21 Apr 2021 MARY NABILIA GWANYAMA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Difficulty accessing community treatment and support after out-of-area placement View source Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based View source Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning View source Discharge from the Home Treatment team on ineffective medication View source Failure to provide coherent community-care planning and care-coordinator involvement at discharge View source Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge View source Lack of policy governing frequency of community review for risk and medication compliance View source Failure to follow the Care Programme Approach during discharge View source Premature discharge before the effectiveness of prescribed medication is adequately observed View source Failure to undertake and record formal pre-discharge risk assessments View source See 7 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
MARY NABILIA GWANYAMA · 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
Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.
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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Difficulty accessing community treatment and support after out-of-area placement
Wider context from the report “7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her . There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based
Wider context from the report “4. The informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Mary of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk . The risk assessments were not sufficiently rigorous and evidence based .
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning
Wider context from the report “1. Mary was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan as to what would happen after the Travel Lodge placement ended . There is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Discharge from the Home Treatment team on ineffective medication
Wider context from the report “6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coherent community-care planning and care-coordinator involvement at discharge
Wider context from the report “6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community . Her care coordinator was not involved in the discharge planning . The CPA was not followed.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge
Wider context from the report “2. Mary was not subject to a medical review from the 28th March 2018 to the 26th May 2018. There is no policy in place which mandates when or if a patient should be subject to face to face review by a consultant psychiatrist after discharge from the acute unit .
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of policy governing frequency of community review for risk and medication compliance
Wider context from the report “7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication .
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Care Programme Approach during discharge
Wider context from the report “5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Premature discharge before the effectiveness of prescribed medication is adequately observed
Wider context from the report “5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication . This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and record formal pre-discharge risk assessments
Wider context from the report “3. No formal risk assessment was undertaken of Mary and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit.
” Open source report
21 Sep 2017 Derek Clifford Dudley · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 8 Failure to require trainee Telecare Operators to obtain approval before closing calls View source Failure to persist in offering and persuading service users to accept help after alarm activation View source Failure to inform emergency contacts of the service user’s control over whether they are telephoned View source Failure to take further action when follow-up contact after an unanswered alarm call fails View source Insufficient background information available to Telecare Operators for assessing service user needs View source Lack of pro forma questions for assessing needs after alarm activation View source Allowing trainee Telecare Operators to take calls without direct supervision View source Failure to keep alarm calls open until service users are safely recovered from falls 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
Derek Clifford Dudley · 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
Derek Clifford Dudley was found deceased from hypothermia outside the back door of his home on 6 March 2017, after previously activating his community alarm following a fall. Concerns included the call being ended before he had got up, limited follow-up after a later unanswered call, unsupervised trainee operators, the absence of pro forma questions, and insufficient background information for assessing service users’ needs.
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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to require trainee Telecare Operators to obtain approval before closing calls
Wider context from the report “The Telecare operator who took Mr Dudley’s call was in her probationary period with the Service but was able to take the call without direct supervision and did not need to seek approval before closing the call .
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to persist in offering and persuading service users to accept help after alarm activation
Wider context from the report “Mr Dudley was only offered an ambulance once during the course of the telephone conversation and no attempt was made to persuade him to accept any help.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform emergency contacts of the service user’s control over whether they are telephoned
Wider context from the report “The court heard evidence that Mr Dudley’s emergency contacts believed they would be telephoned automatically if Mr Dudley activated his alarm, and stated they had signed a form agreeing to be called at any time of day or night. Mr Dudley was not asked if he wanted his emergency contacts to be telephoned and ████████ CSS Telecare Service Manager, stated they would not be contacted unless the service user requested this.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take further action when follow-up contact after an unanswered alarm call fails
Wider context from the report “The operator attempted to contact Mr Dudley by telephone again 1.5 hours later , which ████████ again stated was in breach of Telecare’s policy, but there was no answer and no further action was taken.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient background information available to Telecare Operators for assessing service user needs
Wider context from the report “████████ also confirmed that whilst an extensive assessment of new service users is undertaken with their next of kin, this information is not accessible to the Telecare Operators who are provided with a very brief sentence describing the service user’s requirements.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of pro forma questions for assessing needs after alarm activation
Wider context from the report “Evidence was heard during the inquest that no pro forma questions are provided to the Telecare operators for dealing with calls and call handling guidance is provided to each operator on a USB stick which they can access via their work computer if needed.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Allowing trainee Telecare Operators to take calls without direct supervision
Wider context from the report “The Telecare operator who took Mr Dudley’s call was in her probationary period with the Service but was able to take the call without direct supervision and did not need to seek approval before closing the call.
” 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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to keep alarm calls open until service users are safely recovered from falls
Wider context from the report “The call was terminated without Mr Dudley having got up from his fall , which ████████ confirmed was in breach of the policy of CSS Telecare Service .
” Open source report
3 May 2017 Beryl Varcoe · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to thoroughly range-test alarms throughout service-users’ homes 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
Beryl Varcoe · 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
Beryl Varcoe fell or collapsed in her bedroom and repeatedly pressed her community alarm pendant, but the alarm did not activate because her bedroom was outside the base unit’s radio range. She remained on the floor until the following day, developed pneumonia and chest sepsis, and died in hospital on 21 April 2016. The principal concern was that alarms installed or upgraded without thorough range testing may not function throughout clients’ homes, potentially placing other service users at risk.
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 Elmbridge Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to thoroughly range-test alarms throughout service-users’ homes
Wider context from the report “The court heard evidence from ████████, the head of Elmbridge Borough Council’s Community Alarms Service, who told the court that the service has 1,700 clients and two installation officers, who are responsible for fitting and upgrading alarms in clients’ homes.
████████ told the court that it was his expectation that the installation officers carried out thorough range testing when fitting and upgrading alarms, to check that the pendant was capable of activating the base unit from all internal and external parts of a property.
The court also heard evidence from the particular installer who fitted and upgraded Mrs Varcoe’s alarm. He gave inconsistent evidence with regards to his practises in respect of range testing. However, having considered the entirety of his evidence, the court is concerned that it was his practice only to range test pendants in those parts of the service user’s home, which they used most regularly and in which they felt most vulnerable .
The court was told that the installation officer who fitted Mrs Varcoe’s alarm has now retired. The court was also told that the Community Alarms Service has developed a number of new procedures, which are to be introduced imminently, with the aim of ensuring that thorough range testing is documented at the time of each alarm installation or upgrade.
However, the court is concerned that a significant number of the service’s clients currently have alarms, which were fitted prior to the introduction of the new procedures and by the same installation officer who fitted Mrs Varcoe’s alarm. As such there is a risk that those service-users may have alarms which do not function throughout the entirety of their homes .
Elmbridge Borough Council’s Community Alarms Service has a significant number of clients who currently have alarms, which may not have not been thoroughly range-tested and may not function throughout the entirety of the service-users’ homes .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations