22 Jan 2026 Tamara Jade Logan · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to adapt benefits correspondence to recognised vulnerabilities View source Failure of benefits assessment checking to identify errors 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
Tamara Jade Logan · 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
Tamara Jade Logan had a history of self-harm and suicidal ideation. After her enhanced daily living allowance was incorrectly withdrawn and she received a standard letter about the decision, her mental health deteriorated; she was found suspended on 18 May 2025 and died in hospital on 20 May 2025. The substantive concerns were the incorrect benefits assessment and the failure to adapt communication to her known vulnerabilities.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to adapt benefits correspondence to recognised vulnerabilities
Wider context from the report “2. It was clear from the evidence that her vulnerabilities were recognised by the Department of Work and Pensions and their paperwork was flagged to that effect . Despite that a standard letter was sent with no attempt to reduce the risk that receipt of the letter would cause .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of benefits assessment checking to identify errors
Wider context from the report “1.It was accepted that the assessment of her entitlement to benefits had been incorrectly determined despite it having been checked before the final decision was made. The impact of that on her was very significant. The evidence before the inquest was that the person carrying out the initial assessment carried out the assessment correctly and that the checking process had not picked up on the errors . The purpose of the check was to avoid these errors being made and it was unclear why it had not picked up on the incorrect approach
” 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 Introduce a PIP-system prompt to consider Additional Support whenever the PIP2 timer is extended.
Verbatim wording from the response “Reinforce the importance of considering Additional Support. | Introduce a ‘pop up’ message on the PIP computer system to consider Additional Support whenever the PIP2 timer is extended. Instructions will be updated to coincide with the update. | Formal change request submitted to Digital. | Awaiting implementation date” Source location 2026-0035 - Response from Department for Work and Pensions
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 inactive Advanced Customer Support marker process and update instructions and communications as needed.
Verbatim wording from the response “Reinforce the importance of considering inactive Advanced Customer Support markers. | Review the inactive Advanced Customer Support marker process and communicate to PIP colleagues that, even when an Advanced Customer Support concern is marked as inactive, the vulnerability identified at the time must still be considered. | At ‘Proof of Concept’ stage. | Process review and any updates to instructions scheduled for completion in Q3 2026” Source location 2026-0035 - Response from Department for Work and Pensions
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 Initial Review processes and conformity.
Verbatim wording from the response “The quality of the assessment provider report was not to the standard we would expect and the descriptor advice not fully justified. | Identify learning opportunities with the Assessment Provider and implement an action plan for improvement, with a commitment to share learning across all Assessment Providers to support system-wide learning. | The Assessment Provider has identified a set of recommendations for improvement with a corresponding action plan for implementation.” Source location 2026-0035 - Response from Department for Work and Pensions
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 Circulate a Disability Services memorandum stressing the importance of gathering all available evidence before decisions.
Verbatim wording from the response “The decision to reduce Ms Logan’s benefits may have been unjustified on the evidence DWP had available | Circulate a memorandum across Disability Services to focus on the importance of gathering all of the evidence available before making a decision. | Complete; resource stored centrally for accessibility. | February 2026” Source location 2026-0035 - Response from Department for Work and Pensions
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 Run a VOCAL event using an anonymised case to reinforce considering all evidence and gathering information to resolve inconsistencies.
Verbatim wording from the response “Utilise existing processes to feed back learning from this case to case managers.” Source location 2026-0035 - Response from Department for Work and Pensions
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 Introduce a mandatory notes field requiring Case Managers to explain changes to Additional Support markers.
Verbatim wording from the response “Make it easier for Case Managers to understand why changes have been made to someone’s Additional Support marker. | Introduce a mandatory notes field on the PIP computer system when the Additional Support marker is amended to explain why the change has been made. The case manager will be unable to close the action until a note is added. | Formal change request submitted to Digital. | Awaiting implementation date” Source location 2026-0035 - Response from Department for Work and Pensions
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 Advanced Customer Support and Additional Support instructions for gaps or possible misinterpretation.
Verbatim wording from the response “Instructions on Advanced Customer Support and Additional Support concerns must be clear and robust. | Review the Advanced Customer Support and Additional Support instructions to ensure they are fit for purpose and there are no gaps or parts that could be open to misinterpretation. | Review complete.
The instructions were reviewed and determined to be robust. The department then looked to see what further improvements could be made leading to:” Source location 2026-0035 - Response from Department for Work and Pensions
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 Introduce the Customer Support Information hub as a consolidated reference point for vulnerable-person guidance and support materials.
Verbatim wording from the response “Instructions relating to supporting vulnerable people are held across various parts of the department’s intranet. | Introduce the Customer Support Information hub, a consolidated reference point for all relevant guidance and support materials for vulnerable people. | Complete. | March 2026” Source location 2026-0035 - Response from Department for Work and Pensions
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 updated clinical guidance and targeted learning to Health Professionals on probing depth and accurate descriptor rationale.
Verbatim wording from the response “The quality of the assessment provider report was not to the standard we would expect and the descriptor advice not fully justified. | Identify learning opportunities with the Assessment Provider and implement an action plan for improvement, with a commitment to share learning across all Assessment Providers to support system-wide learning. | The Assessment Provider has identified a set of recommendations for improvement with a corresponding action plan for implementation.” Source location 2026-0035 - Response from Department for Work and Pensions
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 Run an adverse decision-making test-and-learn exercise to improve Case Manager capability in evidence assessment.
Verbatim wording from the response “Improve capability of case managers to assess evidence to make independent reduction or disallowance decisions where appropriate. | Adverse decision-making test and learn exercise. | At ‘Proof of Concept’ stage; a mandatory call to the person claiming the benefit at an earlier stage of the decision-making process already implemented. | Proof of Concept stage scheduled for completion in Q2 2026” Source location 2026-0035 - Response from Department for Work and Pensions
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a systems-based follow-up to identify relevant contributory or system factors.
Verbatim wording from the response “The quality of the assessment provider report was not to the standard we would expect and the descriptor advice not fully justified. | Identify learning opportunities with the Assessment Provider and implement an action plan for improvement, with a commitment to share learning across all Assessment Providers to support system-wide learning. | The Assessment Provider has identified a set of recommendations for improvement with a corresponding action plan for implementation.” Source location 2026-0035 - Response from Department for Work and Pensions
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 an earlier mandatory call to benefit claimants during adverse decision-making.
Verbatim wording from the response “Improve capability of case managers to assess evidence to make independent reduction or disallowance decisions where appropriate. | Adverse decision-making test and learn exercise. | At ‘Proof of Concept’ stage; a mandatory call to the person claiming the benefit at an earlier stage of the decision-making process already implemented. | Proof of Concept stage scheduled for completion in Q2 2026” Source location 2026-0035 - Response from Department for Work and Pensions
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 Run recurring Voice of the Customer Active Learning events using case studies to address consequences of unaddressed vulnerabilities.
Verbatim wording from the response “Reinforce the importance of considering Additional Support and Advanced Customer Support. | Run Voice of the Customer: Active Learning (“VOCAL”) events utilising case studies to discuss the consequences of not addressing identified vulnerabilities. | Ongoing. | VOCAL events occur every 2 months (not all will focus on Additional Support and Advanced Customer Support)” Source location 2026-0035 - Response from Department for Work and Pensions
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 enhanced nil process to consider including benefit reductions.
Verbatim wording from the response “Consider introducing a process to provide Advanced Customer Support where a PIP award is reduced but not stopped. | Review the enhanced to nil process to consider including award reductions. | At data gather stage to understand the volume of cases that may be affected. | Process review and implementation of any improvements scheduled for completion in Q2 2026” Source location 2026-0035 - Response from Department for Work and Pensions
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 reflective learning to auditors on grading thresholds and identifying omissions requiring amendments or learning.
Verbatim wording from the response “The quality of the assessment provider report was not to the standard we would expect and the descriptor advice not fully justified. | Identify learning opportunities with the Assessment Provider and implement an action plan for improvement, with a commitment to share learning across all Assessment Providers to support system-wide learning. | The Assessment Provider has identified a set of recommendations for improvement with a corresponding action plan for implementation.” Source location 2026-0035 - Response from Department for Work and Pensions
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 Formal decision letters must continue because they are required; alternative communications can only supplement them, not replace them.
Verbatim wording from the response “You referred in your concern to the fact that a “standard letter” was sent to Ms Logan. The letter was one sent whenever a DWP decision changes the amount of benefit someone receives. Such letters are system generated and so go out automatically, in one of a number of alternative formats that can be requested by someone who needs specific adjustments to help them manage their claim. They are the formal notification of the decision to the person receiving the benefit, which is required regardless of any other communication of it that may be made. They also formally notify someone of their mandatory reconsideration and appeal rights. Any other communication methods that DWP uses, or might consider using in the future, would be as well as, rather than instead of, letters like the one sent to Ms Logan.” Source location 2026-0035 - Response from Department for Work and Pensions
Open published response
5 Dec 2025 Leonardo Cardoso Machado · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Children working alone at night delivering to private homes View source Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles View source Lack of oversight of the rental of food delivery licences to children under 18 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
Leonardo Cardoso Machado · 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
Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle while travelling at speed and colliding with metal railings. The report raised concerns about limited oversight of rented food delivery licences being provided to children under 18, and the resulting risks of lone night work and road traffic collisions.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Children working alone at night delivering to private homes
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position ;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of the rental of food delivery licences to children under 18
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit . This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age , which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” Open source report
Concerns raised 5 Failure to procure interpreting services through agencies specialising in British Sign Language View source Lack of availability of British Sign Language qualifications and training View source Failure to recruit and retain sufficient BSL-proficient clinicians View source Lack of statutory regulation for British Sign Language interpreters View source Lack of British Sign Language interpreters available to support deaf mental health 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Imogen Alice NUNN · 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
Imogen Alice Nunn died at home on 1 January 2023 after consuming a substance she had obtained approximately six weeks earlier, during a period of deteriorating mental health. The report raises concerns about failures in mental-health risk management and the shortage of British Sign Language interpreters and BSL-proficient clinicians supporting deaf 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to procure interpreting services through agencies specialising in British Sign Language
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of British Sign Language qualifications and training
Wider context from the report “3. Matter for the Department of Education.
Evidence was heard that the lack of BSL interpreters was in part due to the lack of availability of BSL qualifications and training .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit and retain sufficient BSL-proficient clinicians
Wider context from the report “2. Department of Health and Social Care
Evidence indicates that clinicians who are fluent in British Sign Language (BSL) provide a significantly better experience for deaf patients compared to non-BSL - speaking clinicians relying solely on interpreters.
The NHS England response to the earlier Prevention of Future Deaths (PFD) report outlined the role of Integrated Care Boards (ICBs) in commissioning interpreting services for NHS Trusts. However, there is a clear shortage of BSL-proficient clinicians , and insufficient efforts are being made to recruit and retain these professionals . This gap is failing to meet the needs of deaf individuals.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory regulation for British Sign Language interpreters
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of British Sign Language interpreters available to support deaf mental health patients
Wider context from the report “It was issued before the Inquest had concluded as it had already become apparent that there was a real lack of British Sign Language Interpreters (BSLs) able to help support Deaf patients in the community who were being treated with mental health difficulties . This was putting this cohort of individuals at risk . The overall lack of British Sign Language Interpreters was also evidenced directly by the Court in that this Inquest has had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf/mute witnesses over the two week period of the Inquest.
” Open source report
3 Feb 2025 Afolabi Oluwafemi OJERINDE · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Failure of petrol stations and available guidance to ensure compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014 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
Afolabi Oluwafemi OJERINDE · 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
Afolabi Oluwafemi OJERINDE attended a petrol station, dispensed petrol into a plastic water bottle, ignited it and placed himself in the fire. He died at hospital from injuries sustained during the incident. The concern was that the petrol station’s controls did not ensure compliance with regulations governing the dispensing of petrol into suitable containers and to eligible persons.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of petrol stations and available guidance to ensure compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014
Wider context from the report “I am concerned about the safety of ████████ petrol stations and how they do not ensure compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014 .
When comparing this to ████████ petrol stations, ████████ ensuring that the individual is:
seeking to dispense petrol into a motor vehicle or motor boat; seeking to dispense petrol into a suitable portable container; over the age of 16.
The evidence at the Inquest from the companies that operated the site and provided security accepted that the guidance available for ████████ petrol stations do not and cannot ensure compliance with the 2014 Regulations .
” Open source report
19 Nov 2024 Richard William Brookes · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of effective audit of the large payments caseload for record-keeping failures View source Lack of robust assessments and checks before large payments to vulnerable adults View source Failure to record the full content of calls before initiating payments View source Inability to evaluate whether repayment agreements consider relevant vulnerabilities before large payments View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard William Brookes · 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
Richard William Brookes died on 25 January 2024 after intentionally stepping into the path of an approaching train, following a period of mental health crisis and paranoid thoughts. The report raises concerns about the handling of large arrears payments to vulnerable adults, including inadequate records of assessment calls and insufficient ability to audit whether vulnerability-related safeguards were properly considered.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of effective audit of the large payments caseload for record-keeping failures
Wider context from the report “4. I am also concerned that the DWP currently has no ability to effectively audit its large payments caseload to ascertain whether the failure in record keeping evident in the present case has occurred in other cases .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of robust assessments and checks before large payments to vulnerable adults
Wider context from the report “1. This was a large payment of money to a vulnerable adult who was then required to self-manage that money. In these situations, it is important that there are robust systems in place for ensuring that the requisite assessments and checks are made of an individual to ensure that large payments can be made in a way that does not increase any vulnerability .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to record the full content of calls before initiating payments
Wider context from the report “2. I heard evidence from ████████ that the DWP systems that are currently in place are hybrid of electronic and clerical systems and that payments can be initiated without there being a full note on the system of the content of the call with the individual .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Inability to evaluate whether repayment agreements consider relevant vulnerabilities before large payments
Wider context from the report “3. I am therefore concerned that there is no way that an agent, quality assessor or team leader can properly evaluate whether any agreement made between the DWP and an individual regarding repayment has fully considered all the relevant factors regarding their vulnerabilities before a large payment is made .
” 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 Review the Making Large Payments guidance to mandate recording calls, agreements and related documents in DWP systems and the digital repository.
Verbatim wording from the response “Existing guidance does not expressly state that recording notes of calls with customers on computer systems is mandatory, although training packages and upskilling communications do include the need to do this. The department is reviewing the Making Large Payments guidance within Working Age, with a view to mandating that any calls made, and any agreements reached, be recorded on the DWP systems, and that any related documents are stored in the digital repository. The department is also designing a letter to be issued to customers who have requested or agreed a staggered payment.” Source location Response from Department of Work and Pensions
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 Revise specialist-team clerical forms and apply Team Leader and separate quality-assurance checks to verify vulnerability assessment, customer contact, records, payment decisions and calculations.
Verbatim wording from the response “As a result of the issues identified in Mr Brookes’ case, activity has taken place within that specialist team to improve compliance with the Making Large Payments guidance. Clerical forms have been revised to prompt agents to:” Source location Response from Department of Work and Pensions
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 Circulated an upskilling communication to Working Age colleagues reinforcing large-payment vulnerability checks and recording requirements.
Verbatim wording from the response “As part of the learning the department has taken from Mr Brookes’ case, an upskilling communication has been circulated to all colleagues within Working Age to remind them of the correct process to follow when making large payments. This includes the requirement to consider the size of the payments and the importance of recording conversations with customers.” Source location Response from Department of Work and Pensions
Open published response
Concerns raised 5 Failure to act on requests to direct communication through a nominated person View source Failure to adjust communication for vulnerable customers View source Failure to record vital information about vulnerable customers View source Failure to proactively assess the need to direct communication through someone else for vulnerable customers View source Lack of training, upskilling and knowledge refresh for DWP operatives View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 11
Action
Deliver Performance Management training to all 170 team members, focusing on sharing vulnerability information and using the Additional Support tab.
Stated plannedThe respondent said that this action was planned when they made their response on 21 February 2024. View source
Action
Conduct an end-to-end review of the appointee process, including digital solutions, legislative changes, guidance, colleague capability and review timescales.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024. View source
Action
Implement Customer Support Standards across DWP service lines and embed them in two-tier quality assurance processes.
Stated completedThe respondent said that this action was complete when they made their response on 21 February 2024. View source
Action
Conduct insight sessions and workshops, and develop a prototype for an improved Additional Support tab.
Stated completedThe respondent said that this action was complete when they made their response on 21 February 2024. View source
Action
Run an Additional Support tab awareness campaign with refreshed guidance, colleague training and effectiveness assessment.
Stated plannedThe respondent said that this action was planned when they made their response on 21 February 2024. View source
Action
Finalise and launch an improved Additional Support tab based on colleague and customer feedback.
Stated plannedThe respondent said that this action was planned when they made their response on 21 February 2024. View source
Action
Undertake customer research to shape amendments to the Additional Support tab.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024. View source
Action
Deliver Complex Needs training to the entire service delivery team.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024. View source
Action
Add a Universal Credit account banner displaying recorded explicit consent and its currency.
Stated completedThe respondent said that this action was complete when they made their response on 21 February 2024. View source
Action
Update and disseminate consent and disclosure guidance to permit explicit-consent review periods of up to six months where appropriate.
Stated completedThe respondent said that this action was complete when they made their response on 21 February 2024. View source
Action
Deliver an explicit consent information campaign, including intranet dissemination, training videos, colleague training and effectiveness assessment.
Stated completedThe respondent said that this action was complete when they made their response on 21 February 2024. View source See 8 more actions
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AI-generated summary
Nazerine Frances Anderson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nazerine Frances Anderson had a deterioration in her mental health following a Department for Work and Pensions performance review and took a paracetamol overdose on 17 May 2023. She later developed irreversible liver damage and died on 19 June 2023. The report raised concerns about missed opportunities to record her vulnerability, failures to direct communications through her daughter, and the training of DWP staff in supporting vulnerable individuals.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to act on requests to direct communication through a nominated person
Wider context from the report “2. The failure to act upon a simple request for the DWP to direct communication through Naz’s daughter . This was a simple request and had been renewed by Naz during telephone calls and journal entries to the DWP. The request which had been made in writing by Naz’s daughter sat in another DWP computer system for a period of 4 months but even when uploaded to the main DWP computer system was not acted upon . In addition to the active requests of Naz and her daughter being overlooked, DWP staff did not proactively consider the need for communication to be directed to someone else to safeguard Naz, given her obvious vulnerability.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to adjust communication for vulnerable customers
Wider context from the report “1. Despite the DWP case workers and call handlers having the availability of an additional support tab on a profile of a customer on the DWP computer system; there were 6 missed opportunities to use this facility to record vital information about Naz’s vulnerability; despite Naz being tearful and distressed on the telephone on more than one occasion and advising the DWP of information surrounding her mental health and her inability to cope. This meant there was no alert to DWP staff of Naz’s vulnerability and consequently no adjustment to how communication was made with Naz . The trigger for mental health decline and Adjustment Disorder continued.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to record vital information about vulnerable customers
Wider context from the report “1. Despite the DWP case workers and call handlers having the availability of an additional support tab on a profile of a customer on the DWP computer system; there were 6 missed opportunities to use this facility to record vital information about Naz’s vulnerability ; despite Naz being tearful and distressed on the telephone on more than one occasion and advising the DWP of information surrounding her mental health and her inability to cope. This meant there was no alert to DWP staff of Naz’s vulnerability and consequently no adjustment to how communication was made with Naz. The trigger for mental health decline and Adjustment Disorder continued.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively assess the need to direct communication through someone else for vulnerable customers
Wider context from the report “2. The failure to act upon a simple request for the DWP to direct communication through Naz’s daughter. This was a simple request and had been renewed by Naz during telephone calls and journal entries to the DWP. The request which had been made in writing by Naz’s daughter sat in another DWP computer system for a period of 4 months but even when uploaded to the main DWP computer system was not acted upon. In addition to the active requests of Naz and her daughter being overlooked, DWP staff did not proactively consider the need for communication to be directed to someone else to safeguard Naz, given her obvious vulnerability .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of training, upskilling and knowledge refresh for DWP operatives
Wider context from the report “3. I heard evidence from the DWP of plans to introduce a number of changes. What I did not hear was evidence about how DWP operatives were going to be trained, upskilled and refreshed in their knowledge (given the toolkit already available to them) to ensure the issues identified at 1 and 2 above aren’t repeated with other vulnerable individuals.
” 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 Deliver Performance Management training to all 170 team members, focusing on sharing vulnerability information and using the Additional Support tab.
Verbatim wording from the response “information remains secure. However, as a result of this, some colleagues cannot pin information to claims or use the additional support function on the UC system. To counteract this, Performance Management team colleagues will be delivering sessions to all 170 members of the team by the end of June 2024, which will promote awareness and improve understanding of dealing with vulnerable customers. This will provide colleagues with learning that they can apply to different scenarios. There will be a focus on the importance of prioritising sharing information relating to a customer’s vulnerabilities with UC colleagues to allow them to complete the additional support tab. Colleagues who worked on Ms Anderson’s case will take part in planned upskilling sessions.” Source location Response from Department for Work and Pensions
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 Conduct an end-to-end review of the appointee process, including digital solutions, legislative changes, guidance, colleague capability and review timescales.
Verbatim wording from the response “Customers who require an appointee are naturally considered to be vulnerable, and whilst DWP has taken significant steps since 2018 to improve colleagues’ ability to understand the wide range of mental health issues that benefit customers may face, there is more work being undertaken.” Source location Response from Department for Work and Pensions
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 Customer Support Standards across DWP service lines and embed them in two-tier quality assurance processes.
Verbatim wording from the response “Aside from large scale upskilling campaigns, the department has robust quality assurance processes to ensure colleagues are adhering to DWP’s Quality Framework. The newly developed Customer Support Standards were designed specifically to improve the experience of customers with complex needs and significantly reduce instances of serious cases by providing the right support at the right time. The four Customer Support Standards are;” Source location Response from Department for Work and Pensions
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 Conduct insight sessions and workshops, and develop a prototype for an improved Additional Support tab.
Verbatim wording from the response “To investigate how to increase UC colleagues’ use of the additional support function, DWP conducted user research between July and September 2023. Insight sessions were held with UC colleagues to explore what they understood about the concept of additional support and how it relates to a customer’s additional support needs. Following these insight sessions, workshops were conducted between December 2023 and January 2024 with stakeholders from different business areas within DWP (for example colleagues from telephony, Customer Experience, Quality Assurance and product managers) to develop an improved and more comprehensive approach regarding the purpose of the additional support tab.” Source location Response from Department for Work and Pensions
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 Run an Additional Support tab awareness campaign with refreshed guidance, colleague training and effectiveness assessment.
Verbatim wording from the response “A campaign to promote awareness and understanding of the additional support tab amongst UC colleagues is planned for the second half of 2024. This campaign will include upskilling on refreshed guidance and training sessions for colleagues on the additional support tab. It is intended that this will translate to an increase in the use of the additional support function. As with all colleague training, the package will be followed by an assessment to ensure that the training has been effective in improving colleague understanding of the additional support function, and when it should be used. Colleagues who worked on Ms Anderson’s case will take part in the additional support tab awareness campaign.” Source location Response from Department for Work and Pensions
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 Finalise and launch an improved Additional Support tab based on colleague and customer feedback.
Verbatim wording from the response “As a result of the insight sessions and the workshops, the UC design team developed a prototype of what the improved additional support tab would look like. Plans to finalise and launch this improved additional support tab are a priority for the UC design team. User research is now being undertaken with UC customers to gather feedback to shape future amendments to the additional support tab.” Source location Response from Department for Work and Pensions
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 customer research to shape amendments to the Additional Support tab.
Verbatim wording from the response “As a result of the insight sessions and the workshops, the UC design team developed a prototype of what the improved additional support tab would look like. Plans to finalise and launch this improved additional support tab are a priority for the UC design team. User research is now being undertaken with UC customers to gather feedback to shape future amendments to the additional support tab.” Source location Response from Department for Work and Pensions
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 Deliver Complex Needs training to the entire service delivery team.
Verbatim wording from the response “DWP has also launched Complex Needs training events which encourage participants to reflect on tailored customer service. It consists of two versions: one for customer-facing colleagues and another for leaders driving a customer focused experience. These events are different to others as delegates are encouraged to view the customer journey through the lens of the customer, highlighting the potential consequences of getting this wrong, as well as the positive impact of getting it right.” Source location Response from Department for Work and Pensions
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 Add a Universal Credit account banner displaying recorded explicit consent and its currency.
Verbatim wording from the response “In December 2023, the UC computer system was updated to include a banner which displays on a customer’s account when explicit consent is recorded. This immediately identifies that there is explicit consent given by a customer and allows colleagues to see what consent has been given and whether it is current. To support this, an explicit consent information campaign was launched on DWP’s intranet and broadcast to all colleagues working in UC. The campaign clearly explained what explicit consent is and how to record this consent on the UC system and was accompanied by training videos. Training events have been delivered to UC colleagues detailing how to record explicit consent actions to alert other colleagues dealing with the claim. As with all training, this has involved an assessment component to ensure that the training has been effective.” Source location Response from Department for Work and Pensions
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 Update and disseminate consent and disclosure guidance to permit explicit-consent review periods of up to six months where appropriate.
Verbatim wording from the response “The consent and disclosure guidance was most recently updated in January 2024 to allow UC colleagues to extend the review period on explicit consent up to six months where appropriate (for example, where someone is supporting a customer with an appeal which is expected to take longer than one month). Guidance previously advised colleagues to review explicit consent every month, but the department recognised this was not always the best approach and made the amendment. This change was cascaded through DWP communication channels.” Source location Response from Department for Work and Pensions
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 Deliver an explicit consent information campaign, including intranet dissemination, training videos, colleague training and effectiveness assessment.
Verbatim wording from the response “In December 2023, the UC computer system was updated to include a banner which displays on a customer’s account when explicit consent is recorded. This immediately identifies that there is explicit consent given by a customer and allows colleagues to see what consent has been given and whether it is current. To support this, an explicit consent information campaign was launched on DWP’s intranet and broadcast to all colleagues working in UC. The campaign clearly explained what explicit consent is and how to record this consent on the UC system and was accompanied by training videos. Training events have been delivered to UC colleagues detailing how to record explicit consent actions to alert other colleagues dealing with the claim. As with all training, this has involved an assessment component to ensure that the training has been effective.” Source location Response from Department for Work and Pensions
Open published response
6 Nov 2023 KEVIN CONRAD GALE · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 4 Delays in telephone access to DWP advisors View source Unavailability of help for applicants with mental health illness to complete DWP paperwork View source Excessive number and length of DWP forms for applicants with mental health illness View source Long travel distances for DWP appointments for people with mental health illness View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
KEVIN CONRAD GALE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Kevin Conrad Gale died at home on 4 March 2022; the inquest concluded that his death was suicide following deliberate self-suspension. He had a history of severe depression and anxiety and remained anxious about his Universal Credit application. The report raised concerns that DWP procedures, including lengthy forms, telephone queues and travel requirements, may be impractical or exacerbate symptoms for people with mental health illness.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Delays in telephone access to DWP advisors
Wider context from the report “Current DWP procedures may not be practical for those with mental health illness and can exacerbate symptoms. I heard evidence that:
1. The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness. This is perpetuated if the applicant cannot get help to complete the paperwork.
2. There are long telephone queues to speak to a DWP advisor .
3. Having to travel long distances for appointments can be detrimental for those with a mental health illness.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Unavailability of help for applicants with mental health illness to complete DWP paperwork
Wider context from the report “Current DWP procedures may not be practical for those with mental health illness and can exacerbate symptoms. I heard evidence that:
1. The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness. This is perpetuated if the applicant cannot get help to complete the paperwork .
2. There are long telephone queues to speak to a DWP advisor.
3. Having to travel long distances for appointments can be detrimental for those with a mental health illness.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Excessive number and length of DWP forms for applicants with mental health illness
Wider context from the report “Current DWP procedures may not be practical for those with mental health illness and can exacerbate symptoms. I heard evidence that:
1. The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness . This is perpetuated if the applicant cannot get help to complete the paperwork.
2. There are long telephone queues to speak to a DWP advisor.
3. Having to travel long distances for appointments can be detrimental for those with a mental health illness.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Long travel distances for DWP appointments for people with mental health illness
Wider context from the report “Current DWP procedures may not be practical for those with mental health illness and can exacerbate symptoms. I heard evidence that:
1. The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness. This is perpetuated if the applicant cannot get help to complete the paperwork.
2. There are long telephone queues to speak to a DWP advisor.
3. Having to travel long distances for appointments can be detrimental for those with a mental health illness .
” 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 Continue developing clearer and more accessible customer communications through a central improvement, quality-assurance and stakeholder-testing programme.
Verbatim wording from the response “Improving form design” Source location Response from Deparment for Work and Pensions
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 reasonable adjustments including alternative communications, email, visiting support, staff guidance, interpretation and flexible face-to-face interviews.
Verbatim wording from the response “Additionally, DWP has in place a wide range of reasonable adjustments for customers, including:” Source location Response from Deparment for Work and Pensions
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 Introduce online journal messaging to reduce the need for Universal Credit claimants to travel to jobcentres.
Verbatim wording from the response “3. “Having to travel long distances for appointments can be detrimental for those with a mental health illness.”” Source location Response from Deparment for Work and Pensions
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 Use a guided online Universal Credit application that prompts claimants only for necessary information.
Verbatim wording from the response “Collecting personal data from claimants is an essential part of any benefit claim, but DWP strives to make the process as straightforward as possible for its customers. Mr Gale claimed Universal Credit (“UC”), a benefit that DWP has developed primarily as an online service. When someone applies for UC online, the IT system will guide them through the questions required to complete their claim and prompt them only to provide necessary information. This enables a far more streamlined data collection process compared with traditional paper-based forms.” Source location Response from Deparment for Work and Pensions
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 complex-needs toolkits in every jobcentre, linking staff and claimants to appropriate local support organisations.
Verbatim wording from the response “Additional support for customers with complex needs” Source location Response from Deparment for Work and Pensions
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 online claims, telephone support, face-to-face assistance and visiting services are considered sufficient for claimants needing help with applications.
Verbatim wording from the response “Collecting personal data from claimants is an essential part of any benefit claim, but DWP strives to make the process as straightforward as possible for its customers. Mr Gale claimed Universal Credit (“UC”), a benefit that DWP has developed primarily as an online service. When someone applies for UC online, the IT system will guide them through the questions required to complete their claim and prompt them only to provide necessary information. This enables a far more streamlined data collection process compared with traditional paper-based forms.” Source location Response from Deparment for Work and Pensions
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 concern about long telephone queues is disputed because most Universal Credit enquiry calls are answered within minutes, despite variable waiting times.
Verbatim wording from the response “Times taken to answer calls across benefit lines can vary and are influenced by a number of factors. DWP aims to forecast demand on its inbound enquiry lines and balance resources so that more people are available to answer calls at times of peak demand than during quieter periods. Such forecasting cannot be an exact science, however, and unplanned events such as technical issues or labour market instabilities can increase demand with a knock-on effect on wait times.” Source location Response from Deparment for Work and Pensions
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 Online journal messaging, telephone options and flexible appointment arrangements are considered sufficient to reduce detrimental travel for claimants with mental health conditions.
