25 Feb 2026 Emma Irene TURNER · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 3 Insufficient support and assistance for carers in understanding a person's best interests View source Lack of connectivity and information sharing between services View source Safeguarding referral forms failing to capture key GP-relevant information View source
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AI-generated summary
Emma Irene TURNER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emma Irene Turner died at home on 29 January 2023 after her airway became obstructed by vomit following her eating some cake. The report identified concerns about inadequate and untimely multi-agency processes, safeguarding referrals, face-to-face assessments and welfare checks, as well as poor information sharing between services. It also identified a risk that the safeguarding referral form used by GPs could omit key information and delay responses.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient support and assistance for carers in understanding a person's best interests
Wider context from the report “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests.
The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity and information sharing between services
Wider context from the report “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services . Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests.
The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies ; that impacted on their ability to review how other professionals would intervene in Emma's care . There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Safeguarding referral forms failing to capture key GP-relevant information
Wider context from the report “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests.
The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery.
Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams . Thus the safeguarding team may be delayed in responding in a timely way .
” 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 Co-produce and implement a revised safeguarding adults referral form with partners, streamlining information requirements and reducing duplication and complexity.
Verbatim wording from the response “We recognise the concerns raised that some sections of the current template are less directly relevant to GPs and that this may increase the risk of key clinical or contextual information not being clearly set out and potentially delay the safeguarding team’s response. In recognition of this, Derby City Council and Derbyshire County Council have worked in partnership to collate feedback from partner agencies, including GPs, specifically on the structure, content and usability of the Safeguarding Adults Referral Form.” Source location Response from Derby City Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a single safeguarding adults referral form across Derby City and Derbyshire County, available online to public and professional referrers.
Verbatim wording from the response “Across Derby and Derbyshire there is a joined-up, partnership approach to safeguarding adults, underpinned by a joint Safeguarding Adults Policy which operates across both the Derby Safeguarding Adults Board and the Derbyshire Safeguarding Adults Board areas. As part of this partnership approach, a single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. This form is available online for members of the public, all partner agencies and providers, including GP practices, to use when making safeguarding referrals.” Source location Response from Derby City Council
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16 Feb 2024 Sobia Tabasim Khan · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 12 Uncontrolled overseas travel by recently discharged s.41 restricted patients View source Absence of police power to arrest people posing a significant risk of death or serious injury View source Failure to provide clinicians with full risk-assessment reports for discharge decisions View source Inadequate and misleading risk and progress reports for restricted-patient discharge View source Failure to refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny View source Inadequate recording of risk meetings, decisions and actions View source Over-reliance on self-reporting by a manipulative patient about relationships and risk View source Failure to recall s.41 patients solely posing a significant public risk without mental-health decline View source Lack of available forensic supervision pathways for s.41 restricted patients View source Inadequate clinical record-keeping of material risk information View source Failure to investigate culturally relevant family and community information View source Failure to complete and consider a pre-discharge family assessment View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sobia Tabasim Khan · 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
Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.
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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled overseas travel by recently discharged s.41 restricted patients
Wider context from the report “e. Travel overseas for s.41 restricted patients. ████████ was permitted to travel to and from Pakistan freely and to return seemingly as and when he saw fit. Whilst he was outside the jurisdiction there was no way of checking on him, including in terms of his mental health, but also his risk . There were concerns, for example, that he may have been arranging a forced marriage for his niece. He could have entered into a relationship, for all the authorities knew. It also allowed him an opportunity to push and test the boundaries. He was permitted to travel out of the jurisdiction as he pleased, sometimes returning late, sometimes early. By contrast, had he been on licence after serving a custodial sentence, he would in all probability have been prevented from travelling outside the jurisdiction, at least in the early stages. Whilst I acknowledged that there are qualitative differences between a prison sentence and a hospital order, it remains legitimate if not necessary to ensure that those who have recently discharged from a s.41 order are carefully monitored, in the jurisdiction , at least for the first 12 months. This is beneficial not only in terms of monitoring mental health, but also 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Absence of police power to arrest people posing a significant risk of death or serious injury
Wider context from the report “c. Police power to arrest where there is a reason to believe a person is at risk of death/serious injury. Whilst I was critical of the failure of the police to take measures that were reasonably available to them to investigate the intelligence that had been received that ████████ was in a relationship, the one power that was not available to them was to arrest him . This leaves a significant gap in the powers that are available to the police to protect individuals who are at risk of death/serious injury . Although I cannot say whether the threshold would have been met in Sobhia’s case, such a power could in future cases ensure that it is understood that where an individual poses a significant risk of causing serious harm in relationships, and there is evidence that he is concealing a relationship, he can be arrested.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinicians with full risk-assessment reports for discharge decisions
Wider context from the report “f. Clinicians should be provided with full reports when considering discharge. This was a particular concern in relation to the fact that those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary . Given ████████ risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate and misleading risk and progress reports for restricted-patient discharge
Wider context from the report “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed . Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal, such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment. The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny
Wider context from the report “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed. Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal , such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment . The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of risk meetings, decisions and actions
Wider context from the report “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken . In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all . There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on self-reporting by a manipulative patient about relationships and risk
Wider context from the report “g. Over-reliance on self-reporting. This was a theme that ran throughout the inquest and the various agencies involved. This was a case that required a forensic approach throughout, both in hospital and in the community. It was recognised that ████████ was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship . ████████ risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them . This underlined why his self-reporting could not be relied upon and this something that should have featured in his management throughout, and flagged at the point of discharge.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recall s.41 patients solely posing a significant public risk without mental-health decline
Wider context from the report “d. Ministry of Justice power to recall where a patient poses a significant risk to the public. The MoJ will not generally recall dangerous individuals unless there is a decline in their mental health presentation notwithstanding the fact that s.41 MHA 1983, to which ████████ was subject, is designed to protect the public from serious harm. Whilst there is the possibility of the judge imposing a hybrid order, and that was not considered appropriate in this case, it did not mean that ████████ risk only existed in the context of a decline in his mental health . If an individual subject to a s.41 restriction order poses a significant risk to the public he can be protected if he can be recalled to hospital where further assessment can be undertaken.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of available forensic supervision pathways for s.41 restricted patients
Wider context from the report “b. Ensuring that s.41 restricted patients are supervised under a forensic pathway. In this case no such pathway even existed in the locality . This meant that Mustafa’s supervision was inadequate having regard to the risk that he posed . Such orders are imposed to protect the public from the risk of serious harm. Even where it has been adjudged that any previous offending would not have happened but for a mental disorder, there is still the need for a forensic approach. The risk component must not be overlooked as it was here. Forensic pathways must be available across the country .
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical record-keeping of material risk information
Wider context from the report “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not . The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate culturally relevant family and community information
Wider context from the report “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues . Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered.
” 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 Derby City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and consider a pre-discharge family assessment
Wider context from the report “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge , ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered .
” 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 Deliver a rolling Unconscious Bias training programme to develop cultural competence.
Verbatim wording from the response “With particular reference to the Coroner's concern, 5i, Derby City Council have introduced a rolling programme of Unconscious Bias training in relation to developing cultural competence.” Source location Response from Derby City Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.
Verbatim wording from the response “The Council has also introduced training for social supervisors funded jointly by health and social care; previously this was provided on an "ad hoc" basis and was agency specific. Broadly covering all of the matters of concern, in September 2019 Derby City Council in conjunction with Derbyshire County Council commissioned regular training for social supervisors. There is a two day introduction to Part 3 Mental Health Act 1983 and the role of the Social Supervisor and a one day annual refresher.” Source location Response from Derby City Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalize the cross-organisation forensic pathway memorandum and employ a co-located Senior Social Work Practitioner with forensic mental health lead responsibilities.
Verbatim wording from the response “With particular reference to the Coroner's concern, 5b, in July 2019 Derbyshire Healthcare NHS Foundation Trust secured funding for the creation of a Forensic Community Mental Health Team. The Local Authority has been working alongside the team to support supervision of mentally disordered offenders under a forensic pathway.” Source location Response from Derby City Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share forensic casework learning, knowledge, resources, expertise, external network developments, and best-practice processes across organisations.
Verbatim wording from the response “In addition to this, the role will work on key aspects of service and practice development by:” Source location Response from Derby City Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations