8 Feb 2024 Thomas GODDERIDGE · Prevention of Future Deaths report Cumbria
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Concerns raised 2 Failure to account for variable and fluctuating capacity in capacity assessments View source Failure to maintain reliable and routine liaison with care providers about service-user capacity concerns View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Develop and circulate guidance for care providers and Adult Social Care staff on raising concerns about changes in mental capacity.
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Action
Deliver rolling mandatory Mental Capacity Act training covering carers’ observations, executive capacity, fluctuating capacity and interpersonal influence.
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Action
Produce and circulate a seven-minute fluctuating-capacity briefing for managers to deliver in team meetings and staff supervision.
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Action
Deliver recurring legal briefings every six weeks addressing fluctuating capacity.
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Action
Maintain a recurring Mental Capacity Act forum and reflective practice sessions addressing fluctuating capacity.
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AI-generated summary
Thomas GODDERIDGE · 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
Thomas Godderidge, aged 85, died from smoke inhalation after a fire broke out at his home on 16 February 2023. Concerns were raised about unreliable routine liaison between Adult Social Care and care providers when concerns arise about a service user's capacity, and about capacity assessments not consistently accounting for variable or fluctuating capacity.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumberland Council; that does not assign responsibility.
PFD Monitor interpretation Failure to account for variable and fluctuating capacity in capacity assessments
Wider context from the report “(2) Mr Godderidge's carers also reported to me that in their experience consideration of capacity by Adult Social Care does not always reflect the possibility that a person's capacity may be variable and fluctuating . I am concerned that this gives rise to a risk of future deaths if a person is considered on a 'good day' without understanding that their presentation fluctuates substantially over time .
” 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 Cumberland Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain reliable and routine liaison with care providers about service-user capacity concerns
Wider context from the report “(1) During the inquest I heard from the carers who worked with Mr Godderidge. They reported to me that when concerns are raised about a service-user's capacity there is not reliable and routine liaison between Adult Social Care and the care providers . I am concerned that this gives rise to a risk of future deaths. Care workers are very likely to see a service user more often than others. They have a particularly valuable perspective as to a person's capacity. If their observations are not being considered then opportunities to provide care to vulnerable people may well be missed.
” 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 and circulate guidance for care providers and Adult Social Care staff on raising concerns about changes in mental capacity.
Verbatim wording from the response “1. A guidance and briefing note is being developed for care providers on how to raise concerns around potential changes in a person’s mental capacity, or any other issues where Adult Social Care are the responding agency. This will be shared with all providers via the councils Adult Social Care Commissioning team. The note will also be circulated across all Adult Social Care teams for practitioner and manager awareness. The target date for completion and circulation is 29th March 2024.” Source location Response from Cumberland Council
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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 rolling mandatory Mental Capacity Act training covering carers’ observations, executive capacity, fluctuating capacity and interpersonal influence.
Verbatim wording from the response “4. A rolling programme of mandatory training regards the Mental Capacity Act is on the Training Plan and marked as ‘High Priority’. This will incorporate a specific focus around carers noting changes in presentation and how these are to be responded to. The program will also cover the main nuances such as executive capacity, fluctuating capacity and interpersonal influence on capacity. The Advanced Practice Lead team will utilise this training as the grounding from which Mental Capacity Act forums, Community of Practice forums, practice workshops” Source location Response from Cumberland Council
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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 circulate a seven-minute fluctuating-capacity briefing for managers to deliver in team meetings and staff supervision.
Verbatim wording from the response “3. The Adult Social Care Advanced Practice Lead team are producing a 7-minute briefing on fluctuating capacity for managers to deliver in team meetings and individual staff supervisions. This will remain available for continuous professional development for existing and any newly appointed staff in Adult Social Care. The target date for completion and circulation is 29th March 2024. The aim of this briefing is to raise and maintain awareness across all Adult Social Care teams, to improve practice and reduce the risk to our customer’s where fluctuating capacity is a factor in regards their care and support needs.” Source location Response from Cumberland Council
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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 recurring legal briefings every six weeks addressing fluctuating capacity.
Verbatim wording from the response “5. Adult Social Care have planned legal briefings every 6 weeks, with the last briefing on the 20th March covering the matter of fluctuating capacity.” Source location Response from Cumberland Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a recurring Mental Capacity Act forum and reflective practice sessions addressing fluctuating capacity.
Verbatim wording from the response “2. The council have a Mental Capacity Act forum in place which is open to social care and health practitioners across Adults and Childrens services. The last two forums have explored the topic of fluctuating capacity. On the 13th December 2023 the forum focused on Executive Dysfunction and was delivered by Dr Paul Russell (Consultant Clinical Psychologist), who spoke on practice experience of working with fluctuating capacity. A further forum took place on the 25th January 2024 and was a Community of Practice reflective practitioner session, with a focus on fluctuating capacity. The forum is a recurring event, providing a reflective workspace where key learning is shared, and practice is continually developed and improved.” Source location Response from Cumberland Council
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8 Jan 2024 Walter FAULDER · Prevention of Future Deaths report Cumbria
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Concerns raised 1 Risk of further accidents at a busy pedestrian crossing View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Walter FAULDER · 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
Walter Faulder, aged 88, was struck by a vehicle while crossing the A595 at Orton Grange on 13 December 2022 and was pronounced deceased at the scene. Concerns included his apparent misunderstanding of the crossing arrangements and the safety of the busy crossing point, particularly for schoolchildren and older people, with a concern that further accidents and fatalities could occur without safety alterations.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumberland Council; that does not assign responsibility.
PFD Monitor interpretation Risk of further accidents at a busy pedestrian crossing
Wider context from the report “(1) Walter seems to have believed that as a pedestrian he had right of way, he may have been a bit confused having forgotten his wallet however the day before the collision be referred to the illuminated pole in the central refuge as a Belisha Beacon.
(2) I heard that this is a busy crossing point, schoolchildren cross morning and evening for busses too and from school. There are also an increasing number of older people living in nearby developments.
(3) I am concerned that without safety alterations further accidents and possible fatalities may occur. Is there a case for lights to be installed?
” Open source report
19 May 2023 Elsie Mary MURPHY · Prevention of Future Deaths report Cumbria
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Concerns raised 1 Failure to prevent water pooling on the path at the base of the steps View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Install additional drainage to prevent standing water in the area.
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AI-generated summary
Elsie Mary MURPHY · 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
Elsie Mary MURPHY slipped in a puddle on a footpath in Maryport on 27 September 2022, fell, and died in Cumberland Infirmary the following day from a fatal injury. The concern was that a puddle regularly formed at the location because water appeared to discharge onto the path, creating a risk of further accidents.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumberland Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent water pooling on the path at the base of the steps
Wider context from the report “(1) Evidence has heard that a puddle always forms at this location in wet weather and that people have slipped here in the past . Pictures taken on the evening Elsie fell were accepted in evidence and are attached. It seems that a drain or soak away from under Ewanrigg Road discharges down the grassy bank to the left of the steps looking up them and pools on the path . There is a drain on the right hand side of the path a few feet from the base of the steps but water does not seem to reach it . I am concerned that if this issue is not addressed by some remedial work further accidents will occur
” 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 Install additional drainage to prevent standing water in the area.
Verbatim wording from the response “With this in mind, the Highways Department had commenced work to install additional drainage in this area to further prevent standing water. Subsequent to that work commencing, information was received from United Utilities and it would appear that their water/sewerage systems may have been defective and contributed to the standing water. United Utilities have confirmed it has now been repaired and is currently being monitored by them. Should the problem reappear, we will take further action as required.” Source location Response from Cumberland Council
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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 United Utilities is responsible for the defective water and sewerage systems contributing to standing water and has repaired and is monitoring them.
Verbatim wording from the response “With this in mind, the Highways Department had commenced work to install additional drainage in this area to further prevent standing water. Subsequent to that work commencing, information was received from United Utilities and it would appear that their water/sewerage systems may have been defective and contributed to the standing water. United Utilities have confirmed it has now been repaired and is currently being monitored by them. Should the problem reappear, we will take further action as required.” Source location Response from Cumberland Council
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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 does not inspect or maintain the land, paths or steps because they are not Council structures or areas within its inspection responsibility.
Verbatim wording from the response “• None of the area in or around the immediate area of the incident is inspected by Cumberland Council as Highway Authority.” Source location Response from Cumberland Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations