Callum had a tenancy. The question (and test) then of whether ‘... it [is] reasonable to occupy..’ should have been considered and applied following any concerns of alleged disrepair and suspected cuckooing. If the threshold for priority need was also met, then an offer of interim accommodation under s188 duty would be triggered.” Source location Response from Cornwall Council (Housing)
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 Implement a Quality Assurance Framework using induction training, continuing professional development and case sampling.
Verbatim wording from the response “We will also implement a Quality Assurance Framework to ensure expertise and legal compliance. This will be achieved through a combination of rigorous induction training, continual professional development and continual case sampling. Once approved through internal governance, we expect this to be in place by 1st December 2025.” Source location Response from Cornwall Council (Housing)
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 Council cannot dictate individual social housing providers’ operational policies for resolving cuckooing concerns.
Verbatim wording from the response “1. While we cannot dictate what individual providers do operationally in terms of their own policy, we are in a position to promote and encourage the adoption of a unified understanding of cuckooing and, if possible, reach consensus in the following key areas;” Source location Response from Cornwall Council (Housing)
Open published response
Concerns raised 2 Road safety hazards at the collision location View source Failure to implement road safety recommendations at the collision location View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
JAMES EDWARD TURNER · 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
James Edward Turner died instantly on 25 July 2023 after his motorcycle collided with a grain-laden trailer being towed across the B3252. The substantive concerns were road safety at the collision location, including limited visibility for tractor drivers and speeding, and the fact that recommended road-safety improvements had not been implemented.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Road safety hazards at the collision location
Wider context from the report “(1) Road safety at the location of the collision taking account of
• the speed limit at the location,
• the limited visibility for tractor drivers,
• the nature of the tractor loads being conveyed at the collision site and the time it takes for combinations to cross the road,
• the data that indicates some motorists are speeding at that location.
(2) The fact that the recommendations made by the Council to improve road safety at the collision location have not been implemented.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement road safety recommendations at the collision location
Wider context from the report “(1) Road safety at the location of the collision taking account of
• the speed limit at the location,
• the limited visibility for tractor drivers,
• the nature of the tractor loads being conveyed at the collision site and the time it takes for combinations to cross the road,
• the data that indicates some motorists are speeding at that location.
(2) The fact that the recommendations made by the Council to improve road safety at the collision location have not been implemented.
” 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 Erect warning signs indicating farm traffic at the access.
Verbatim wording from the response “I can confirm our contractor has been instructed and that warning signs indicating 'Farm Traffic' (diagram 553.1 & 553.2) will be erected shortly.” Source location Response from Cornwall 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 authority has no power to require closure or relocation of the privately owned access.
Verbatim wording from the response “The highway authority's view remains that relocating the access is the best long-term preventative measure, given the limited view out of the field. As noted at the inquest, however, Cornwall Council has no power to require closure or relocation of the access, which is privately owned and has been in use for many years. We are though willing to work with the landowner on potential relocation options and would be grateful to be advised of any response Mr Harper makes to his own copy of your R28 letter.” Source location Response from Cornwall Council
Open published response
Concerns raised 11 Absence of a planned route back to mental health assessment View source Failure to distinguish GP requests for advice from referrals View source Lack of professional curiosity about drug-taking and its clinical contribution View source Lack of continuity in primary care after patient relocation View source Delays in responding to GP requests for mental health advice due to staffing shortages View source Discharging referrals without clinical triage of non-response View source Failure to adapt patient contact methods to known communication needs View source Failure to share relevant presentation information with family View source Delays in recording family-provided clinical timelines View source Failure to advise Nearest Relatives of statutory rights to request MHA assessment View source Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty View source See 8 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
Sally Poynton · 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
Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a planned route back to mental health assessment
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish GP requests for advice from referrals
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity about drug-taking and its clinical contribution
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity in primary care after patient relocation
Wider context from the report “Primary Care
There was an accepted lack in continuity in ████████ primary care after he moved from Sally’s address (and a GP in Marazion) to his father’s house in Ponsanooth (and a GP in Penryn.)
The inquest was told that there are now regular Multi Agency Safeguarding Hubs (MASH) where patients who may be known to both the mental health service and adult safeguarding are discussed.
It struck me that there may be value in someone from the ICB attending MASH meetings on behalf of GPs in Cornwall. That individual could then feed back information to the surgery where a patient was registered. In this instance, that would have provided ████████ with the ‘backstory’ she did not have, now being in receipt of ████████ records or the discharge summary from Longreach when she saw him and given the difficulties associated with taking a history from Jacob when he was mute.
I wonder if you feel an initiative in this regard would be sensible?
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to GP requests for mental health advice due to staffing shortages
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP . This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain .
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Discharging referrals without clinical triage of non-response
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment . ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge .
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to adapt patient contact methods to known communication needs
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone . It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond . Policy appears to have been followed without consideration of the clinical circumstances .
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant presentation information with family
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented , notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Delays in recording family-provided clinical timelines
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to advise Nearest Relatives of statutory rights to request MHA assessment
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA . This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Provide Adult Social Care access to NHS SPINE to verify individuals’ GP registration records through its recording system.
Verbatim wording from the response “• ASC now has access to NHS SPINE. This functionality allows us though our own recording system to check that we have the correct records in respect of an individuals GP registration.” Source location Response from Cornwall Council
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 No further difficulties need to be overcome in the referral pathway into secondary mental health services.
Verbatim wording from the response “• In terms of its function as a referral pathway I do not believe that there are any difficulties which need to be overcome.” Source location Response from Cornwall Council
Open published response
Concerns raised 1 Failure to undertake health-related enquiries in response to potential mental impairment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michaela Hall · 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
Michaela Hall was stabbed through the eye by her partner on 31 May 2021 and was found deceased the next day; life was formally pronounced extinct on 1 June 2021. The report identified shortcomings in recruitment, pre-sentence reporting and risk assessment, including the partner’s risk being assessed as medium rather than high. It also raised concerns about how Children and Adult Services assessed, recorded, shared and acted on information concerning domestic abuse, safeguarding and potential mental impairment.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake health-related enquiries in response to potential mental impairment
Wider context from the report “Be curious. There were multiple examples of potential mental impairment – a diagnosis of OCD, mentions of suicidality and depression, the Acton email, yet no health-related enquiries appear to have been undertaken .
” 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 Complete and implement the Adult Social Care Practice Framework requiring holistic, collaborative and enquiring practice.
Verbatim wording from the response “We have recently completed our Practice Framework within Adult Social Care. It instructs workers to be holistic, collaborative and enquiring in their practice to ensure that they are responsible for drawing out the information they require rather than passive receivers of information. This would include making enquiries with other agencies it was believed to have been in touch with individuals.” Source location Response from Cornwall Council
Open published response
Concerns raised 4 Downhill overtaking section remaining at the location View source Fading and disappearance of deflection arrows on the road View source Marginal-benefit overtaking opportunity at the collision location View source Visibility deficiencies between downhill traffic and cars exiting the roundabout View source See 1 more concern
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
KAIUS JOHN PAUL TUTT · 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
Kaius John Paul Tutt died from multiple injuries after the motorcycle he was riding collided with a car on the A391 near St Austell on 14 October 2022. The principal concerns were faded or missing road-marking deflection arrows, visibility issues at the collision location, and the limited benefit of the downhill overtaking opportunity. The report also records a recommendation to amend the road layout, with no funding then available to facilitate it.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Downhill overtaking section remaining at the location
Wider context from the report “(4) The court found that Cormac has made a recommendation to Cornwall Council that the road layout is amended to remove the downhill overtaking section at this location at the first reasonable opportunity , but that currently no funding is available to facilitate this recommendation .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Fading and disappearance of deflection arrows on the road
Wider context from the report “(1) The deflection arrows on this stretch of road were found to have faded and to have almost entirely disappeared in places .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Marginal-benefit overtaking opportunity at the collision location
Wider context from the report “(3) The court found that the overtaking opportunity at the collision location is of marginal benefit , given that there are other better overtaking opportunities on this stretch of road.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Visibility deficiencies between downhill traffic and cars exiting the roundabout
Wider context from the report “(2) The court found that there were visibility issues for those travelling downhill viewing cars exiting roundabout and vice versa .
” Open source report
Concerns raised 6 Failure to close the pier to public access when unsafe conditions are present View source Harbour currents making swimming to safety difficult View source Lack of access ladders or a refuge area for people in the water View source Lack of railing protection alongside harbour and pier sheer drops View source Inadequate lighting on the pier View source Unaddressed trip hazards around the harbour wall View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Francis PARSONS · 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
James Francis PARSONS died by drowning at Porthleven Harbour on 23 April 2022 after falling from the harbour wall into the water. The report identified safety concerns including sheer drops without railings, trip hazards, poor lighting, the absence of access ladders or refuge areas, and the pier being open to the public during the festival.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to close the pier to public access when unsafe conditions are present
Wider context from the report “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Harbour currents making swimming to safety difficult
Wider context from the report “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of access ladders or a refuge area for people in the water
Wider context from the report “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area . The pier is sometimes closed to access by the public but was not closed at the time of the festival.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of railing protection alongside harbour and pier sheer drops
Wider context from the report “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water , and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate lighting on the pier
Wider context from the report “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards. The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit . For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Unaddressed trip hazards around the harbour wall
Wider context from the report “There were safety issues revealed at Porthleven Harbour, particularly in the evening when festival goers will have been drinking alcohol. Sections of the harbour wall feature sheer drops into water with no railings and trip hazards . The pier presents a particular risk due the absence of railings on one side with a sheer drop into water, and being poorly lit. For anyone falling from the pier, swimming to safety will be difficult due to current and the absence of access ladders or refuge area. The pier is sometimes closed to access by the public but was not closed at the time of the festival.
” 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 Consider the event organiser’s response before permitting the event to proceed, ensuring reasonable precautions are in place.
Verbatim wording from the response “The SAG are awaiting a response from the event organiser in relation to what additional measures are planned for this year following the tragic death, including safety measures for the harbour area and the sale of alcohol. The response will be supported by attendance at a SAG, so that all agencies have an opportunity to speak directly with the event organiser. The response will be considered by the members of the SAG prior to the event going ahead to ensure that reasonable precautions are in place.” Source location Response from Cornwall Council
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 Health and Safety Executive is responsible for statutory enforcement concerning safety at the harbour’s dock premises.
Verbatim wording from the response “In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.” Source location Response from Cornwall Council
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 Statutory health and safety enforcement for dock premises falls outside the council’s powers under the Health and Safety at Work etc. Act 1974.
Verbatim wording from the response “In relation to the safety concerns of the Harbour itself, Cornwall Council has no statutory powers under the Health and Safety At Work etc Act 1974 because Dock Premises fall to the Health & Safety Executive (HSE) for statutory enforcement purposes Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation (hse.gov.uk). We have passed your FDR to the local inspectors for the HSE, however you may wish to consider sending the HSE an FDR directly.” Source location Response from Cornwall Council
Open published response
Concerns raised 1 Failure to undertake advised remedial works to trees aligning Sailors Creek View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul John Welch · 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
Paul John Welch was struck by an overhanging tree while walking with his daughter at Sailors Creek on 2 January 2021, suffered a serious head injury and died at the scene. Trees in the area had been omitted from previous surveys, and recommended remedial works had not been carried out, leaving an identified risk to people accessing the foreshore.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake advised remedial works to trees aligning Sailors Creek
Wider context from the report “As set out above, the remedial works that it has been advised be carried out to the trees aligning Sailors Creek have not been undertaken notwithstanding the obvious risks to individuals present there, as evidenced by the tragic death of Mr Welch.
” Open source report
×
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 Council could not determine the tree works application because the supporting information lacked sufficient detail and justification.
Verbatim wording from the response “The Council received an application from Sailors Creek CIC for works to various trees subject to Tree Preservation Order at Sailors Creek, Trevisome, Flushing on 14th January 2022. The application reference is PA22/00364. Such applications are required to provide sufficient detail for the Local Planning Authority to be clear on the extent of the works and the justification therein. In this instance, the supporting information provided with the application was not sufficiently detailed for the Local Planning Authority to determine the application. This was raised with the applicant on 9th March 2022 and further justification was requested to support the application. The Council's Tree Officer sought out the applicant's arboriculturist at that time but there was a reluctance to do so and on 23rd March 2022 the applicant asked for the application to be put on hold for the time being.” Source location Response from Planning and Housing Cornwall Council
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 applicant and its appointed arboriculturalist must finalise and submit proportionate, evidence-based tree management proposals, including replanting measures.
Verbatim wording from the response “4. These proposals, including any replanting measures, once finalised to the satisfaction of the applicant (SC CIC) and their appointed arboriculturalist/arborist, should be submitted to Cornwall Council planning service, care of the Case Officer.” Source location Response from Planning and Housing Cornwall Council
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 TreeWise must submit the final tree-work specification in accordance with the client's requirements and the Forestry Officer's guidance.
Verbatim wording from the response “2. TreeWise to submit final specification in line with the requirements of their client (Sailors Creek CIC) and, where acceptable, in line with the advice and guidance provided by CC Forestry Officer. Treewise to confirm timeframe for this. An updated specification was received from Treewise on Monday 8th August.” Source location Response from Planning and Housing Cornwall Council
Open published response
Concerns raised 4 Inadequate cross-organisational access to clinical records and information View source Failure to use an assertive approach to engage clients referred to mental health services View source Failure to provide an adequate service to people presenting with a dual diagnosis View source Failure to consider suitable alternative agency support for patients outside severe and enduring mental illness criteria View source See 1 more concern
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
Emma Burbury · 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
Emma Burbury collapsed after an altercation with her partner and died in hospital on 19 September 2018; the forensic pathologist considered it possible that injuries from the altercation caused or contributed to her death, but the evidence was insufficient to establish this as probable or certain. The report identified a missed opportunity to provide treatment after her July 2017 assessment and concerns about services for people with dual diagnoses, including care coordination, communication between organisations, engagement, and discharge arrangements.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate cross-organisational access to clinical records and information
Wider context from the report “a] I heard that CMHT staff have read-only access to WAWY notes and records, but this fact is not widely known amongst Trust staff . It was recognised that a reciprocal arrangement allowing WAWY clinicians to have read-only access to the Trust’s RiO records would be of benefit . I understand a formal request in this regard has been made and is receiving due consideration. One of the most common concerns I hear at inquest is the difficulty with communication between separate organisations and this may also be an initiative you feel able to support in delivering a more integrated 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to use an assertive approach to engage clients referred to mental health services
Wider context from the report “b] There was concern raised on the part of We Are With You that clients referred to the Trust were too easily discharged , for example, where they failed to attend for two appointments . It was felt a more assertive approach towards engagement would be beneficial . You may feel it would be desirable to try and minimise the amount of wasted and limited CMHT/WAWY resource through non-attendance at appointments or otherwise. You may consider reflection on how this can best be achieved through a more joined up approach would be sensible.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequate service to people presenting with a dual diagnosis
Wider context from the report “It was accepted in evidence that it was “very regrettable” Emma was not taken on to caseload after her assessment in July 2017. There was clearly a missed opportunity to work with her while she was open to treatment. It was accepted that there was no guarantee this would have avoided the eventual outcome, but it was recognised a better service needed to be provided to those presenting with a dual diagnosis, like Emma .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider suitable alternative agency support for patients outside severe and enduring mental illness criteria
Wider context from the report “c] It was felt patients referred to the Trust who did not fall within the strict parameters of a severe and enduring mental illness were discharged without sufficient thought being given by the Trust’s clinicians to whether another agency such as Valued Lives may be able to offer assistance . You may feel it would be a worthwhile exercise to consider how to join up the wider services available within the Trust, the voluntary sector or elsewhere.
” Open source report
Concerns raised 2 Failure to implement feasible road drainage improvements View source Converging surface water on the A390 during heavy rainfall 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
Ryan Gareth TAYLOR · 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
Ryan Gareth TAYLOR died after his vehicle lost control and collided with another vehicle while aquaplaning on converging surface water during heavy rain. The principal concerns were that road drainage allowed surface water from Coliza Hill to converge with water on the A390, a similar aquaplaning incident had occurred previously, and feasible drainage improvements had not yet been implemented.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement feasible road drainage improvements
Wider context from the report “(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car.
(2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision.
(3) Improvements to road drainage are feasible in this particular location but have not yet been implemented . These improvements may diminish the risks of vehicles aquaplaning due to converging surface water.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Converging surface water on the A390 during heavy rainfall
Wider context from the report “(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car.
(2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision.
(3) Improvements to road drainage are feasible in this particular location but have not yet been implemented. These improvements may diminish the risks of vehicles aquaplaning due to converging surface water.
” Open source report
Concerns raised 2 Converging surface water on the A390 during heavy rainfall View source Failure to implement feasible road drainage improvements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ryan Gareth TAYLOR · 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
Ryan Gareth TAYLOR died after losing control of his Jaguar XF when surface water converged on the A390 during heavy rain, causing aquaplaning and a collision. The principal concerns were inadequate road drainage, a previous similar aquaplaning incident at the same location, and feasible drainage improvements that had not yet been implemented.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Converging surface water on the A390 during heavy rainfall
Wider context from the report “(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car.
(2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision.
(3) Improvements to road drainage are feasible in this particular location but have not yet been implemented. These improvements may diminish the risks of vehicles aquaplaning due to converging surface water.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement feasible road drainage improvements
Wider context from the report “(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car.
(2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision.
(3) Improvements to road drainage are feasible in this particular location but have not yet been implemented . These improvements may diminish the risks of vehicles aquaplaning due to converging surface water.
” 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 Erect warning signs on both approaches alerting drivers to possible surface water on the road ahead.
Verbatim wording from the response “• Signs will shortly be erected on both approaches warning of the possibility of surface water on the road ahead. This is an interim measure pending more substantial improvement.” Source location 2021-0176-Response-from-CORMAC_Published
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 Replace existing Coliza Hill slip-road gully grids with larger-capacity gratings.
Verbatim wording from the response “• The existing gully grids on the Coliza Hill slip road will be replaced with larger capacity gratings. This is scheduled to take place in October, in combination with maintenance work programmed after the summer road works embargo period.” Source location 2021-0176-Response-from-CORMAC_Published
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 Undertake detailed drainage and topographical surveys of the main road alignment.
Verbatim wording from the response “• Detailed drainage and topographical surveys will be undertaken on the main road alignment, again in combination with the scheduled maintenance work in October.” Source location 2021-0176-Response-from-CORMAC_Published
Open published response
Concerns raised 1 Lack of warning signs for the junction with Trebost Lane on Tubbоn Hill 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
Caitlin Ann SWAN · 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
On 28 December 2019, Caitlin Ann SWAN lost control of her bicycle while descending Tubbоn Hill, collided with a vehicle, and fell into the path of an oncoming vehicle, sustaining catastrophic head and neck injuries. The principal concern was that there were no signs warning road users of the junction with Trebost Lane, which was only visible 75 to 50 metres away and required vehicles to negotiate an acute turn at near walking pace.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signs for the junction with Trebost Lane on Tubbоn Hill
Wider context from the report “There are no signs on Tubbоn Hill to warn road users of the junction with Trebost Lane , notwithstanding that the junction is only visible between 75 and 50 metres away for a road user descending the hill and that any vehicles negotiating the acute left turn into Trebost Lane are likely to be almost stationary in the road at some point.
” Open source report
Concerns raised 2 Lack of visibility for drivers at the accident locus View source Lack of view available to drivers at the accident location 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
Aaron Antony Lauder · 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
Aaron Antony Lauder died in a road traffic collision while riding his Kawasaki motorbike on the A30 near Penzance. The principal concern was the lack of view available to both the tractor driver and Mr Lauder at the collision location.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of visibility for drivers at the accident locus
Wider context from the report “I concluded that the prime cause of the collision was the lack of view available to either driver at the accident locus .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of view available to drivers at the accident location
Wider context from the report “I concluded that the prime cause of the collision was the lack of view available to either driver at the accident locus .
” Open source report
Concerns raised 1 Shortage of suitable placements for individuals with mental health histories View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael John Owen COX · 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
Michael John Owen Cox had a long history of mental illness and was living at Ridgewood Care Home after being placed there in July 2016. He was found deceased in his room on 01/04/2017; the inquest jury recorded a conclusion of misadventure due to drug/alcohol use. The principal concern was the potential shortage of suitable placements for people with similar mental health histories, including persistent difficulties in finding appropriate facilities and limited resources.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Shortage of suitable placements for individuals with mental health histories
Wider context from the report “The potential shortage of suitable placements for individuals with a mental health history similar to Michael. Evidence was heard at the inquest that when such individuals are placed at a suitable facility, it can become their home and they may live there for years and even decades. Accordingly, spare places can be at a premium . Evidence was also heard that social workers (and in this case an occupational therapist) have persistent difficulties in finding suitable placements suggesting that resources are limited .
” 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 Develop the multiagency Cornwall Complex Needs Strategy to improve coordinated support and accommodation provision for people with complex needs.
Verbatim wording from the response “The Cornwall Community Safety Partnership has developed a draft multiagency Cornwall Complex Needs Strategy (2019-23) to improve the approach to partnership working and provision in Cornwall, including for people with complex needs related to mental health and drugs/alcohol. The strategy includes recommendations to develop a more coordinated multiagency approach to support this group of people, and a system of accommodation provision with access to care and support that meets the needs of those at different stages of recovery.” Source location 2019-0203-Response-by-Cornwall-Council
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 Explore opportunities to develop appropriate accommodation for people with complex and enduring mental health conditions.
Verbatim wording from the response “The draft multiagency Cornwall and Isles of Scilly Adult Mental Health Strategy (2019-24) also identifies the need to improve access to specialist support for those with a dual diagnosis of both mental health and drug/alcohol problems. It highlights the need to improve the pathway for people to receive a social care assessment and to access appropriate care and individualised support, and commits to exploring future opportunities to develop appropriate accommodation to meet the needs of those with complex and enduring mental health conditions.” Source location 2019-0203-Response-by-Cornwall-Council
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 Implement a complex-needs system model using multidisciplinary meetings, lead professionals, community links and escalation routes for unmet support or accommodation needs.
Verbatim wording from the response “For the delivery of services and support, a complex needs system model has been proposed, which will be implemented by the Cornwall MEAM Strategic Board. The model includes the expectation that multi-disciplinary team meetings take place where people have multiple needs, that a lead professional is identified to ensure that the person is linked to all appropriate support, that creative solutions are considered including links to community assets, and that there is a clear escalation route for any cases where appropriate support and/or accommodation has not been identified.” Source location 2019-0203-Response-by-Cornwall-Council
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 Work with housing providers to assess supported-housing needs, availability and provision gaps for people with mental health or complex needs.
Verbatim wording from the response “Social care and accommodation with care. A strategic task and finish project including Adult Social Care (ASC), NHS Kernow Clinical Commissioning Group (NHSK), Cornwall Partnership NHS Foundation Trust (CPFT), Housing Strategy and Partnerships, and the Drug and Alcohol Action Team, as well as other partners, is currently being established to take forward recommendations in relation to social care and accommodation to ensure that the available provision is meeting people’s needs. This task and finish project runs until April 2021, during which time it will work on the following.” Source location 2019-0203-Response-by-Cornwall-Council
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 Agree a strategic approach to specialist supported housing, including demand, supply, location and accommodation-type analysis.
Verbatim wording from the response “A clear strategic approach will be agreed by the task and finish group regarding the development of specialist supported housing for people with mental health and/or complex needs in Cornwall. The project will include analysis of demand and supply, and a profile on the housing requirements,” Source location 2019-0203-Response-by-Cornwall-Council
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 Review residential, nursing-care-home and supported-living provision to identify gaps and inform how the market should meet needs.
Verbatim wording from the response “including required locations and types of accommodation. A review will take place regarding the current residential/nursing care home and supported living provision to better understand the gaps and shape the market to meet needs. The work required to shape the market following this is expected to go beyond April 2021. (Timescales for this are to be confirmed.)” Source location 2019-0203-Response-by-Cornwall-Council
Open published response
Concerns raised 1 Lack of an alarm or other warning for developing air-mattress deflation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jeanette Ann Robinson · 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
Jeanette Ann Robinson, who had morbid obesity and type II diabetes, suffered a fall, developed a sacral pressure ulcer, and was admitted to hospital in a septic condition. She died in hospital on 21 December 2016. The report raised concerns that an accidentally deflated pressure-relieving mattress had no alarm or other warning system, and that an unsuccessful attempted transfer to a community hospital contributed to the outcome.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an alarm or other warning for developing air-mattress deflation
Wider context from the report “Mrs Robinson was using a nimbus 3 air mattress and a Toto (electronic turning device) at the time the mattress was found to be accidentally deflated. The mattress became deflated when the power cable into the pump was dislodged. I understand there was no alarm fitted to the system or any other warning to alert Mrs Robinson to the developing problem .
” 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 Replace community Nimbus systems with the fully alarmed Elite mattress system.
Verbatim wording from the response “We have undertaken a process of all Nimbus systems in the community being replaced. This action was taken following clinical reasoning and a new mattress system called Elite is now being used. These are also fully alarmed.” Source location 2019-0185-Response-by-Cornwall-Council
Open published response
Concerns raised 4 Failure to develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement View source Failure of the working relationship between CMHT and Addaction View source Failure to operate the Cornwall dual diagnosis policy effectively View source Inadequate interface between Addaction and community mental-health teams View source See 1 more concern
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
PAUL MATTHEW GILLAM · 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
Paul Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery plan.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement
Wider context from the report “(2) The development and implementation of the delivery plan in relation to the existing service level agreement between CMHT and Addaction .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the working relationship between CMHT and Addaction
Wider context from the report “(3) The working relationship between CMHT and Addaction .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to operate the Cornwall dual diagnosis policy effectively
Wider context from the report “(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate interface between Addaction and community mental-health teams
Wider context from the report “(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT .
” Open source report
Concerns raised 5 Failure to provide cliff-danger training to Lands End resort staff View source Lack of internationally recognisable cliff-danger warning signs for non-English speakers View source Lack of maintenance of temporary rope barriers at cliff hot spot sites View source Lack of warning signs and pictograms at discrete public locations within Lands End resort View source Lack of permanent barriers at cliff hot spot sites View source See 2 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.
×
AI-generated summary
Hans-Peter Schmidt · 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
Hans-Peter Schmidt died on 17 June 2017 at Lands End, Cornwall, from multiple injuries following an unwitnessed fall from a cliff while cycling along the cliff edge. The report raised concerns about the maintenance and absence of permanent barriers at identified cliff hot spots, inadequate warning signs and pictograms, and the lack of staff training uptake offered by the RNLI.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide cliff-danger training to Lands End resort staff
Wider context from the report “(4) The lack of uptake by the Lands End resort of the RNLI offer to provide training to 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of internationally recognisable cliff-danger warning signs for non-English speakers
Wider context from the report “(3) The lack of internationally recognisable warning signs in accordance with British Signage Institute (BSI) guidelines to warn non-English speakers of the dangers presented by the cliffs as recommended by the RNLI.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of maintenance of temporary rope barriers at cliff hot spot sites
Wider context from the report “(1) The apparent lack of maintenance of the temporary rope barriers located at two hot spot sites identified by RNLI and police witnesses, namely 1) that immediately below Greeb farm where a path from the farm meets the cliff face at a right angle and forms a junction with other paths above the sheer cliff face, this being the sight of two fatal accidents in 2017, namely those of Mr Jachec and Herr Schmidt. 2) that known as the arch viewing area, being the furthest southern location of the Lands End resort on the border with National Trust property.
(2) Regarding the lack of permanent barriers as recommended by the RNLI at the two hot spot sites discussed above.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signs and pictograms at discrete public locations within Lands End resort
Wider context from the report “(5) The lack of warning signs and pictograms at discrete public locations within Lands End resort to promote awareness of the dangers presented by the cliffs .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of permanent barriers at cliff hot spot sites
Wider context from the report “(1) The apparent lack of maintenance of the temporary rope barriers located at two hot spot sites identified by RNLI and police witnesses, namely 1) that immediately below Greeb farm where a path from the farm meets the cliff face at a right angle and forms a junction with other paths above the sheer cliff face, this being the sight of two fatal accidents in 2017, namely those of Mr Jachec and Herr Schmidt. 2) that known as the arch viewing area, being the furthest southern location of the Lands End resort on the border with National Trust property.
(2) Regarding the lack of permanent barriers as recommended by the RNLI at the two hot spot sites discussed above .
” Open source report
Concerns raised 2 Reduced access to face-to-face alcohol reduction workers and Alcoholics Anonymous support on the Mainland View source Lack of accessible face-to-face alcohol support on the Isles of Scilly 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
Robert Lloyd · 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
Robert Lloyd drowned after becoming motionless and floating face down while swimming at Porthcressa Beach on 30 July 2016. Post-mortem toxicology found a blood alcohol level likely to have affected his cognition. Evidence at the inquest raised concerns about limited face-to-face alcohol-support services on the Isles of Scilly, particularly after the termination of the helicopter service, and the resulting difficulty engaging with service users.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Reduced access to face-to-face alcohol reduction workers and Alcoholics Anonymous support on the Mainland
Wider context from the report “At the inquest evidence was read from the GP and Addaction as to Mr Lloyd’s abuse of alcohol and the difficulty in providing supportive treatment for alcohol abusers on the Isles of Scilly. It was acknowledged that due to the island's location and with limited air and boat services after the termination of the helicopter service some years ago, the support was limited. This has meant that the service users on the Islands have had limited face to face support and had to rely of video link support due to the inability of alcohol support professionals to travel to the Islands in bad weather. This had led to a difficulty in engaging with this group of users.
Mr Lloyd’s mother, at inquest explained how the reduction in service (on the termination of the helicopter service) had affected her son and made it more difficult for him to control his drinking habit especially on a small island with a strong alcohol drinking culture. In the past he had access to face to face alcohol reduction workers and he was able to attend (for a small travel fee) the Alcoholics Anonymous group on the Main Land.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible face-to-face alcohol support on the Isles of Scilly
Wider context from the report “At the inquest evidence was read from the GP and Addaction as to Mr Lloyd’s abuse of alcohol and the difficulty in providing supportive treatment for alcohol abusers on the Isles of Scilly . It was acknowledged that due to the island's location and with limited air and boat services after the termination of the helicopter service some years ago, the support was limited . This has meant that the service users on the Islands have had limited face to face support and had to rely of video link support due to the inability of alcohol support professionals to travel to the Islands in bad weather . This had led to a difficulty in engaging with this group of users.
Mr Lloyd’s mother, at inquest explained how the reduction in service (on the termination of the helicopter service) had affected her son and made it more difficult for him to control his drinking habit especially on a small island with a strong alcohol drinking culture. In the past he had access to face to face alcohol reduction workers and he was able to attend (for a small travel fee) the Alcoholics Anonymous group on the Main Land.
” Open source report
Concerns raised 1 Failure to prevent people from easily crossing the walkway barrier 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
Charles Edward Pitcher · 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
On 5 July 2016, Charles Edward Pitcher jumped over the walkway barrier of the Tamar Bridge and landed in Wolseley Road, Plymouth, suffering fatal injuries. The report raised concerns that the barrier was too easy to cross, that people in Wolseley Road were at risk, and that further procedures and measures should be reviewed to reduce the likelihood of suicide from the bridge.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent people from easily crossing the walkway barrier
Wider context from the report “At the Inquest I received information from Detective Constable ████████ who informed me there have been 11 persons who had jumped from the bridge in the last 10 years. He formed the view that it was all too easy to jump the barrier . He also made the observation there was a risk to persons in Wolseley Road arising from people crossing the walkway barrier at that point . He made the observation that on other significant bridges and he gave as an example the Humber Bridge, the operators have established precautions and set up appropriate notices.
” Open source report
24 May 2016 Beverley Lawford John Siddall · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 2 Inadequacy of the road layout at the collision location View source Inadequacy of safety notices or barriers at the collision location View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Beverley Lawford John Siddall · 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
Beverley Siddall died from multiple injuries after his car left the A3075 near Perranwell on 7 August 2015 and entered a river; he was pronounced dead at hospital on 8 August 2015. At the inquest, concerns were raised that the road layout, safety notices and/or barriers at that location might not have been adequate, following evidence of several vehicles leaving the road at the same point.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the road layout at the collision location
Wider context from the report “That two witnesses to the traffic collision noted in evidence that they had seen evidence of a good number of cars leaving the A3075 road at Cosy Cottage, Perranwell at the same point as Mr Siddall. The police Collision Investigator at inquest, noted when he went to survey the scene there was another car present that had come off the road which had nothing to do with Mr Siddall’s collision. There was concern at inquest that the road layout , or safety notices and/or barriers in place, were not adequate and that this section of road should be reviewed with the view to reducing the risk of cars leaving the road at this point.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of safety notices or barriers at the collision location
Wider context from the report “That two witnesses to the traffic collision noted in evidence that they had seen evidence of a good number of cars leaving the A3075 road at Cosy Cottage, Perranwell at the same point as Mr Siddall. The police Collision Investigator at inquest, noted when he went to survey the scene there was another car present that had come off the road which had nothing to do with Mr Siddall’s collision. There was concern at inquest that the road layout, or safety notices and/or barriers in place , were not adequate and that this section of road should be reviewed with the view to reducing the risk of cars leaving the road at this point.
” 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 Maintain the local safety scheme’s large yellow-backed chevrons, widened carriageway and bend hatching.
Verbatim wording from the response “In 2003/4 the council carried out a Local Safety Scheme on this bend, erecting large yellow-backed chevrons and widening and hatching the bend. This has proven to be very effective in terms of the accident record, and the bend has not been on the Council’s list of accident cluster sites since this work was undertaken. In recent years the speed limit has also been reduced to 40mph (from 60mph), although this is somewhat academic given the nature of the corner. There is little further that could be done to ensure drivers are aware of the severity of the bend, and to help them remain on the road.” Source location Response from Cornwall Council
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 Solid restraints may cause more injuries than they prevent by increasing impact severity or redirecting vehicles into oncoming traffic.
Verbatim wording from the response “After careful consideration of the facts resulting from our investigations, advice from the Council’s lead Road Safety Auditor, the content of your report and the geometry of this particular highway, the Council has concluded that any works at this site such as crash barriers or Cornish hedging are as likely to cause injury to occupants of any vehicle that fails to negotiate the bends as to protect them from it. We note that in this instance the head injuries to Mr Siddall resulted partly from his failure to wear a seat belt rather than from an excessively violent impact. Indeed, the impact itself was relatively minor and Mr Siddall’s vehicle continued to drive over the field largely undamaged until it came to rest at the stream.” Source location Response from Cornwall Council
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 Existing chevrons, bend widening, hatching and the reduced speed limit have improved safety, leaving little further to do.
Verbatim wording from the response “In 2003/4 the council carried out a Local Safety Scheme on this bend, erecting large yellow-backed chevrons and widening and hatching the bend. This has proven to be very effective in terms of the accident record, and the bend has not been on the Council’s list of accident cluster sites since this work was undertaken. In recent years the speed limit has also been reduced to 40mph (from 60mph), although this is somewhat academic given the nature of the corner. There is little further that could be done to ensure drivers are aware of the severity of the bend, and to help them remain on the road.” Source location Response from Cornwall Council
Open published response
11 Jan 2016 Colin Keith Williams · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 2 Failure of services to provide clear, accessible routes to care and funding for people with complex health and social needs View source Failure to maintain continuity of funding when required paperwork cannot be completed or understood independently 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
Colin Keith Williams · 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
Colin Williams was found dead at his home on 9 April 2013, where he had been lying on the kitchen floor in a state of decomposition. He was known to numerous agencies as a vulnerable adult with complex needs, alcohol misuse and a tendency to self-neglect, but his body was not found for some weeks. Evidence at the inquest described difficulties arising from the number of agencies involved, variable mental capacity and complex or unavailable funding arrangements, which hindered his access to support.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure of services to provide clear, accessible routes to care and funding for people with complex health and social needs
Wider context from the report “Mr Colin Williams was known to numerous agencies and personnel. At inquest evidence was given from Ocean Housing, Adult care, Health and Wellbeing, Taylors of Grampound, the Police, Royal Cornwall Hospital (together with minutes of Complex planning meetings arranged by Cornwall Council on 11.11.12, 13.03.12) the extent of his complex needs and tendency to self-neglect, particularly when under the influence of alcohol. Despite being known to have complex needs his body was not found for some weeks. Those at inquest gave evidence that due to the large number of potential agencies involved in his care, his age (below 65), and the fact he had variable mental capacity due to his chronic alcoholism (no mental health diagnosis) it made it difficult for Mr Williams to know which agency provided what service and whether they were free or not . This led to agency “blindness” preventing him from accessing help/funding particularly at a time of crisis (especially when he lacked capacity due to alcoholism).
An example was given by Ocean Housing who had been involved with Mr Williams since 2011. Initially he was provided support through his tenancy which was funded by Cornwall Council supporting people budget. In 2011 the way funding was provided was changed and Mr Williams no longer qualified. An independent living service was set up in lieu which clients had to contribute towards. From this time forward Mr Williams did not engage as he had difficulty in understanding the structure. His funding was made more complicated by hospital admissions/care home placements which meant on occasions he was left without funds due to the necessary paperwork being completed – which he was unable to complete or understand on his own.
Those at inquest considered that this was not an uncommon scenario; particular when a client had both health and social issues and this was made even more difficult if they were drug and/or alcohol dependant.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuity of funding when required paperwork cannot be completed or understood independently
Wider context from the report “Mr Colin Williams was known to numerous agencies and personnel. At inquest evidence was given from Ocean Housing, Adult care, Health and Wellbeing, Taylors of Grampound, the Police, Royal Cornwall Hospital (together with minutes of Complex planning meetings arranged by Cornwall Council on 11.11.12, 13.03.12) the extent of his complex needs and tendency to self-neglect, particularly when under the influence of alcohol. Despite being known to have complex needs his body was not found for some weeks. Those at inquest gave evidence that due to the large number of potential agencies involved in his care, his age (below 65), and the fact he had variable mental capacity due to his chronic alcoholism (no mental health diagnosis) it made it difficult for Mr Williams to know which agency provided what service and whether they were free or not. This led to agency “blindness” preventing him from accessing help/funding particularly at a time of crisis (especially when he lacked capacity due to alcoholism).
An example was given by Ocean Housing who had been involved with Mr Williams since 2011. Initially he was provided support through his tenancy which was funded by Cornwall Council supporting people budget. In 2011 the way funding was provided was changed and Mr Williams no longer qualified. An independent living service was set up in lieu which clients had to contribute towards. From this time forward Mr Williams did not engage as he had difficulty in understanding the structure. His funding was made more complicated by hospital admissions/care home placements which meant on occasions he was left without funds due to the necessary paperwork being completed – which he was unable to complete or understand on his own.
Those at inquest considered that this was not an uncommon scenario; particular when a client had both health and social issues and this was made even more difficult if they were drug and/or alcohol dependant.
” Open source report
Concerns raised 5 Delays in determining patients’ mental health state View source Lack of resources for dealing with challenging and vulnerable patients View source Delays in recognising patients for whom usual discharge options are unavailable View source Lack of guidelines or protocols for discharging challenging patients View source Delays in approaching nursing homes able to accommodate patients View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William John Charles Harnell · 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 John Charles Harnell suffered a fractured left hip while attempting to mobilise from his wheelchair on 22 October 2014, remained in hospital, developed hospital-acquired pneumonia and died on 15 December 2014. Concerns included delays in recognising the difficulties surrounding his discharge, assessing his mental health, approaching suitable nursing homes, and a lack of resources and guidance for managing challenging and vulnerable patients.
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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Delays in determining patients’ mental health state
Wider context from the report “(2) There appears to have been delay in determining Mr Harnell’s state of mental health
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for dealing with challenging and vulnerable patients
Wider context from the report “(4) There appears to be a lack of resources available for dealing with challenging (and vulnerable) patients like Mr Harnell.
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising patients for whom usual discharge options are unavailable
Wider context from the report “(1) There was delay in recognising that Mr Harnell was a most challenging patient for whom the usual means of discharge would not all be available .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines or protocols for discharging challenging patients
Wider context from the report “(5) There appears to be no guideline or protocol to assist staff on how best to deal with the discharge of patients like Mr Harnell .
” 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 Cornwall Council; that does not assign responsibility.
PFD Monitor interpretation Delays in approaching nursing homes able to accommodate patients
Wider context from the report “(3) There appears to have been delay in approaching the Nursing Homes that may have been able to accommodate him .
” 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 Work with health colleagues to obtain mental health input when required in future cases.
Verbatim wording from the response “• The team in the Hospital works closely with Health colleagues to determine the appropriate care. The team will work with Health colleagues to seek mental health input as required for any future cases.” Source location william-harnell-Response
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 Remind staff to seek timely placements for people requiring them.
Verbatim wording from the response “I can confirm that we have a dedicated Social Work Service working in Derriford Hospital and that staff have been reminded of the requirements to seek timely placements for people who need such placements. The staff working in the Hospital are dedicated and committed. These cases are often complex and need careful management. In response to the matters of concern cited in the Report:” Source location william-harnell-Response
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 Maintain a dedicated hospital social work service.
Verbatim wording from the response “I can confirm that we have a dedicated Social Work Service working in Derriford Hospital and that staff have been reminded of the requirements to seek timely placements for people who need such placements. The staff working in the Hospital are dedicated and committed. These cases are often complex and need careful management. In response to the matters of concern cited in the Report:” Source location william-harnell-Response
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 Produce and disseminate guidance to assist staff managing such cases.
Verbatim wording from the response “• I note the comment about guidance to assist staff in such cases and am asking for this guidance to be produced and disseminated.” Source location william-harnell-Response
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 Robust senior management oversight is considered sufficient to prevent such delays recurring.
Verbatim wording from the response “• We acknowledge that on occasion there may be delays; however with our robust Senior Management oversight I do not expect such delays in future.” Source location william-harnell-Response
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations