18 Jul 2025 Dorothy Elizabeth Wagstaff · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Presence of plastic barriers in gaps in road barrier railings 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.
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AI-generated summary
Dorothy Elizabeth Wagstaff · 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
Dorothy Elizabeth Wagstaff died at the scene after the car she was driving collided with a post, temporary plastic barriers, railings and a lamp post on the A660 Leeds Road at Otley. It was found more likely than not that she had suffered a medical episode before the collisions. The principal concern was that temporary plastic barriers provided little resistance, allowing the car to leave the road, and that similar barriers remained elsewhere along the road.
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× 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Presence of plastic barriers in gaps in road barrier railings
Wider context from the report “(2) Upon examining photographs of the scene, the road barrier/railings and sections of the road, it was noted that plastic barriers similar to those referred to in the Record of Inquest above were present in another section of the A660 Leeds Road .
(3) Within the evidence adduced at the inquest, it was noted that Leeds City Council Highways Department have indicated that a schedule of works will be created with a view to replacing the old concrete and metal pole barriers with metal pedestrian railings in this area of the A660.
(4) The concern that I raise is that photographs considered at the inquest indicated the on-going presence of plastic barriers in a gap in the existing barrier/railings elsewhere along the stretch of road . Plastic barriers were a factor in the circumstances of the accident in which Mrs Langstaff sadly died . If that remains the case, I am of the view that action should be taken to prevent a risk of future deaths.
” Open source report
1 May 2024 Laura Gawthorpe · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Failure to provide complete fall-prevention fencing and barriers at car park levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Laura Gawthorpe · 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
Laura Gawthorpe, a voluntary patient at the Becklin Centre in Leeds, left on escorted leave on 13 September 2022 and deliberately fell from a car park, dying instantly from unsurvivable injuries. The report raised concern that fencing and barriers were only partially installed at the level from which she fell, leaving a parapet wall that could still easily be climbed over.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete fall-prevention fencing and barriers at car park levels
Wider context from the report “(1) The evidence of West Yorkshire Police was that, by the erection of extensive fencing and barriers, measures have been put in place on levels ████████ at the car park to make it harder for people to fall from those levels, whether deliberately or accidentally.
(2) The erection of similar measures on level ████████ has been only partial. The point from where Mrs Gawthorpe fell was identified by correlating her location on the ground with the location on level ████████ where she had left her phone before her fall. At that location, the parapet wall could still easily be climbed over.
” Open source report
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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 Procure and install additional physical barriers at identified upper-floor locations and throughout the car park.
Verbatim wording from the response “Since receiving your report we have been working very closely with a range of partners, including The Samaritans, Leeds City Council Public Health, and internal colleagues including Leeds Building Services, (our internal building services team), health and safety, communications, and our design and architecture technical consultants at Norse Consulting Ltd. to deliver a range of new prevention measures in relation to suicide at ████████. As part of our action plan, we have now finalised a technical specification for additional physical barriers at the locations you have identified on the ████████ floor and throughout the car park. A significant part of the car park already has barriers which have been installed at various times since the car park was originally built.” Source location 2024-0242 - Response from Leeds City Council
Open published response
21 Aug 2023 David Joseph Celino · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 5 Lack of authoritative guidance on permitted front-of-house drug testing View source Failure of festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions View source Lack of reliable records of drug-related festival casualties View source Lack of governing oversight of music festivals View source Lack of accurate information about the number of under-18 festival attendees View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Joseph Celino · 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
David Joseph Celino, aged 16, took tablets sold as an illicit drug at Leeds Festival in August 2022, developed an adverse reaction, and died after being treated at the festival field hospital and in hospital. The concerns included inadequate information about the number of under-18 attendees, the absence of national oversight and reliable data on drug-related casualties at music festivals, insufficient action to deter drug supply, and a failure by festival staff to identify and assist David as his condition deteriorated.
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× 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of authoritative guidance on permitted front-of-house drug testing
Wider context from the report “(6) Various witnesses raised the issue of “Front of House” drug testing, expressing views as to the benefits and disadvantages of this being permitted. It would help all those involved in the management of events similar to the Leeds Festival to have authoritative guidance on this subject, from the Home Office , along with clarification as to exactly what is permitted .
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions
Wider context from the report “(5) Evidence at the inquest indicated David Celino had walked about the Leeds Festival site between approximately 7pm and 8.45pm on the evening of Saturday 27 August 2022. As the signs of his adverse drug reaction developed, he was unable to walk straight, was pale, sweating profusely and agitated. In the latter stages he needed help from two other 16-year-olds to prevent him falling over. In this period, he passed through at least one check point manned by stewards or security staff. It is likely he encountered other festival staff and/or volunteers in this period also. Lamentably, no staff or volunteers spotted the need to intervene to ask about his well-being or offer assistance. This history suggests further instruction or training for festival staff and volunteers is required as to the need to be proactive, particularly in view of the prevalence of illicit drugs and teenagers. As it was, David Celino’s friends only obtained advice as to his condition from the drug dealer they happened to encounter, who reassured them that his reaction as “normal”.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of reliable records of drug-related festival casualties
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties , which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of governing oversight of music festivals
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate information about the number of under-18 festival attendees
Wider context from the report “(1) Neither the organiser of the festival (Festival Republic) nor Leeds City Council which licenced the event had accurate information about the number of people under 18 who were attending the festival. It was estimated to be 20% of the 90,000 attending, so about 18,000. In consequence, the magnitude of the problem of potentially vulnerable, naïve teenagers exposed to possible exploitation by drug dealers, was not appreciated.
” Open source report
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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 Write to the Secretary of State supporting a national music-festival oversight body and the availability of national drug-related casualty data.
Verbatim wording from the response “The Licensing Committee draws upon available specialist expertise from the multi-agency SAG in its consideration of the EMP for the Leeds Festival. The Council agrees that guidance, oversight and data from a national governing body for music festivals would be extremely valuable in this process and would welcome such a body being introduced. The Licensing Committee chair will write to the Secretary of State to support the introduction of such a body.” Source location Response from Leeds City Council
Open published response
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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 Festival Republic is responsible for providing detailed responses on drug deterrence measures and training for festival staff and volunteers.
Verbatim wording from the response “The Council can give an overview of steps taken on this issue in its role as Licensing Authority for the festival, but the responses from Festival Republic Ltd and West Yorkshire Police contain greater detail.” Source location Response from Leeds City Council
Open published response
25 Jul 2023 Paul Keating · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of statutory power to enter private dwellings to install sprinkler systems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Keating · 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
Paul Keating, aged 59, died on 15 April 2023 in a fire at the flat where he lived alone, from the combined effects of carbon monoxide toxicity and pre-existing heart disease. His flat was the only one in the tower block not connected to the sprinkler system because contractors could not enter without his consent, and smoke detectors had been disabled. The report raised concerns about the absence of statutory power for the local authority to enter the flat to install the sprinkler system.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory power to enter private dwellings to install sprinkler systems
Wider context from the report “(2) Being a single private dwelling, albeit in a tower block, Mr Keating’s flat was not covered by the provisions of The Regulatory Reform (Fire Safety) Order 2005. The local authority had no statutory power to enter Mr Keating’s flat for the purposes of installing a sprinkler system without his consent.
(3) Over a period of six months during which the sprinkler system was installed in the tower block where Mr Keating lived, he did not respond to letters informing him of the planned installation of the sprinkler system and inviting his agreement to contractors entering his flat as part of that work. He additionally refused to open his door to the tenant liaison officer. (Further, it was discovered after his death that Mr Keating had disabled the hard-wired smoke detector and a battery-operated smoke detector within his flat.)
(4) The necessary work was done in the common parts of the building to connect Mr Keating’s flat to the sprinkler system, but the work done could not cross the threshold of his flat without his consent. Of the 98 flats in the building, Mr Keating’s was the only flat not connected to the sprinkler system.
(5) If the local authority had had the statutory power to enter Mr Keating’s flat for the purposes of installing the sprinkler system, it would have exercised that power and Mr Keating’s flat would have been connected to that system.
” Open source report
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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 Install sprinkler systems in tower blocks, including coverage for individual flats.
Verbatim wording from the response “As your report recognises, since 2017 Leeds City Council has adopted a proactive approach to improving fire safety within its tower blocks, following the Grenfell tragedy. This included installing sprinkler systems in those tower blocks. These sprinklers are intended to cover not only the common parts of the buildings, which fall within the scope of the Regulatory Reform (Fire Safety) Order 2005 (as amended by the Fire Safety Act 2021), but also individual flats within the blocks, which are outside the scope of the 2005 order.” Source location Response from Leeds City Council
Open published response
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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 Legal powers did not permit entry without tenant consent to install sprinklers classified as improvement works and not legally required inside flats.
Verbatim wording from the response “Because the works to install sprinklers would be deemed to be improvement works rather than repair or emergency works, and because sprinklers are not currently a legal requirement inside individual flats, the Council did not have legal powers to gain entry against Mr Keating’s wishes to carry out those works. This is the main area of concern raised in your report.” Source location Response from Leeds City Council
Open published response
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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 Central government must consider granting landlords additional legal powers to undertake safety works without tenant consent.
Verbatim wording from the response “The granting of additional legal powers to landlords, in order to permit them to carry out safety works without the tenant’s consent, is a matter over which the Council has no control but falls to be considered by central government, and I note that the report was also addressed to the Home Office. I would however like to endorse your concerns as expressed in paragraphs 5 and 6 of the Matters of Concern.” Source location Response from Leeds City Council
Open published response
23 Jun 2021 Netlyn Mae ROBINSON · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 8 Failure to assess current medical needs before vulnerable people return home View source Failure to check that premises have heating, running water and smoke alarms before vulnerable people return View source Failure to check that vulnerable people have a working telephone for calling assistance or communicating View source Lack of defined social services responsibilities for ensuring premises are suitable View source Failure to check the availability and operation of personal alarm systems before vulnerable people return home View source Failure to provide relevant information about the absence of an alarm before a person decides whether to return home View source Lack of a checklist for assessing numerous issues before vulnerable people return home View source Lack of risk assessment for how an alarm could be raised View source See 5 more concerns
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
Develop and publish guidance for the Conversation Record pro-forma covering medical needs, equipment and referrals, risk assessment, mitigation plans, service-user views, and documented capacity decisions.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Purchase a temporary pay-as-you-go mobile phone for discharge where a telephone, personal mobile or required telecare equipment is unavailable.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Develop and deliver lessons-learned training for Mental Health Unit staff covering telecare, discharge planning, equipment checks, capacity recording and related safety processes.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Establish a task-and-finish group to develop a discharge checklist covering utilities, safety equipment, environmental and occupational therapy assessments, and discharge-day home visits where indicated.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source See 1 more action
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AI-generated summary
Netlyn Mae ROBINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Netlyn Mae ROBINSON returned home on 2 October 2020 after adaptations for her reduced mobility, with three daily care visits. She was found the following morning at the dining table having choked on food. The report identified concerns about the absence of a falls alarm and working telephone, lack of risk assessment and checks for heating, water and smoke alarms, and insufficient processes for assessing whether her home was safe for her return.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess current medical needs before vulnerable people return home
Wider context from the report “(5) The social worker stated he had been trained on the job to risk assess. He had never been shown a check list for the numerous issues that need to be checked prior to allowing a vulnerable person to be returned home. This included checking on current medical needs (although Mrs Robinson did not have any reported issue regarding eating/chewing/swallowing the question was not asked by the social worker ensuring her safe return home )
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check that premises have heating, running water and smoke alarms before vulnerable people return
Wider context from the report “(4) The heating was not working/turned on and again there appeared to be no process in place to check premises had heating, running water or smoke alarms and therefore was fit and safe for a vulnerable person to return 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check that vulnerable people have a working telephone for calling assistance or communicating
Wider context from the report “(2) The telephone line was not connected. There appeared to be no process in place to check that telephones are working and that a vulnerable person has the ability to call for assistance (emergency or otherwise) or communicate with friends/relatives.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of defined social services responsibilities for ensuring premises are suitable
Wider context from the report “(6) It was acknowledged that the home was owned by Mrs Robinson however there appeared no processes in place to outline what social services would and would not do to ensure that Mrs Robinson’s premises were suitable.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check the availability and operation of personal alarm systems before vulnerable people return home
Wider context from the report “(1) In evidence it became apparent that there was no falls pendant or alarm provided on Mrs Robinson’s return home despite her previously having one when last at home. There appeared to be no process in place to check whether there was a fully operational alarm system in place when needed. Further that Mrs Robinson was not consulted about the lack of an alarm until she had arrived home, thus no process in place to provide a person with relevant information in order that they are able to decide whether or not to return to their home address without any form of alarm.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant information about the absence of an alarm before a person decides whether to return home
Wider context from the report “(1) In evidence it became apparent that there was no falls pendant or alarm provided on Mrs Robinson’s return home despite her previously having one when last at home. There appeared to be no process in place to check whether there was a fully operational alarm system in place when needed. Further that Mrs Robinson was not consulted about the lack of an alarm until she had arrived home, thus no process in place to provide a person with relevant information in order that they are able to decide whether or not to return to their home address without any form of alarm.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a checklist for assessing numerous issues before vulnerable people return home
Wider context from the report “(5) The social worker stated he had been trained on the job to risk assess. He had never been shown a check list for the numerous issues that need to be checked prior to allowing a vulnerable person to be returned home. This included checking on current medical needs (although Mrs Robinson did not have any reported issue regarding eating/chewing/swallowing the question was not asked by the social worker ensuring her safe return home)
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for how an alarm could be raised
Wider context from the report “(3) With a lack of alarm or phone line there was still no risk assessment as to how an alarm could be raised.
” Open source report
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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 Develop and publish guidance for the Conversation Record pro-forma covering medical needs, equipment and referrals, risk assessment, mitigation plans, service-user views, and documented capacity decisions.
Verbatim wording from the response “Conversation Record Pro-Forma Guidance Notes (applies to points 1,5,6)” Source location 2021-0219-Response-from-Leeds-City-Council_Published
Open published response
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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 Purchase a temporary pay-as-you-go mobile phone for discharge where a telephone, personal mobile or required telecare equipment is unavailable.
Verbatim wording from the response “MHU Emergency Telephone (applies to point 1)” Source location 2021-0219-Response-from-Leeds-City-Council_Published
Open published response
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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 Develop and deliver lessons-learned training for Mental Health Unit staff covering telecare, discharge planning, equipment checks, capacity recording and related safety processes.
Verbatim wording from the response “Lessons Learnt Training Session (applies to points 1-6)” Source location 2021-0219-Response-from-Leeds-City-Council_Published
Open published response
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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 Establish a task-and-finish group to develop a discharge checklist covering utilities, safety equipment, environmental and occupational therapy assessments, and discharge-day home visits where indicated.
Verbatim wording from the response “Discharge Checklist/Crib Sheet (applies to points 1,2,3,4,6)” Source location 2021-0219-Response-from-Leeds-City-Council_Published
Open published response
19 Jan 2021 Anya Lily Buckley · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Availability of illicit drugs at festivals View source Admission of 16-17-year-olds without adult supervision View source Exposure of potentially vulnerable young people to available illicit drugs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Anya Lily Buckley · 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
Anya Lily Buckley, aged 17, attended the Leeds Festival, took various illicit drugs, collapsed and died at the festival site on 24 August 2019 despite CPR. The concerns included the admission of unsupervised 16- and 17-year-olds to the festival, their exposure to illicit drugs and alcohol, and whether Leeds City Council’s licensing arrangements adequately addressed risks to potentially vulnerable teenagers.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Availability of illicit drugs at festivals
Wider context from the report “(1) Young people aged 16-17 are admitted to the Leeds Festival without any adult supervision.
(2) Illicit drugs are a fact of life at festivals such as this, despite the efforts made by the organiser to prevent them getting in, and to treat those who are harmed by them. The infrastructure of drug searches and medical resources testifies to this.
(3) The mixture of potentially vulnerable young people and available illicit drugs creates a tempting situation for the excited teenagers and exposes them to the potential harm which illicit drugs can inflict.
(4) As teenagers aged 16-17 are not legally permitted to be in public houses or night clubs, it seems anomalous that they should be free to spend the while night in an environment where illicit drugs and alcohol are prevalent.
(5) Evidence was given at Inquest by Miss Buckley's mother that entry should be restricted to people under the age of 18. In fairness, evidence was also given in relation to: a) the difficulty of checking age, and b) the possibility that young people will search for excitement elsewhere if they cannot attend well-organised festivals and the casualty rate of those adversely affected by drugs is low when set against the huge numbers of young people attending.
(6) As Leeds City Council licenses the Leeds Festival, it is for them to consider whether admitting 16-17 year old teenagers into the festival (when they are not permitted in other licensed premises) amounts to an abdication of responsibility in relation to impressionable and potentially vulnerable teenagers.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Admission of 16-17-year-olds without adult supervision
Wider context from the report “(1) Young people aged 16-17 are admitted to the Leeds Festival without any adult supervision.
(2) Illicit drugs are a fact of life at festivals such as this, despite the efforts made by the organiser to prevent them getting in, and to treat those who are harmed by them. The infrastructure of drug searches and medical resources testifies to this.
(3) The mixture of potentially vulnerable young people and available illicit drugs creates a tempting situation for the excited teenagers and exposes them to the potential harm which illicit drugs can inflict.
(4) As teenagers aged 16-17 are not legally permitted to be in public houses or night clubs, it seems anomalous that they should be free to spend the while night in an environment where illicit drugs and alcohol are prevalent.
(5) Evidence was given at Inquest by Miss Buckley's mother that entry should be restricted to people under the age of 18. In fairness, evidence was also given in relation to: a) the difficulty of checking age, and b) the possibility that young people will search for excitement elsewhere if they cannot attend well-organised festivals and the casualty rate of those adversely affected by drugs is low when set against the huge numbers of young people attending.
(6) As Leeds City Council licenses the Leeds Festival, it is for them to consider whether admitting 16-17 year old teenagers into the festival (when they are not permitted in other licensed premises) amounts to an abdication of responsibility in relation to impressionable and potentially vulnerable teenagers.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Exposure of potentially vulnerable young people to available illicit drugs
Wider context from the report “(1) Young people aged 16-17 are admitted to the Leeds Festival without any adult supervision.
(2) Illicit drugs are a fact of life at festivals such as this, despite the efforts made by the organiser to prevent them getting in, and to treat those who are harmed by them. The infrastructure of drug searches and medical resources testifies to this.
(3) The mixture of potentially vulnerable young people and available illicit drugs creates a tempting situation for the excited teenagers and exposes them to the potential harm which illicit drugs can inflict.
(4) As teenagers aged 16-17 are not legally permitted to be in public houses or night clubs, it seems anomalous that they should be free to spend the while night in an environment where illicit drugs and alcohol are prevalent.
(5) Evidence was given at Inquest by Miss Buckley's mother that entry should be restricted to people under the age of 18. In fairness, evidence was also given in relation to: a) the difficulty of checking age, and b) the possibility that young people will search for excitement elsewhere if they cannot attend well-organised festivals and the casualty rate of those adversely affected by drugs is low when set against the huge numbers of young people attending.
(6) As Leeds City Council licenses the Leeds Festival, it is for them to consider whether admitting 16-17 year old teenagers into the festival (when they are not permitted in other licensed premises) amounts to an abdication of responsibility in relation to impressionable and potentially vulnerable teenagers.
” Open source report
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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 Carefully assess the Event Management Plan through the Safety Advisory Group to verify safeguarding, drug prevention and medical provisions.
Verbatim wording from the response “• The Event Management Plan (EMP) will be carefully considered through the Safety Advisory Group process for all relevant agencies to be satisfied with the safeguarding, drug prevention and medical provisions at the Festival;” Source location 2021-0014-Response-from-Leeds-City-Council-Redacted
Open published response
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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 Use the Safety Advisory Group process after the 2021 festival to measure the effectiveness of additional welfare and safeguarding measures and inform future arrangements.
Verbatim wording from the response “• Following the 2021 festival, the Safety Advisory Group process will be used to measure the effectiveness of additional welfare and safeguarding measures and future arrangements going forward, which could include, if necessary, consideration of an age restriction of attendees.” Source location 2021-0014-Response-from-Leeds-City-Council-Redacted
Open published response
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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 Establish a Leeds Festival Safety Advisory Group subgroup to review education, welfare, safeguarding, drug prevention, voluntary testing, attendee demographics and protection of minors.
Verbatim wording from the response “• A sub group of the Safety Advisory Group process, specific to the Leeds Festival, will be set up to consider education, welfare and safeguarding, and in particular:” Source location 2021-0014-Response-from-Leeds-City-Council-Redacted
Open published response
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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 An age restriction is not required by legislation or national guidance and might not have prevented attendance.
Verbatim wording from the response “The licensing of festivals is dealt with by councils within a statutory framework. The Premises Licence for the festival was granted pursuant to the Licensing Act 2003. To limit the age range of attendees at a festival would require a condition to be attached to the licence. This could be by consent, or otherwise could arise from a review of the licence through application of a responsible authority. If a licence holder were to disagree with a condition there is a process to follow including a hearing, with a right of appeal to the Magistrates’ Court.” Source location 2021-0014-Response-from-Leeds-City-Council-Redacted
Open published response
27 Feb 2019 Hoshi Jane Naylor · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Sparse provision of facilitated pedestrian crossing points on the A6120 View source Failure of street lighting to adequately illuminate grass verges at the collision site View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hoshi Jane Naylor · 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
Hoshi Jane Naylor, aged 12, was struck by a car while crossing the A6120 Leeds outer ring road on 4 January 2018 and died from her injuries in hospital one week later. Concerns included the sparse provision of pedestrian crossing facilities near the collision site and limited illumination of the grass verges, which could restrict motorists’ awareness of pedestrians intending to cross.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Sparse provision of facilitated pedestrian crossing points on the A6120
Wider context from the report “(1) The point at which Hoshi started to cross the road is approximately opposite a bus stop and a shop which she was intending to visit to buy packed lunch provisions for a school trip the following day. It is a point where pedestrians can reasonably be anticipated to cross the road to and from the bus stop and the shop.
(2) The nearest pedestrian refuge island to the scene of the collision is approximately 500 metres away from it, in an eastbound direction.
(3) The nearest traffic signal controlled pedestrian crossing to the scene of the collision is approximately 940 metres away from it, in an eastbound direction.
(4) In the opinion of a Forensic Collision Investigator called as an expert witness to the Inquest, the provision of facilitated pedestrian crossing points on this stretch of the A6120 (whether facilitated by refuge islands or pedestrian crossings) is sparse in comparison to such provision on similar stretches of the A6120 elsewhere along its length.
(5) The street lighting at the collision site appears to offer little illumination of the grass verges to either side of the road. In dark conditions, motorists' awareness of pedestrians intending to cross the road is likely to be restricted.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of street lighting to adequately illuminate grass verges at the collision site
Wider context from the report “(1) The point at which Hoshi started to cross the road is approximately opposite a bus stop and a shop which she was intending to visit to buy packed lunch provisions for a school trip the following day. It is a point where pedestrians can reasonably be anticipated to cross the road to and from the bus stop and the shop.
(2) The nearest pedestrian refuge island to the scene of the collision is approximately 500 metres away from it, in an eastbound direction.
(3) The nearest traffic signal controlled pedestrian crossing to the scene of the collision is approximately 940 metres away from it, in an eastbound direction.
(4) In the opinion of a Forensic Collision Investigator called as an expert witness to the Inquest, the provision of facilitated pedestrian crossing points on this stretch of the A6120 (whether facilitated by refuge islands or pedestrian crossings) is sparse in comparison to such provision on similar stretches of the A6120 elsewhere along its length.
(5) The street lighting at the collision site appears to offer little illumination of the grass verges to either side of the road. In dark conditions, motorists' awareness of pedestrians intending to cross the road is likely to be restricted.
” Open source report
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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 Widen the carriageway to construct a pedestrian refuge at the crossing location.
Verbatim wording from the response “However given the circumstance behind the sad death of Ms Naylor and the continued desire line to the shop for the residential area to the south of the Ring Road, a scheme has been included in this year’s works program to widen the carriageway at this location to enable a pedestrian refuge to be constructed. In addition to these proposed works it is also proposed to provide lighting within the grassed area to illuminate the route and to highlight the presence of any pedestrians walking towards the road to cross.” Source location 2019-0076-Response-by-Leeds-City-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 Install lighting in the grassed area to illuminate the pedestrian route and highlight pedestrians approaching the road.
Verbatim wording from the response “However given the circumstance behind the sad death of Ms Naylor and the continued desire line to the shop for the residential area to the south of the Ring Road, a scheme has been included in this year’s works program to widen the carriageway at this location to enable a pedestrian refuge to be constructed. In addition to these proposed works it is also proposed to provide lighting within the grassed area to illuminate the route and to highlight the presence of any pedestrians walking towards the road to cross.” Source location 2019-0076-Response-by-Leeds-City-Council
Open published response
2 Oct 2018 Joshua Lee Edwards · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to provide road signs that preserve emergency vehicle access at designated crossing points View source Failure to escalate repeated requests for an ambulance in the control room View source Failure to ensure public-event personnel and participants are informed about emergency vehicle crossings View source Failure to ensure ambulance crews understand emergency authority to cross road closure signs View source Failure to maintain emergency vehicle access during public events View source See 2 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
Joshua Lee Edwards · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joshua Lee Edwards, aged 19, became unwell in Leeds after taking ecstasy and cocaine and died in hospital on 15 May 2017 despite treatment. The ambulance was delayed by road closures for the Leeds 10K run, and concerns were raised that repeated calls from police did not lead to escalation and that ambulance crews were unclear about crossing road-closure signs in an emergency.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide road signs that preserve emergency vehicle access at designated crossing points
Wider context from the report “(4) Road closure signs at such designated crossing points should be replaced by signs indicating ‘Access to emergency vehicles only’ or equivalent wording.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate repeated requests for an ambulance in the control room
Wider context from the report “(1) The ambulance despatched to the scene encountered roads closed for the Leeds 10K run that day. It then navigated a route around the course, thus encountering a delay in reaching the casualty. The Police Officers at the scene telephoned three times to ask where the ambulance was but this did not result in the situation being escalated in the control room at Yorkshire Ambulance Service.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure public-event personnel and participants are informed about emergency vehicle crossings
Wider context from the report “(3) In the preparation for such public events, the organisers should be required to brief their Marshalls that at specified crossing points, the event may require to be halted momentarily to allow emergency response vehicles to cross . In short, that an emergency may take precedence. Participants in the event should also be forewarned of the possibility of this occurring.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure ambulance crews understand emergency authority to cross road closure signs
Wider context from the report “(2) Evidence taken at the Inquest indicated that ambulance crews were unclear as to whether they were entitled to cross ‘road closure’ signs in an emergency . Clarification of the Ambulance Service authority to do so in an emergency has been given, but has not yet been circulated to all ambulance crews . This needs to be done on the morning of such events. Ambulance crews should be reminded of this power by way of a refresher briefing. Similar considerations arise in relation to the Fire and Rescue Service.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain emergency vehicle access during public events
Wider context from the report “(1) The ambulance despatched to the scene encountered roads closed for the Leeds 10K run that day . It then navigated a route around the course, thus encountering a delay in reaching the casualty . The Police Officers at the scene telephoned three times to ask where the ambulance was but this did not result in the situation being escalated in the control room at Yorkshire Ambulance Service.
