Recipient

Family

First report 7 Jul 2014•Latest report 7 Jul 2014

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Family linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Jul2014
Inner North London
Concerns raised9
1. Lack of guidance on assessment conduct and recording
2. Inaccurate and incomplete recording of carers and care arrangements
3. Failure to assess suitability of a commode for the service user
1. Inconsistent recording between assessments and correspondence
2. Failure to reconcile assessments with referral and historical information
3. Failure of senior review of assessments against referral information
4. Failure to conduct comprehensive assessments addressing referral concerns
5. Lack of good practice guidelines for assessments
6. Failure to verify care arrangements and support needs
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

Harold George de Mello · 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

Harold George de Mello, who had multiple co-morbidities, limited mobility and incontinence, died in hospital on 13 April 2014 after collapsing at home and being treated for bronchopneumonia. The principal concerns were that social-care assessments did not adequately investigate or record the reported incontinence, hygiene problems, care arrangements and differing information, and lacked sufficiently comprehensive guidance and senior review.

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 Family; that does not assign responsibility.
PFD Monitor interpretation
Lack of guidance on assessment conduct and recording
Wider context from the report
“(6) guidelines should, therefore, refer to both the manner and the recording of the assessments and senior colleagues should thoroughly check assessments against the referrals or reports made ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate and incomplete recording of carers and care arrangements
Wider context from the report
“(4) that no reference was made to any of the people to whom the service user referred as being carers, that information was wrongly recorded (a person wrongly described as a niece who was not a relative) and that there is a significant difference in the fact that the visit assessment suggests that the deceased had adequate social care whilst also noting that a ‘carer’ was not fit and able to undertake domestic tasks. That no investigation was properly made into the actual care available to Mr de Mello and no contact made with either the claimed carer or the relative with power of attorney to confirm the reality of his situation and the extent of his dependence or needs ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess suitability of a commode for the service user
Wider context from the report
“(5) that there was a difference in the actions recorded in the assessment (apparently the ordering of urine bottles) and the letter written to Mr de Mello stating that a commode had been ordered and no consideration of whether he could use a commode ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent recording between assessments and correspondence
Wider context from the report
“(5) that there was a difference in the actions recorded in the assessment (apparently the ordering of urine bottles) and the letter written to Mr de Mello stating that a commode had been ordered and no consideration of whether he could use a commode ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Failure to reconcile assessments with referral and historical information
Wider context from the report
“(3) that, given that a conclusion was made that there would be no social care provided, the assessment was made (and signed off by a senior colleague) without any reference to the rather different reports from the referrer and in the deceased’s historical record. There is an incongruence between the claimed observations of the First Response Officer and the information that led to the assessment that was not explored ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Failure of senior review of assessments against referral information
Wider context from the report
“(6) guidelines should, therefore, refer to both the manner and the recording of the assessments and senior colleagues should thoroughly check assessments against the referrals or reports made ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct comprehensive assessments addressing referral concerns
Wider context from the report
“(2) a First Response Officer could go to a person’s home, could be told that it was OK to look in the occupant’s bedroom but feels it is ‘inappropriate’ to do so despite the fact that there have been concerns about the service user’s incontinence and personal hygiene from the referrer including a report as to the bedding being soiled with urine and faeces. Assessments should be made bearing in mind the referral and the actual concerns made and should be comprehensive, particularly when a service user has agreed to the assessment and examination proposed ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Lack of good practice guidelines for assessments
Wider context from the report
“(1) that there are no good practice guidelines for assessments that are being carried out leading to the fact that: ”
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 Family; that does not assign responsibility.
PFD Monitor interpretation
Failure to verify care arrangements and support needs
Wider context from the report
“(4) that no reference was made to any of the people to whom the service user referred as being carers, that information was wrongly recorded (a person wrongly described as a niece who was not a relative) and that there is a significant difference in the fact that the visit assessment suggests that the deceased had adequate social care whilst also noting that a ‘carer’ was not fit and able to undertake domestic tasks. That no investigation was properly made into the actual care available to Mr de Mello and no contact made with either the claimed carer or the relative with power of attorney to confirm the reality of his situation and the extent of his dependence or needs ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised9

Lack of guidance on assessment conduct and recording

Inaccurate and incomplete recording of carers and care arrangements

Failure to assess suitability of a commode for the service user

Inconsistent recording between assessments and correspondence

Failure to reconcile assessments with referral and historical information

Failure of senior review of assessments against referral information

Failure to conduct comprehensive assessments addressing referral concerns

Lack of good practice guidelines for assessments

Failure to verify care arrangements and support needs