Concerns raised 9 Failure to formally request one-to-one supervision funding when necessary View source Failure to provide appropriate falls prevention for a resident with evolving dementia View source Failure to escalate a significant number of falls sustained by a frail older person View source Failure to provide organisational learning on accurate reporting and escalation View source Failure to provide training and development on falls prevention View source Failure to conduct appropriate risk assessment for a resident with evolving dementia View source Failure to meet the mobility needs of a resident with evolving dementia View source Failure to provide appropriate supervision for a resident with evolving dementia View source Failure to accurately and promptly report falls and complete falls-prevention referral forms View source See 6 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
Julia MURPHY · 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
Julia Murphy, known as Sheila, died in hospital on 9 April 2023 after a fall in her care home caused a hip fracture and her condition deteriorated. The report raises concerns about repeated falls, incomplete or inaccurate referrals to the falls prevention team, inadequate escalation, and failure to formally seek one-to-one supervision funding where appropriate.
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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to formally request one-to-one supervision funding when necessary
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate falls prevention for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate a significant number of falls sustained by a frail older person
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide organisational learning on accurate reporting and escalation
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide training and development on falls prevention
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct appropriate risk assessment for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to meet the mobility needs of a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility , supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate supervision for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately and promptly report falls and complete falls-prevention referral forms
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” Open source report
Concerns raised 3 Inadequate maintenance of road surfacing affected by natural movement and local geography View source Failure of inspections to reasonably identify hazardous defects on geologically unstable road surfacing View source Failure of highway operatives to identify defects hazardous to cyclists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Deliver approved toolbox-talk awareness training to all Highway Operatives, including defect impacts and procedures for reporting defects for assessment.
Stated plannedThe respondent said that this action was planned when they made their response on 23 February 2024. View source
Action
Deliver and disseminate an incident debrief covering lessons learned, operational instructions, defect reporting, surface cracking and hazards to all road users.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Continue researching techniques and products to increase the longevity of moss roads, including geosynthetic materials.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024. View source
Action
Conduct a commissioned peer review of the Highway Safety Inspection Policy, prioritising learning from this case.
Stated plannedThe respondent said that this action was planned when they made their response on 23 February 2024. View source
Action
Review the Moss Road Strategy, republish it with updates, and review it annually from 2024.
Stated plannedThe respondent said that this action was planned when they made their response on 23 February 2024. View source
Action
Deliver annual workshops for staff inspecting and assessing highway defects, covering policy compliance, national guidance and operational learning.
Stated plannedThe respondent said that this action was planned when they made their response on 23 February 2024. View source See 3 more actions
×
AI-generated summary
Harry College · 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
Harry Colledge, an 84-year-old man, died after his bicycle entered a crack in the carriageway on Island Lane, throwing him from the bicycle and causing fatal injuries. Concerns included highway operatives’ ability to identify defects hazardous to cyclists and the adequacy of maintaining road surfacing affected by natural movement and underlying geological features.
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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate maintenance of road surfacing affected by natural movement and local geography
Wider context from the report “2. Evidence from a Highways Expert, ████████, explained that Island Lane is part of peat/moss road which is the subject of natural movement when it rains. The water is absorbed by the peat/moss and swells caused the tarmac to move then it compacts when it dries and the road surface lowers, causing cracks. ████████’s evidence was that there is natural movement but these defects rarely get better, only worse. I am concerned that the road surfacing on Island Lane, Winmarleigh will continue to be the subject of natural movement and the present surfacing is hampered by the geography of the location including camber of the road . I consider there is a risk of future deaths to road users if the surfacing of this road is not adequately maintained . Whilst the inspection schedule timescales enacted by the Council are considered to be appropriate, I consider there is a risk of future deaths due to the present surfacing and underlying geological features of this road if inspections are unable to reasonably identify hazardous defects.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of inspections to reasonably identify hazardous defects on geologically unstable road surfacing
Wider context from the report “2. Evidence from a Highways Expert, ████████, explained that Island Lane is part of peat/moss road which is the subject of natural movement when it rains. The water is absorbed by the peat/moss and swells caused the tarmac to move then it compacts when it dries and the road surface lowers, causing cracks. ████████’s evidence was that there is natural movement but these defects rarely get better, only worse. I am concerned that the road surfacing on Island Lane, Winmarleigh will continue to be the subject of natural movement and the present surfacing is hampered by the geography of the location including camber of the road. I consider there is a risk of future deaths to road users if the surfacing of this road is not adequately maintained. Whilst the inspection schedule timescales enacted by the Council are considered to be appropriate, I consider there is a risk of future deaths due to the present surfacing and underlying geological features of this road if inspections are unable to reasonably identify hazardous defects .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of highway operatives to identify defects hazardous to cyclists
Wider context from the report “1. Highway operatives gave evidence that their inspections primarily consider the impact of defects upon cars using that road surface . All gave evidence of no specific training or experience with regards to identifying defects which present a hazard to bicycle users , when expert evidence indicated that the Council’s statutory duty required reasonable steps to protect all road users which includes cyclists. The evidence of Council witnesses was unanimous that since Mr Colledge’s death, there has been no additional training, updates, briefings or policy reviews to offer further knowledge of operatives in safely assessing defects which pose risks to cyclists or road users other than car drivers . I consider there is a risk of future deaths of all cyclists if Highways Operatives are not able to identify defects on a carriageway which present a risk to cyclists as opposed to simply car users .
” Open source report
×
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 approved toolbox-talk awareness training to all Highway Operatives, including defect impacts and procedures for reporting defects for assessment.
Verbatim wording from the response “As outlined above, there is an instruction in place that Highway Operatives are not to be used for defect identification through the "find and fix" method of working, their capacity being limited to repairing additional defects to those directed where they can be seen within existing traffic management arrangements.” Source location Response from Lancashire County Council
Open published response
×
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 and disseminate an incident debrief covering lessons learned, operational instructions, defect reporting, surface cracking and hazards to all road users.
Verbatim wording from the response “1. Inquest Debrief” Source location Response from Lancashire County Council
Open published response
×
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 Continue researching techniques and products to increase the longevity of moss roads, including geosynthetic materials.
Verbatim wording from the response “5. Moss Road Strategy” Source location Response from Lancashire County Council
Open published response
×
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 Conduct a commissioned peer review of the Highway Safety Inspection Policy, prioritising learning from this case.
Verbatim wording from the response “The Council has also identified that a peer review of the Highway Safety Inspection Policy could assist in identifying any changes or improvements to the current policy. The original policy was written in 2018 and was compared with other local authorities at that time. A peer authority has been commissioned and the review will start on 22.01.2024. It is anticipated that this review will take up to 8 months to complete.” Source location Response from Lancashire County Council
Open published response
×
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 Review the Moss Road Strategy, republish it with updates, and review it annually from 2024.
Verbatim wording from the response “Awareness of common defects on peat moss roads has been raised through the post-incident debrief, which is set out above.” Source location Response from Lancashire County Council
Open published response
×
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 annual workshops for staff inspecting and assessing highway defects, covering policy compliance, national guidance and operational learning.
Verbatim wording from the response “d) Awareness Training – front line highway teams” Source location Response from Lancashire County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highway Operatives are not responsible for identifying defects; Highway Safety Inspectors and Technicians carry out the inspection regime.
Verbatim wording from the response “Highway Operatives are not required to identify or assess any defect as set out in the Highway Safety Inspection Policy, however they are given the scope to repair additional defects they may see within the area of highway contained in any traffic management already in place.” Source location Response from Lancashire County Council
Open published response
17 Jun 2022 Margaret Florence Joyce Stringer · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of a fail-safe, documented system preventing residents’ access to restricted items View source Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers View source Lack of staff training on the detrimental effects of isolation and loneliness in elderly people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Florence Joyce Stringer · 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
Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.
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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a fail-safe, documented system preventing residents’ access to restricted items
Wider context from the report “1) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’)
Whereas the court heard evidence that Nightingales would not accept another patient with an equivalent medical profile/history and that, should a resident within one of Nightingales’ homes require access to items to be restricted, they would be given 1:1 support pending a mental health assessment and discharge to a more appropriate facility, it was not possible for the home concerned to advise the court as to how and by whom the lead in question had been returned to Mrs Stringer . The concern arises that, in the case of a resident whose care requires access to items to be restricted, there should be a fail-safe, documented system, known to and implemented by staff, by which access to those items by the resident is prevented . In the circumstances that the possibility of a resident requiring such care may still arise, this concern exists notwithstanding the decisions now 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers
Wider context from the report “3) (Addressed to Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited (the latter referred to collectively as ‘Nightingales’))
The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs Stringer’s risk of suicide . They included the following:
i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review;
ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge to Nightingales and for the family to have been invited, to ensure that everyone was aware of the plan, that the family was aware of Mrs Stringer’s legal status and to discuss next steps in terms of liaison with other services;
iii. There should have been greater professional curiosity and better communication at the time of transfer;
iv. The Harbour mental health hospital’s RNNA should have been reviewed to determine whether it needed to be updated and it should have been updated if there was any different clinical information. Further self harm or suicidal ideation, if seen to be significant, should have given rise to a further RNNA;
v. There had, in fact, been further indications of self harm and suicidal ideation and, in any event, of a wish to die, on 30th June 2020, in August 2020 and on 3rd September 2020 which were significant and should have been addressed in the information provided to Nightingales and had not been;
vi. Mrs Stringer was discharged from The Harbour mental health hospital without an up-to-date Care Act Assessment and, in any event, taking into account the need for Mrs Stringer to be transferred to the acute hospital (which had been necessary), an up-to-date Care Act Assessment had not been completed during the period of her admission to the latter hospital;
vii. The risk assessment should have been completed and provided to Nightingales;
viii. A positive behaviour support plan should have been completed and provided to Nightingales;
ix. A care plan, compliant with CPA Policy and Procedures Key Standard 10, which should have identified a suitable environment in which to manage Mrs Stringer’s risk, her needs and mental health and crisis and contingency planning, to cater for the event of a significant relapse in her mental health, should have been completed and provided to Nightingales;
x. Risk behaviour should have been identified to Nightingales and context given, whereas that had not been the case in respect of certain behaviour, including the incident on 30th June 2020;
xi. The care coordinator should have been better informed at the points of transfer and discharge;
xii. There should have been more robust follow up by the care coordinator whilst Mrs Stringer was at the acute hospital;
xiii. There had been no mental health service involvement between the 7-day follow up and 28th September 2020 or, if there had, it had not been recorded;
xiv. During the COVID-19 pandemic, it was not possible for a manager to carry out a face-to-face assessment in the mental health hospital but no equivalent measure had been implemented;
xv) Whereas it would have been helpful for Nightingales to have received the Continuing Healthcare Checklist, it had not been provided;
xvi) Nightingales would have wished to see the risk of suicide referred to in the “Risks to the Service User” section of the FACE Overview Assessment;
xvii) The court appointed expert had concerns about the accessibility of key information in the FACE Overview Assessment given the format of that document.
Whereas the court heard evidence concerning subsequent, significant, purposeful, developments in practice, the matters listed above can be condensed into a single concern that there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training on the detrimental effects of isolation and loneliness in elderly people
Wider context from the report “2) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’)
The court heard evidence as to the potential detrimental effects of isolation and loneliness in the elderly, including evidence from the court appointed expert that isolation can be very corrosive, that it is the single most potent causative risk factor for depression in the elderly and that it can have a very detrimental effect on a person’s mental state. There is a need for this to be known amongst staff . The concern arises as one member of staff gave (disputed) evidence that they had little or no training in such matters .
” Open source report
×
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 Review the format of the overview document to improve how risk information is presented.
Verbatim wording from the response “xvii - the format of this document will be reviewed, but it has a clear heading “risk” with a subdivision re self-harm/injury described as “serious apparent risk” and details of risk setting out mental health deterioration and attempts to kill herself (A1253). The review is taking place in line with the adoption of a strength based approach framework which has started and is planned to be rolled out across all Adult Social Care teams within the next 18 months. The Local Authority would question the proportionality of using Reg 28 in respect of a detail such as the format of a particular document.” Source location Response from Adult Community Social Care
Open published response
×
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 Meet and continue working with the relevant NHS Trusts to improve discharge information and systems.
Verbatim wording from the response “Hospitals NHS Foundation Trust in ensuring that their provision of information and systems at discharge are as effective as possible, LCC have agreed to meet with and will continue to work with the Trusts in the future.” Source location Response from Adult Community Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing assessment, risk management, information sharing and placement arrangements were considered adequate, requiring no specific corrective action.
Verbatim wording from the response “vi - an Assessment was available at discharge and this was provided to Nightingale prior to them accepting Mrs Stringer. The social worker was not able to see Mrs Stringer in BVH due to Covid restrictions. The placement at Nightingale was “for assessment” (A1264);” Source location Response from Adult Community Social Care
Open published response
Concerns raised 4 Fitting or adjustment of bed levers in the absence of the patient View source Lack of a policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team View source Failure to ensure prescribed bed levers are fitted by trained Occupational Therapy staff View source Failure to ensure bed levers fitted to Divan beds use a strap View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Implement service-user-present assessment and trained Occupational Therapy fitting of bed levers, with risk assessments, updated support plans, delivery-only supply, and twice-daily positioning checks.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source
Action
Review the updated bed rail and bed lever policy in April 2021 to confirm its clarity and appropriate implementation.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Rectify the miscommunication at Thornton House and agree that bed levers may be used when appropriate to residents’ needs.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source
Action
Update, publish, train staff on, and implement the bed rail and bed lever policy, including escalation of risk-assessment concerns, across all 16 LCC-operated older people’s residential homes.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source See 1 more action
×
AI-generated summary
Jean Williams · 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
Jean Williams, aged 80, died at Thornton House Care Home between 6.30 a.m. and 8.27 a.m. on 19 November 2017 after her head became trapped between her bed and a chest of drawers, with her neck resting on a bed lever. The report found that the bed lever’s securing strap had not been used. Concerns included bed levers being fitted or adjusted without the patient present, insufficient reporting and training arrangements, and the possible supply or fitting of bed levers without the required strap.
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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Fitting or adjustment of bed levers in the absence of the patient
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prescribed bed levers are fitted by trained Occupational Therapy staff
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House . Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them .
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure bed levers fitted to Divan beds use a strap
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report
×
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 Implement service-user-present assessment and trained Occupational Therapy fitting of bed levers, with risk assessments, updated support plans, delivery-only supply, and twice-daily positioning checks.
Verbatim wording from the response “The Occupational Therapist is responsible for the assessment of need for a bed lever which is undertaken with input from individual service users and considering their individual needs. The therapist will complete a prescription to the retailer on a deliver only basis. Only a trained member of the Occupational Therapy team can fit the bed lever and only with the service user present, to ensure it is relevant to their individual need. Risk assessments are undertaken at this time by both Occupational Therapy staff and LCC staff and support plans are updated to reflect the use of the bed lever.” Source location 2020-0239-Response-from-Lancashire-County-Council-Redacted.pdf
Open published response
×
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 Review the updated bed rail and bed lever policy in April 2021 to confirm its clarity and appropriate implementation.
Verbatim wording from the response “Following the hearing immediate action was taken to give guidance to staff on the escalation process. Our 'Bed Rail and Bed Lever Policy and Procedure' was already in place but that has now been updated, as referred to above, to make clear how concerns should be escalated and which staff/colleagues are to be made aware.
This updated document is live as of 08 January 2021 and a further review will take place in April 2021 to ensure it is clear to all staff and has been appropriately implemented.” Source location 2020-0239-Response-from-Lancashire-County-Council-Redacted.pdf
Open published response
×
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 Rectify the miscommunication at Thornton House and agree that bed levers may be used when appropriate to residents’ needs.
Verbatim wording from the response “c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.” Source location 2020-0239-Response-from-Lancashire-County-Council-Redacted.pdf
Open published response
×
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 Update, publish, train staff on, and implement the bed rail and bed lever policy, including escalation of risk-assessment concerns, across all 16 LCC-operated older people’s residential homes.
Verbatim wording from the response “This process is detailed in the updated LCC document titled OP103 Bed Rails and Bed Levers Policy and Procedure, which governs the process and to which staff are trained. LCC staff will also ensure that new bed lever deliveries are not fitted until a trained member of the Occupational Therapy team is able to fit them.” Source location 2020-0239-Response-from-Lancashire-County-Council-Redacted.pdf
Open published response
Concerns raised 1 Failure to proactively identify problems requiring repair in bus shelters 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
Freda Odette Mason · 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
Freda Odette Mason, who had underlying conditions including chronic obstructive pulmonary disease, osteoporosis and frailty fractures, fell through a bus shelter panel that was missing and sustained multiple rib fractures. She died in hospital three days later; the substantive concern was that the local authority used a reactive system for identifying bus shelter defects, without routine inspections or a requirement for users to report problems.
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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively identify problems requiring repair in bus shelters
Wider context from the report “LCC has a duty to maintain bus shelters within its area, and does so using a process whereby complaints are made to LCC by third parties – members of the public, councillors, employees of LCC and of bus companies – and LCC assesses the complaint and responds, effecting repairs where necessary. This is best described as a reactive process; and LCC does not operate an inspection system where it views the bus shelters. This means that unless a third party notifies LCC of a problem, it has no knowledge of it and cannot respond/repair.
In my opinion a more pro-active system of anticipating necessary repairs could prevent future deaths ; and LCC has the power to take further additional steps to ensure that problems requiring repair are brought to its attention immediately – whether by implementing a regime of inspection or by ensuring that those who use/visit the shelters [including bus drivers and inspectors] are required [or encouraged, where LCC does not have the authority to require it] to notify LCC of any problem which needs attention.
” Open source report
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 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
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective information .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Lancashire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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