Verbatim wording from the response “• A flexible approach to mandatory face-to-face interviews within a jobcentre (and I cover travelling to appointments in more detail below).” Source location Response from Deparment for Work and Pensions
Open published response
30 Dec 2022 Malcolm James BASTEN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of mandatory accredited health and safety training for principal contractors before project engagement View source Lack of mandatory accredited health and safety training for principal contractors after a project incident View source Lack of mandatory HSE notification of projects undertaken by principal contractors after an incident View source Lack of mandatory statutory agency inspection during construction View source Lack of mandatory notification of construction work to a statutory agency 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
Malcolm James BASTEN · 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
Malcolm James Basten died after sustaining head and chest injuries in a fall while working at height on a construction site. The report identified inadequate safeguards, including no edge protection, incomplete boarding, no safe internal access, and an unsecured scaffold ladder. Concerns also included the absence of required notification and inspection for this project and no mandatory accredited health and safety training requirements for principal contractors.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory accredited health and safety training for principal contractors before project engagement
Wider context from the report “2. There is no mandatory requirement for the principal contractor to undertake health and safety training from an accredited organisation before engaging in this type of project .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory accredited health and safety training for principal contractors after a project incident
Wider context from the report “3. There is no mandatory requirement for principal contractors to undertake health and safety training from an accredited organisation after an incident such as this has occurred on one of their projects , nor to notify the HSE of any projects they undertake thereafter.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory HSE notification of projects undertaken by principal contractors after an incident
Wider context from the report “3. There is no mandatory requirement for principal contractors to undertake health and safety training from an accredited organisation after an incident such as this has occurred on one of their projects, nor to notify the HSE of any projects they undertake thereafter .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory statutory agency inspection during construction
Wider context from the report “1. This was a sizable project with considerable work at height. No statutory agency was required to be notified of the work and then inspect the project during the construction .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory notification of construction work to a statutory agency
Wider context from the report “1. This was a sizable project with considerable work at height. No statutory agency was required to be notified of the work and then inspect the project during the construction.
” Open source report
4 Jan 2022 Sylvia Frances PRICE · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Lack of an enforceable requirement for appropriate signage identifying accessible toilet facilities in public access buildings 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
Sylvia Frances PRICE · 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
Sylvia Frances Price died after falling down stairs while using toilet facilities at Ufford Park Hotel and Spa, sustaining cerebral haemorrhages and spinal injuries. She later developed aspiration pneumonia while being treated in hospital, which was recorded as the medical cause of death. The report identified inadequate signage for an accessible toilet as a contributing factor and expressed concern that similar deaths could occur because such signage was not required or enforceable.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of an enforceable requirement for appropriate signage identifying accessible toilet facilities in public access buildings
Wider context from the report “Evidence was heard that Sylvia had underlying medical issues that required an easily accessible toilet facility.
The jury concluded that the lack of appropriate signage, to readily identify an easily accessible toilet facility , was a directly contributory factor leading to Sylvia’s death.
The Local Authority Food and Safety Officer who investigated this case identified no other contributing factors, with the stairs themselves meeting building and safety regulations.
The officers report contained only one recommendation for the premises owner, which was the provision of more adequate signage.
However, the officer stated in evidence that there was no statutory power to enforce the provision of such signage , and should a premises owner wish to ignore such a recommendation, they could (it is acknowledged that the premise owner in this case has put new signage in place). In addition, current building regulations do not require any such signage to be fitted into new buildings .
The court was informed that the provision of accessible toilet facilities is now a legal requirement for the majority of buildings designed for public use, but as detailed above there is no requirement for these facilities to be clearly identified with appropriate signage .
As a failure to provide adequate signage was found to be a contributing factor in this case, and there is no enforceable requirement that such signage should be provided , I am concerned further deaths may occur in other public access buildings, should similar circumstances arise in the future.
” Open source report
3 Dec 2021 TERENCE TALBOT · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 7 Lack of formal mental capacity assessments for treatment decisions View source Lack of regular dietitian input for malnutrition View source Lack of application of emollients for severe exfoliative dermatitis View source Requirement for severely ill inpatients to attend benefit offices in person View source Inadequate provision of food and fluid to meet patient needs View source Failure of multidisciplinary meetings to focus on treatment needs View source Lack of specialist dermatology review for severe exfoliative dermatitis View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
TERENCE TALBOT · 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
Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of formal mental capacity assessments for treatment decisions
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of regular dietitian input for malnutrition
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of application of emollients for severe exfoliative dermatitis
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients . Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Requirement for severely ill inpatients to attend benefit offices in person
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim . I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Inadequate provision of food and fluid to meet patient needs
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of multidisciplinary meetings to focus on treatment needs
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist dermatology review for severe exfoliative dermatitis
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Trigger alternative identity-verification processes when a claimant indicates they are in hospital.
Verbatim wording from the response “Where a claimant is unable to verify their ID online, they are no longer automatically directed to contact the UC helpline to book an appointment. Jobcentre agents are now responsible for booking all ID appointments. In the majority of cases, claimants will now be booked a biographical check by phone. Jobcentre agents have full access to the claimant’s account, including all answers provided by the claimant to the questions that form part of the application process. Jobcentre staff are trained to identify and provide support to customers with complex needs. If a claimant indicates that they are in hospital, this should trigger the Jobcentre agent to invoke alternative processes for verifying ID.” Source location 2021-0419-Response-from-DWP_Published
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 Assign Jobcentre agents responsibility for booking identity appointments and usually conducting biographical identity checks by telephone.
Verbatim wording from the response “Where a claimant is unable to verify their ID online, they are no longer automatically directed to contact the UC helpline to book an appointment. Jobcentre agents are now responsible for booking all ID appointments. In the majority of cases, claimants will now be booked a biographical check by phone. Jobcentre agents have full access to the claimant’s account, including all answers provided by the claimant to the questions that form part of the application process. Jobcentre staff are trained to identify and provide support to customers with complex needs. If a claimant indicates that they are in hospital, this should trigger the Jobcentre agent to invoke alternative processes for verifying ID.” Source location 2021-0419-Response-from-DWP_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 Implement strengthened remote identity verification using two-factor authentication and online checks against background sources.
Verbatim wording from the response “In November 2021 we changed our processes around ID verification. The revised process helps to strengthen the ID verification to reduce fraud and error. We have introduced two-factor authentication by SMS or email. The online identity check verifies the claimant’s identity by cross-referencing their personal information against a variety of background sources. As UC is a digital service, we are aiming to provide a remote option to verify ID where possible and safe to do so.” Source location 2021-0419-Response-from-DWP_Published
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 support, reasonable adjustments and November 2021 identity-verification changes are considered sufficient for vulnerable claimants to access benefits; no specific changes are proposed.
Verbatim wording from the response “We are constantly reviewing the service we provide to claimants across all DWP services and are committed to improving accessibility for all our customers, especially the many vulnerable people who rely our services. As highlighted in our response, once we were fully aware of Mr Talbot’s circumstances, we made reasonable adjustments based on his needs. This was to enable Mr Talbot to manage and maintain his UC claim. Upon reviewing the full circumstances of this case and in light of the changes made in November 2021, we are satisfied that the appropriate support is available to allow vulnerable claimants with complex needs to access benefits and, on that basis, we do not propose to take any specific actions or make any changes at this time in response to the concerns raised by HM Assistant Coroner.” Source location 2021-0419-Response-from-DWP_Published
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 Jobcentre attendance requirement was for identity verification, not the Habitual Residence Test, and alternatives were available if inability to attend was reported.
Verbatim wording from the response “As part of his online application, Mr Talbot disclosed that he had been out of the UK for more than 4 weeks at a time. This prompted a check to determine whether a HRT interview was needed. I understand, from the evidence adduced at inquest, that there was a suggestion that the reason Mr Talbot was asked to attend a DWP Jobcentre was due to HRT requirements. This is not the case. Claimants are notified of the need to have a HRT when first attending the Jobcentre for their IEI as part of the usual process of making a claim. Mr Talbot was required to attend in person to verify his ID as he had not completed this online via GOV.UK Verify. Had DWP been made aware of concerns about Mr Talbot’s ability to attend a DWP Jobcentre in person, a referral could have been completed for a home visit or support visit.” Source location 2021-0419-Response-from-DWP_Published
Open published response
3 Aug 2021 Emma Day · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 11 Failure to identify all children when sharing risk information View source Failure to record the duration and conditions of protective orders View source Failure to require escalation of domestic-violence concerns beyond immediate risk View source Failure to include the Non-Molestation Order in the Merlin Report View source Lack of safety netting for escalation of risk View source Inadequate caseworker training on the wider domestic-violence risk context View source Lack of guidance on accepting a caller’s assessment of domestic-violence risk View source Lack of a procedure for responding to threats and passing information to other authorities View source Lack of a system for direct entry of protective orders on the Police National Computer View source Failure of case-record access and handover of key domestic-violence risk information View source Failure to hold or know protective-order conditions and arrest powers View source See 8 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
Emma Day · 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 Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to identify all children when sharing risk information
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report, and when shared with Lambeth CSC only one of the children was mentioned .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to record the duration and conditions of protective orders
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order , nor did there appear to be any safety netting if the situation escalated.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to require escalation of domestic-violence concerns beyond immediate risk
Wider context from the report “d) A caseworker who learnt from a caller of domestic violence was only required to escalate for consideration of signposting or reporting to police if there was an immediate risk of violence , not necessarily if the worker was concerned or an immediate risk was likely to eventuate in the future , in particular on reapplying for maintenance.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to include the Non-Molestation Order in the Merlin Report
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report , and when shared with Lambeth CSC only one of the children was mentioned.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of safety netting for escalation of risk
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order, nor did there appear to be any safety netting if the situation escalated .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Inadequate caseworker training on the wider domestic-violence risk context
Wider context from the report “b) Training of caseworkers at the time on domestic violence was focused on domestic violence as a criterion to grant waiver of the fee and did not provide information about the wider definition, the reluctance to self-declare or the available services to be signposted .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on accepting a caller’s assessment of domestic-violence risk
Wider context from the report “e) Nevertheless in relation to 16th May, Ms Lilley expected case workers to pick up the degree of risk from a report of past threat to kill and escalate and Mr Gilchrist thought the response of the case worker inadequate, as there was a specific request to continue the maintenance claim in the knowledge of a specific threat. But the guidance at the time was silent as to whether to accept the caller’s assessment of risk . I concluded that staff would likely be uncertain of their duties .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for responding to threats and passing information to other authorities
Wider context from the report “f) Asked about the Domestic Homicide Report’s reference to systemic issues, Mr Gilchrist’s own words were that in May 2017 is where the system fell down. There should be a threat procedure and how to initiate it and pass information to other authorities
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for direct entry of protective orders on the Police National Computer
Wider context from the report “4. The Domestic Homicide Review recommended (R24) that the Home Office work with the Ministry of Justice to implement a system whereby protective orders can be input directly to the Police National Computer . It was not clear whether all State bodies that needed to were able to make entries themselves on the Police National Computer Conflicting evidence was heard, but one police officer stated that R24 had not been adopted , and to do so would be welcomed by other agencies and that without this change there might be missed opportunities to save lives .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of case-record access and handover of key domestic-violence risk information
Wider context from the report “The Coroner concluded that there was a system failure in Child Maintenance Service of Department of Work and Pensions in handling reports of domestic violence.
a) There was no mutual access of case records or system of handing on key risk information between CMO and CMS and so the eliciting of domestic violence risks relies upon repeated self-reporting by a victim .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to hold or know protective-order conditions and arrest powers
Wider context from the report “2. Lambeth Children’s Social Care (CSC) had no copy nor knew conditions of either Order, nor that there was a power of arrest . There seem to be steps taken by the CSC to consider action to mitigate the risk posed by the perpetrator in light of these Orders.
” Open source report
12 Feb 2021 Philippa Jane Louise Day · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure to provide accurate information about the consequences of not attending an upcoming appointment View source Failure of call records to be sufficiently detailed and accurate View source Unavailability of a non-prejudicial process for cancelling upcoming review appointments View source Failure of the assessment process to rectify incorrect decisions without evidence of changed circumstances View source Lack of specific mental health interaction training for call handlers 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
Philippa Jane Louise Day · 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
Philippa Jane Louise Day took an overdose of prescribed insulin on 7 or 8 August 2019, suffered hypoglycaemic encephalopathy and died of her injuries on 16 October 2019. The principal concerns related to inadequate training for call handlers dealing with people with mental ill health, brief and inaccurate call records, and an assessment and review process that failed to rectify an incorrect decision and included a misleading appointment letter.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about the consequences of not attending an upcoming appointment
Wider context from the report “3. The change of assessment process did not allow for a decision, which was incorrect, to be rectified without evidence of a subsequent change of circumstances. In addition, when a change of review process was appropriate, there was no means by which upcoming appointments could be cancelled without causing prejudice to Philippa Day. A misleading letter was sent which led Philippa Day to consider that her benefits would be stopped if she did not attend the upcoming appointment.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of call records to be sufficiently detailed and accurate
Wider context from the report “2. Records of calls handled were very brief and, at times, inaccurate. The records did not facilitate accurate decision making or enable queries to be dealt with efficiently and without inadvertently exacerbating the difficulties experienced by Philippa Day in progressing her benefits claims;
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a non-prejudicial process for cancelling upcoming review appointments
Wider context from the report “3. The change of assessment process did not allow for a decision, which was incorrect, to be rectified without evidence of a subsequent change of circumstances. In addition, when a change of review process was appropriate, there was no means by which upcoming appointments could be cancelled without causing prejudice to Philippa Day . A misleading letter was sent which led Philippa Day to consider that her benefits would be stopped if she did not attend the upcoming appointment.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of the assessment process to rectify incorrect decisions without evidence of changed circumstances
Wider context from the report “3. The change of assessment process did not allow for a decision, which was incorrect, to be rectified without evidence of a subsequent change of circumstances. In addition, when a change of review process was appropriate, there was no means by which upcoming appointments could be cancelled without causing prejudice to Philippa Day. A misleading letter was sent which led Philippa Day to consider that her benefits would be stopped if she did not attend the upcoming appointment.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of specific mental health interaction training for call handlers
Wider context from the report “1. Call handlers as the DWP had not received, in their preparatory course prior to commencing work taking calls from claimants, specific training as to how best to interact with persons suffering from mental ill health in such a way as to avoid inadvertently exacerbating the difficulties experienced in progressing claims for benefits by such persons;
” 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 Build accurate note-taking into PIP quality-assurance checks and standards, including the required IT change.
Verbatim wording from the response “To ensure a consistent focus on recording accurate notes on the system we are now building the subject into our PIP decision-making “quality assurance checks” and updating the documents that define quality standards for PIP colleagues. Dedicated “quality checkers” within DWP check notes are compliant with those standards; are recorded in a standard format and accurately represent conversations and decisions. Updating these processes requires an IT change, which we have planned. We also plan to add a new section, about recording notes on the PIP computer system, to the instructions that colleagues working on PIP claims use for guidance. We expect both of these actions to be completed by the end of Summer 2021.” Source location 2021-0043-Response-from-DWP-Redacted
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 Issue internal communications reinforcing accurate, factual note-taking for PIP and ESA interactions, actions and decisions.
Verbatim wording from the response “We issued internal communications to all staff working on PIP and ESA early in March 2021 to reinforce the importance of recording notes on the appropriate computer systems and remind them that all colleagues are required to ensure that notes:” Source location 2021-0043-Response-from-DWP-Redacted
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 PIP assessment-pause process with assessment providers, including IT changes and protection of claims during pauses.
Verbatim wording from the response “I now turn to the third matter of concern described by the Coroner. DWP is working with Capita and IAS, to ensure a process is put in place that allows assessments to be paused even when an appointment has already been scheduled to allow for the gathering of additional information or changing the type or location of the assessment. The new process ensures that a claimant’s assessment can be paused without affecting that claim while the reason for the pause is addressed. Elements of this change have already been implemented with the full process, including the IT elements, being implemented across the whole of the PIP assessment service by the end of September 2021.” Source location 2021-0043-Response-from-DWP-Redacted
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 Provide supporting-vulnerable-customers training to new service-delivery staff.
Verbatim wording from the response “DWP has taken significant steps to improve its staff’s ability to understand the wide range of mental health issues that benefit claimants may face. It may help if I cover in some detail the training in place before and after this case.” Source location 2021-0043-Response-from-DWP-Redacted
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 Require PIP and ESA call handlers to complete both relevant mental-health training modules before handling calls independently, including training outstanding existing colleagues.
Verbatim wording from the response “We recognise the need to treat everyone with empathy and care; especially those with mental health conditions. Because of this, and in response to the Coroner’s concerns, we have amended our training for new entrants. From 1 April 2021 all new entrants handling PIP and Employment Support Allowance (“ESA”: an income-maintenance benefit for people with a disability or health condition that limits their capacity to work or engage in work-related activity) will therefore undertake the mental health, behaviour and relationships training in addition to the “supporting vulnerable customers” training before they handle calls from claimants on their own. We are also arranging for existing colleagues in those roles who have not yet received the training to undertake it by 30 June 2021.” Source location 2021-0043-Response-from-DWP-Redacted
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 Issue further ESA note-taking communications and apply strengthened quality standards through quality-assurance checks.
Verbatim wording from the response “At the same time we have also strengthened the guidance around note-taking for colleagues who manage ESA claims. We plan to issue two further communications to those colleagues, covering specific aspects of ESA claims, in the next few months. As in PIP, we have set new quality standards around note-taking. Quality checkers will now deem only notes that meet the standards outlined in the best-practice guides to have complied with ESA processes. The changes to quality assurance checks in ESA came into effect from March 2021.” Source location 2021-0043-Response-from-DWP-Redacted
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 Add PIP computer-system note-taking guidance to colleagues’ instructions.
Verbatim wording from the response “To ensure a consistent focus on recording accurate notes on the system we are now building the subject into our PIP decision-making “quality assurance checks” and updating the documents that define quality standards for PIP colleagues. Dedicated “quality checkers” within DWP check notes are compliant with those standards; are recorded in a standard format and accurately represent conversations and decisions. Updating these processes requires an IT change, which we have planned. We also plan to add a new section, about recording notes on the PIP computer system, to the instructions that colleagues working on PIP claims use for guidance. We expect both of these actions to be completed by the end of Summer 2021.” Source location 2021-0043-Response-from-DWP-Redacted
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 Roll out mental-health, behaviour and relationships training to service-delivery colleagues.
Verbatim wording from the response “From July 2019 we began rolling out further training, on mental health, behaviour and relationships. This enables colleagues to recognise the effect of their personal impact on people with mental health conditions, and to respond appropriately to unexpected customer behaviour and identify a claimant’s ability to proceed with a call or a face-to-face meeting. It also helps colleagues identify a claimant’s needs and signpost them to sources of help and support, where appropriate.” Source location 2021-0043-Response-from-DWP-Redacted
Open published response
5 Jul 2019 Alexander Boamah · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Risk from unrestrained access to illicit substances following receipt of large sums of money View source Risk to individuals without capacity to manage their finances who receive funds View source Lack of a process for treating clinicians to raise concerns about financial risks with the Department of Work and Pensions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander Boamah · 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
Alexander Boamah, who had a history of heroin and crack cocaine misuse, was found deceased at his residence on 26 January 2019 after receiving approximately £18,000 in Personal Independence Payment and disengaging from addiction treatment while increasing his reported illicit substance use. The principal concern was the risk that large payments could give individuals at risk through illicit substance use unrestrained access to funds, with no apparent process for treating clinicians to raise concerns with the Department for Work and Pensions.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Risk from unrestrained access to illicit substances following receipt of large sums of money
Wider context from the report “(1) There is a real risk that future deaths will occur where large sums of money are received by individuals who are then placed at risk through unrestrained access to illicit substances.
Whilst it is recognised that individuals should not be deprived of funds owed to them, it does not seem that there is a process whereby concern about such risks can be raised by treating clinicians to the Department of Work and Pensions.
A specific concern relates to the potential that individuals, without capacity to manage their finances, may come into receipt of funds which place them at particular risk.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Risk to individuals without capacity to manage their finances who receive funds
Wider context from the report “(1) There is a real risk that future deaths will occur where large sums of money are received by individuals who are then placed at risk through unrestrained access to illicit substances.
Whilst it is recognised that individuals should not be deprived of funds owed to them, it does not seem that there is a process whereby concern about such risks can be raised by treating clinicians to the Department of Work and Pensions.
A specific concern relates to the potential that individuals, without capacity to manage their finances, may come into receipt of funds which place them at particular risk .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for treating clinicians to raise concerns about financial risks with the Department of Work and Pensions
Wider context from the report “(1) There is a real risk that future deaths will occur where large sums of money are received by individuals who are then placed at risk through unrestrained access to illicit substances.
Whilst it is recognised that individuals should not be deprived of funds owed to them, it does not seem that there is a process whereby concern about such risks can be raised by treating clinicians to the Department of Work and Pensions .
A specific concern relates to the potential that individuals, without capacity to manage their finances, may come into receipt of funds which place them at particular risk.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and strengthen safeguarding policy and guidance for vulnerable claimants, including coordination with relevant bodies and communication with treating clinicians.
Verbatim wording from the response “10. DWP is committed to regularly reviewing claimant support policies and guidance for our staff. This is to ensure claimants are safe and receive the support they need. This is particularly important for those at risk of suicide and self-harm or who are considered vulnerable because of their particular circumstances.” Source location 2019-0232-Response-by-DWP
Open published response
27 Dec 2018 Kenneth Roy Bardsley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Lack of statutory minimum requirements for lift servicing View source Lack of a care home system for reviewing and passing lift examination details to the servicing company View source Lack of formal minimum qualification standards for lift engineers View source Lack of clarity about informing engineers of and following up regulatory lift examination requirements View source Electronic lift servicing appointment systems lacking checklists View source Failure of home inspections to identify unacted-on regulatory lift examination faults View source Failure to read, act on, and escalate regulatory lift examination findings View source Failure to require lift servicing and repair engineers to obtain regulatory examination reports View source See 5 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
Kenneth Roy Bardsley · 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
Kenneth Roy Bardsley died at Salford Royal Hospital on 30 January 2017 from multiple injuries sustained as a passenger in a lift that malfunctioned at Serendipity Care Home. The inquest concluded that his accidental death was contributed to by failure of the lift’s interior door mechanism. Concerns included gaps in lift-engineer qualification requirements, failures to read and act on regulatory examination findings, unclear communication and follow-up processes, and insufficient systems for lift servicing and examination records.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory minimum requirements for lift servicing
Wider context from the report “7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist. One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of a care home system for reviewing and passing lift examination details to the servicing company
Wider context from the report “5. That Serendipity Care Home did not have a system in place to ensure details from the lift examinations were read; considered and passed on to the lift servicing company ;
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of formal minimum qualification standards for lift engineers
Wider context from the report “1. The inquest heard that there are no formal requirements for a minimum standard of qualification for people to be lift engineers . In effect, anyone can advertise themselves as a lift engineer/maintenance company ;
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about informing engineers of and following up regulatory lift examination requirements
Wider context from the report “3. During the inquest evidence was given that within the specific lift company in this case and more widely, there was a lack of clarity as to how engineers should be made aware and follow up requirements made by engineers carrying out the regulatory lift examinations ;
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Electronic lift servicing appointment systems lacking checklists
Wider context from the report “7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist . One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of home inspections to identify unacted-on regulatory lift examination faults
Wider context from the report “4. In inspections of the home, the CQC did not pick up that there were faults identified in the regulatory examination that had not been acted upon ;
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to read, act on, and escalate regulatory lift examination findings
Wider context from the report “2. The evidence given to the inquest was that there was a gap in the system which meant that regulatory lift examinations could take place but not be read or acted upon , with no escalation process ;
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to require lift servicing and repair engineers to obtain regulatory examination reports
Wider context from the report “6. That the lift company Lancs and Cumbria engineers carrying out serving/repairs were not expected to ask to see the regulatory examination reports ;
” Open source report
13 Sep 2016 Zane Ilorie Christopher Yusuf GBANGBOLA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Inadequacy and inaccuracy of safety guidance for internal-combustion-engine equipment used in confined or enclosed areas View source Use of HSE logos or equivalent representations creating an appearance of endorsement of unendorsed guidance 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
Zane Ilorie Christopher Yusuf GBANGBOLA · 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
Zane Ilorie Christopher Yusuf GBANGBOLA, aged seven, died on 7 February 2014 after exposure to carbon monoxide from a petrol-driven pump used during severe flooding at his family home. The report raised concerns that HAE safety guidance for internal-combustion-engine equipment used in confined areas was inadequate and potentially misleading, and that the use of HSE branding could be interpreted as endorsement of the guidance.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Inadequacy and inaccuracy of safety guidance for internal-combustion-engine equipment used in confined or enclosed areas
Wider context from the report “I am concerned that the Safety Guidance documents currently prepared by HAE in relation to equipment that is driven by an internal combustion engine, where there is a realistic risk that that equipment might be used in confined areas, are inadequately and potentially misleading . Further, that the use of the HSE logo, in whatever form it might appear, runs the risk of being interpreted by someone reading the document as being an endorsement by the HSE of the document and its contents, thereby exacerbating the potential risk of harm by increasing that person’s confidence in the guidance albeit that the guidance may be poor.
a. The adequacy and accuracy of the Safety Guidance documents prepared by HAE for their members, not only in relation to this centrifugal pump, but in relation to any piece of equipment that is powered by an internal combustion engine where there is a realistic prospect that that piece of equipment might be used in an enclosed area.
b. The use of the HSE logo on documents that are prepared for general use by trades people and members of the public alike, whether that be the official HSE logo or whether it be in the form of an HSE banner Consideration should be given to taking steps to ensure that the use of any such logo, banner or equivalent representation of the HSE emblem does not give the appearance of the guidance within that document having been endorsed by the HSE when in fact it has not been.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Use of HSE logos or equivalent representations creating an appearance of endorsement of unendorsed guidance
Wider context from the report “I am concerned that the Safety Guidance documents currently prepared by HAE in relation to equipment that is driven by an internal combustion engine, where there is a realistic risk that that equipment might be used in confined areas, are inadequately and potentially misleading. Further, that the use of the HSE logo, in whatever form it might appear, runs the risk of being interpreted by someone reading the document as being an endorsement by the HSE of the document and its contents , thereby exacerbating the potential risk of harm by increasing that person’s confidence in the guidance albeit that the guidance may be poor.
a. The adequacy and accuracy of the Safety Guidance documents prepared by HAE for their members, not only in relation to this centrifugal pump, but in relation to any piece of equipment that is powered by an internal combustion engine where there is a realistic prospect that that piece of equipment might be used in an enclosed area.
b. The use of the HSE logo on documents that are prepared for general use by trades people and members of the public alike, whether that be the official HSE logo or whether it be in the form of an HSE banner Consideration should be given to taking steps to ensure that the use of any such logo, banner or equivalent representation of the HSE emblem does not give the appearance of the guidance within that document having been endorsed by the HSE when in fact it has not been.
” Open source report
10 May 2016 Peter William RICHARDSON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to record lift tolerance levels for comparison by subsequent examiners View source Failure to record vehicle-lift operator training View source Failure to ensure lift users are appropriately competent to maintain the lift View source Lack of formal guidance on safe tolerances for safety-critical elements of two-post lifts View source Failure to provide guidance on required torque for safety-critical elements of Bendpak two-post lifts View source Use of foreign objects between two-post lift pads and vehicles during lifting View source Failure to provide guidance on safe tolerance levels for supplied two-post lifts View source See 4 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
Peter William RICHARDSON · 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 27 September 2015, Peter William Richardson was working beneath a car on a two-post vehicle lift when the car became dislodged and fell onto him, causing fatal head injuries. The substantive concerns included the absence of formal guidance on safe tolerances and torque levels for safety-critical lift components, inadequate recording and training arrangements, and the practice of placing foreign objects between lift pads and vehicles to provide clearance.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to record lift tolerance levels for comparison by subsequent examiners
Wider context from the report “c) Safe tolerance should be considered at a LOLER ‘Thorough Examination’ however there is no guidance to be followed and there is no requirement for such tolerance levels to be recorded and as such the levels are not available to any subsequent examiner .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to record vehicle-lift operator training
Wider context from the report “d) Mr Richardson who operated the lift only received training on the specific lift at the point it was installed in 2012. All other users were subsequently trained by him in its use, which was not recorded and all users of the lift were expected to maintain the lift properly.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure lift users are appropriately competent to maintain the lift
Wider context from the report “d) Mr Richardson who operated the lift only received training on the specific lift at the point it was installed in 2012. All other users were subsequently trained by him in its use, which was not recorded and all users of the lift were expected to maintain the lift properly .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Lack of formal guidance on safe tolerances for safety-critical elements of two-post lifts
Wider context from the report “a) No formal guidance exists as to safe tolerances of safety critical elements of two-post lifts . The Court heard from two HSE witnesses and a ‘Thorough examiner’ who examined the lift for the purposes of complying with LOLER 1988, who gave differing views on what was a safe tolerance or ‘play’ for an extended lift arm . Further, it was accepted that this was an issue of concern to the HSE, but as yet remained to be dealt with.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to provide guidance on required torque for safety-critical elements of Bendpak two-post lifts
Wider context from the report “b) The supplier of the Bendpak Lift in the UK, Liftmaster, do not supply guidance as to the required torque for safety critical elements of their two-post lifts and neither do they provide guidance on safe tolerance levels.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Use of foreign objects between two-post lift pads and vehicles during lifting
Wider context from the report “e) It is a known practice for a variety of different objects (for example a piece of wood) to be placed on top of the lift pads between the pad and the vehicle when it is lifted in order to provide clearance and to assist with difficult jobs such as removing a car under-shield.
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure to provide guidance on safe tolerance levels for supplied two-post lifts
Wider context from the report “b) The supplier of the Bendpak Lift in the UK, Liftmaster, do not supply guidance as to the required torque for safety critical elements of their two-post lifts and neither do they provide guidance on safe tolerance levels .
” Open source report
13 Jan 2014 Michael Brendan O’SULLIVAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure of ultimate decision makers to obtain and review treating clinicians’ reports View source Failure of assessing doctors to take into account treating doctors’ views View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Brendan O’SULLIVAN · 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 O’Sullivan took his own life by hanging while suffering anxiety and depression, following a recent assessment by a DWP doctor that he was fit for work. The assessing doctor and the ultimate decision maker did not obtain or consider reports from his treating doctors, including his general practitioner, psychiatrist and clinical psychologist.
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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of ultimate decision makers to obtain and review treating clinicians’ reports
Wider context from the report “The DWP assessing doctor (who saw Mr O’Sullivan for a 90 minute consultation) did not take into account the views of any of Mr O’Sullivan’s treating doctors, saying that the ultimate decision maker would do that.
However, the ultimate decision maker (who is not, I understand, medically qualified) did not request and so did not see any reports or letters from Mr O’Sullivan’s general practitioner (who had assessed him as being unfit for work), his psychiatrist or his clinical psychologist .
” 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 Department for Work and Pensions; that does not assign responsibility.
PFD Monitor interpretation Failure of assessing doctors to take into account treating doctors’ views
Wider context from the report “The DWP assessing doctor (who saw Mr O’Sullivan for a 90 minute consultation) did not take into account the views of any of Mr O’Sullivan’s treating doctors , saying that the ultimate decision maker would do that.
However, the ultimate decision maker (who is not, I understand, medically qualified) did not request and so did not see any reports or letters from Mr O’Sullivan’s general practitioner (who had assessed him as being unfit for work), his psychiatrist or his clinical psychologist.
” 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 Keep processes for collecting further medical evidence under constant review and improve them where possible.
Verbatim wording from the response “71. We, of course, remain committed to keeping our processes for collecting further evidence under constant review and to improving these processes where possible. It remains important to retain a balance between the added value of further evidence in any claim for ESA and time demands on GPs and other healthcare professionals.” Source location 2014-0012-Response-by-DWP
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 Ongoing litigation limits comment on universal further medical evidence, and an interim judgment found that requiring this change was not reasonable.
Verbatim wording from the response “68. It has been routinely suggested that DWP should obtain medical reports for individuals with a mental illness, learning disability or related condition who are beginning the WCA process.” Source location 2014-0012-Response-by-DWP
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 existing division between Atos-trained healthcare professionals and GPs is retained because each has a distinct role and GPs generally lack relevant assessment expertise.
Verbatim wording from the response “70. This issue of further medical evidence has also been considered as part of the independent review process. The distinction drawn between the respective functions of HCPs and GPs is a key element of the policy intent behind the WCA, and is supported by the British Medical Association. In its response to Professor Harrington’s call for evidence for his third independent review, the BMA said:” Source location 2014-0012-Response-by-DWP
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations