Health Centre

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First report 29 Apr 2015•Latest report 7 Jan 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

7 Jan2026
Black Country
Concerns raised4
1. Use of insensitive Capillary Refill Time testing for dehydration assessment
2. Lack of clear national guidance on autism assessment
3. Failure to provide onward referral to dieticians experienced in autism and ARFID
1. Risk of dehydration among autistic children in similar circumstances
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Joshua Lee Allcock · 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

Joshua Lee Allcock, a five-year-old boy with complex medical needs and a limited diet, developed severe dehydration after entering foster care and died on 3 January 2023 despite hospital treatment. Concerns included the lack of a formal autism diagnosis and related dietary support, variation in autism assessment practice, and the potential for the capillary refill time test to provide misleading reassurance when assessing dehydration in children with similar circumstances.

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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Use of insensitive Capillary Refill Time testing for dehydration assessment
Wider context from the report
“5. The expert evidence also indicated that the Capillary Refill Time (CRT) test used to assess dehydration by checking peripheral blood flow is a very insensitive test and can provide misleading reassurance. Therefore, my concern is that young children with similar circumstances to Joshua maybe at risk when assessing levels of dehydration. NHS England may wish to consider reviewing their guidance for health professionals. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear national guidance on autism assessment
Wider context from the report
“2. My concern is that Joshua was never formally diagnosed with Autism and there appears to be nationally, a variation in practice before an assessment for autism can be made. Some areas specify 3 years of age or above but there is no clear national guidance. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide onward referral to dieticians experienced in autism and ARFID
Wider context from the report
“3. Regrettably, without a formal diagnosis of autism being made, there was no onward referral to dieticians with experience of autism and therefore an understanding of the link between autism and Avoidant restrictive food intake disorder (ARFID). ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Risk of dehydration among autistic children in similar circumstances
Wider context from the report
“4. In addition, I heard expert evidence that Joshua’s death wasn’t an isolated incident and another autistic child died in very similar circumstances by developing dehydration. ”
Open source report
30 Nov2017
Manchester South
Concerns raised5
1. Failure to enter engagement notes into the electronic system contemporaneously
2. Failure to verify and coordinate necessary referrals from the 136 suite to the GP
3. Failure to make documentation accessible to all relevant staff
1. Failure to retain contemporaneous engagement notes
2. Failure to keep records of information provided verbally by Police Officers in the s.136 suite
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Lindsey Theresa Hassall · 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

Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.

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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to enter engagement notes into the electronic system contemporaneously
Wider context from the report
“• Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager. (Lifeline/CGL) ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to verify and coordinate necessary referrals from the 136 suite to the GP
Wider context from the report
“• The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or 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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to make documentation accessible to all relevant staff
Wider context from the report
“• The documentation held by Pennine Care was not easily accessible to all of the staff working for Pennine Care which meant that the full history of engagement was not known to workers dealing with her. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to retain contemporaneous engagement notes
Wider context from the report
“• Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager. (Lifeline/CGL) ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep records of information provided verbally by Police Officers in the s.136 suite
Wider context from the report
“• There is no provision for a record to be kept of the information, which Police Officers provide verbally to the RAID practitioners in the s.136 suite. The inquest heard that there was a record of the initial circumstances but no further record was kept. (Pennine Care) ”
Open source report
9 Dec2015
Manchester South
Concerns raised5
1. Lack of medication-prescribing capability within substance misuse services
2. Failure to identify relevant safety issues in reviews of deaths
3. Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm
1. Failure to ensure relevant prescribing information is received and communicated to drug services
2. Fragmented substance-misuse care requiring young people to engage with an age-inappropriate second service
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Jake Robinson · 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

Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before his death.

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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of medication-prescribing capability within substance misuse services
Wider context from the report
“3) The fact that Phoenix Futures have no ability to prescribe medication to their services users was a concern. It meant that young people with substance misuse issues have to be referred to Trafford Aim, who are a service for people over the age of 26. Jake had a good relationship with Phoenix Futures but he did struggle to engage with services. The fact that he then had to engage with two services added to what in the Courts view was a disconnected approach to dealing with Jakes increasing difficulties. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify relevant safety issues in reviews of deaths
Wider context from the report
“2) The failure to identify the above issue as part of the review into the death of Jake Robinson is a concern as it highlights a missed opportunity to potentially learn lessons. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm
Wider context from the report
“4) There was no explanation in the review as to why the appointment clash between Trafford Aim and the Community Mental Health Team led to the appointment with the CMHT being rearranged. Particularly as Jake had made two recent serious attempts of self-harm in July 2015 and was at the very least recognised as a high risk of accidental harm. Given that Trafford Aim were not prescribing Jake at this time the Court had some difficulties in understanding what their role was given that he was also under Phoenix Futures for his substance misuse. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure relevant prescribing information is received and communicated to drug services
Wider context from the report
“1) The Court heard evidence that his GP had written to Greater Manchester West on the 23rd June 2015 (exactly to whom this letter was addressed is not known as it was not provided in the evidence from the GP practice) indicating that Jake could be prescribed diazepam following the investigation for his seizure. There was no indication in the review by GM West as to whether this letter had been received and if not why not. However neither of the Drug Services who were involved with Jake were aware of this information and therefore he was not commenced on any benzodiazepine reduction. This issue is being brought to the attention of all the recipients of this Regulation 28 report including the Medical Director for the Greater Manchester NHS Area who will be aware of the same concern raised in a separate recent case. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Fragmented substance-misuse care requiring young people to engage with an age-inappropriate second service
Wider context from the report
“3) The fact that Phoenix Futures have no ability to prescribe medication to their services users was a concern. It meant that young people with substance misuse issues have to be referred to Trafford Aim, who are a service for people over the age of 26. Jake had a good relationship with Phoenix Futures but he did struggle to engage with services. The fact that he then had to engage with two services added to what in the Courts view was a disconnected approach to dealing with Jakes increasing difficulties. ”
Open source report
29 Apr2015
Nottinghamshire
Concerns raised3
1. Failure to ensure learning from INR dosing events reaches all GPs at the practice
2. Failure to ensure relevant clinical information is systematically passed to the GP for INR dosing decisions
3. Lack of internal investigation of INR monitoring matters
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Doreen Wood · 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

Doreen Wood, who had atrial fibrillation and was taking Warfarin, died on 25 September 2014 from an intracerebral haemorrhage after repeated raised INR results. The report raised concerns that her INR was not checked soon enough and that the surgery’s monitoring system relied on healthcare assistants to volunteer relevant clinical information without routinely using standardised questionnaires.

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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure learning from INR dosing events reaches all GPs at the practice
Wider context from the report
“(1) I invite Newgate Street surgery to review their system of INR monitoring, in discussion with Nottinghamshire Healthcare NHS Foundation Trust. (2) Specifically, I invite the surgery to consider the use of standardised questionnaires, and not rely on healthcare assistants to volunteer – or indeed be aware of – relevant clinical information to pass on to the GP when dosing decisions are made. (3) There has been no internal investigation of these matters within the practice, other than a discussion between two of the GPs who treated Mrs Wood. We heard that there are at least six other GPs at the practice who deal with decisions like this on a regular basis. I invite the practice to carry out its own internal investigation, to ensure that the learning from these events includes all GPs at the practice. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure relevant clinical information is systematically passed to the GP for INR dosing decisions
Wider context from the report
“(1) I invite Newgate Street surgery to review their system of INR monitoring, in discussion with Nottinghamshire Healthcare NHS Foundation Trust. (2) Specifically, I invite the surgery to consider the use of standardised questionnaires, and not rely on healthcare assistants to volunteer – or indeed be aware of – relevant clinical information to pass on to the GP when dosing decisions are made. (3) There has been no internal investigation of these matters within the practice, other than a discussion between two of the GPs who treated Mrs Wood. We heard that there are at least six other GPs at the practice who deal with decisions like this on a regular basis. I invite the practice to carry out its own internal investigation, to ensure that the learning from these events includes all GPs at the practice. ”
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 Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of internal investigation of INR monitoring matters
Wider context from the report
“(1) I invite Newgate Street surgery to review their system of INR monitoring, in discussion with Nottinghamshire Healthcare NHS Foundation Trust. (2) Specifically, I invite the surgery to consider the use of standardised questionnaires, and not rely on healthcare assistants to volunteer – or indeed be aware of – relevant clinical information to pass on to the GP when dosing decisions are made. (3) There has been no internal investigation of these matters within the practice, other than a discussion between two of the GPs who treated Mrs Wood. We heard that there are at least six other GPs at the practice who deal with decisions like this on a regular basis. I invite the practice to carry out its own internal investigation, to ensure that the learning from these events includes all GPs at the practice. ”
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 raised4

Use of insensitive Capillary Refill Time testing for dehydration assessment

Lack of clear national guidance on autism assessment

Failure to provide onward referral to dieticians experienced in autism and ARFID

Risk of dehydration among autistic children in similar circumstances

Concerns raised5

Failure to enter engagement notes into the electronic system contemporaneously

Failure to verify and coordinate necessary referrals from the 136 suite to the GP

Failure to make documentation accessible to all relevant staff

Failure to retain contemporaneous engagement notes

Failure to keep records of information provided verbally by Police Officers in the s.136 suite

Concerns raised5

Lack of medication-prescribing capability within substance misuse services

Failure to identify relevant safety issues in reviews of deaths

Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm

Failure to ensure relevant prescribing information is received and communicated to drug services

Fragmented substance-misuse care requiring young people to engage with an age-inappropriate second service

Concerns raised3

Failure to ensure learning from INR dosing events reaches all GPs at the practice

Failure to ensure relevant clinical information is systematically passed to the GP for INR dosing decisions

Lack of internal investigation of INR monitoring matters