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First report 6 Nov 2019•Latest report 6 Nov 2019

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
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Manchester North

    AI-generated summary

    Hazel Maureen Lewis · 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

    Hazel Maureen Lewis died in hospital on 28 November 2018 after an unwitnessed fall caused a hip fracture; the medical cause of death was metastatic breast cancer, with the fracture contributing. Concerns were raised about the best-interest decision-making process, including inadequate consultation, failure to formally instruct an IMCA, insufficient exploration of support to help her engage with investigations, and uncertainty about the advocate’s role.

    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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to correctly identify the statutory advocate’s role

    Wider context from the report

    “The statutory advocate involved in the Deceased’s care was acting as a Care Act Advocate rather than an IMCA. I heard evidence that in order for the advocate to act as an IMCA, a separate referral to Advocacy Together would be required. Both the GP and social worker had understood that the advocate involved in the Deceased’s case was acting as an IMCA. There is a need for greater clarity as to which role an advocate is acting so that all agencies involved in the care of individuals lacking capacity can ensure that the requirements of the MCA are complied 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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate Mental Capacity Act training for decisions concerning life-sustaining treatment

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”
    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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about the referral requirements for IMCA involvement

    Wider context from the report

    “The statutory advocate involved in the Deceased’s care was acting as a Care Act Advocate rather than an IMCA. I heard evidence that in order for the advocate to act as an IMCA, a separate referral to Advocacy Together would be required. Both the GP and social worker had understood that the advocate involved in the Deceased’s case was acting as an IMCA. There is a need for greater clarity as to which role an advocate is acting so that all agencies involved in the care of individuals lacking capacity can ensure that the requirements of the MCA are complied 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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify and consult relevant consultees in Mental Capacity Act decisions

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”
    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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to correctly apply Mental Capacity Act capacity requirements to decisions about investigations

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”
    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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow the required order of Mental Capacity Act best-interest decision-making steps

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”
    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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to formally instruct an Independent Mental Capacity Advocate when required

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”
    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 Heywood Health; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to explore and advise on available support options for engagement with medical investigations or care

    Wider context from the report

    “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment. It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached. The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision. ”
    Open source report
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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