” Open source report
6 Jun 2018 Carol Metcalfe · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of measures to protect pedestrians crossing the A63 dual carriageway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carol Metcalfe · 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
Carol Metcalfe died from chest and abdominal injuries after being struck by a heavy goods vehicle while crossing the A63 Selby Road near Waterloo Manor Hospital. The principal concern was the need for measures to protect pedestrians, including patients leaving the hospital, when crossing the dual carriageway near the hospital.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of measures to protect pedestrians crossing the A63 dual carriageway
Wider context from the report “The need for measures to be taken to protect pedestrians crossing the A63 dual carriageway in the vicinity of Waterloo Manor Hospital.
” Open source report
×
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 informal pedestrian crossing measures were considered the most appropriate provision, so no further highway intervention was offered.
Verbatim wording from the response “I have as part of this investigation assessed the site for a formal pedestrian crossing based on the national assessment criteria based the LTN 1/95 “The assessment of pedestrian crossings”. This assessment process considered the site characteristics, vehicular and pedestrian usage, forward visibility, road environment, speed of road and previous road safety history. My conclusion after this review was that informal measures which have already been provided are the most appropriate provision for this location.” Source location 2018-0175-Response-by-Leeds-City-Council
Open published response
2 Mar 2015 Alison Dawn Evers · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Lack of a policy ensuring first-aid-trained staff on duty for each shift View source Lack of a written no-treats policy View source Insufficient first-aid training level among health support workers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alison Dawn Evers · 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
Alison Dawn Evers, who was dependent on care staff and had swallowing difficulties, suffered hypoxia and cardiac arrest after choking on a sweet given contrary to her dietary support plan. The principal concerns were the lack of a written no-treats policy, the absence of a policy ensuring first-aid-trained staff on every shift, and the level of first-aid training among healthcare support workers.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy ensuring first-aid-trained staff on duty for each shift
Wider context from the report “(2) The lack of a policy ensuring a first aid trained member of staff is on duty for each shift .
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a written no-treats policy
Wider context from the report “(1) The lack of a written ‘no treats policy’ .
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient first-aid training level among health support workers
Wider context from the report “(3) Level of first Aid training of health support workers , particularly if working with service users who suffer from cognitive and/or physical impairment and are dependant on carers to meet their personal and dietary needs .
” Open source report
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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 Provide and renew First Aid at Work and Fundamental First Aid training through a continuing professional-development programme.
Verbatim wording from the response “The Council provides staff with First Aid Training as part of its on-going programme of continuing professional development. The courses which are provided are First Aid in Work and Fundamental First Aid.” Source location 2015-0074-Response-by-Leeds-City-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 Assess individual customer needs with specialist professional input and create bespoke risk assessments, support plans and dietary placemat plans.
Verbatim wording from the response “The ethos of the Council’s Social Care Services is to provide in all cases the best and most appropriate person centred care that it can for each individual that it serves. The customers of the Learning Disability Community Support Service have vastly divergent and highly individualised needs and wishes. We aim to meet them all. To achieve this we have created a range of highly personalised risk assessment tools and Individual Support Plans which are bespoke to each of our customers.” Source location 2015-0074-Response-by-Leeds-City-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 Individual risk assessments, support plans and placemat plans adequately address choking risks, making a mandatory written no-treats policy inappropriate.
Verbatim wording from the response “The ethos of the Council’s Social Care Services is to provide in all cases the best and most appropriate person centred care that it can for each individual that it serves. The customers of the Learning Disability Community Support Service have vastly divergent and highly individualised needs and wishes. We aim to meet them all. To achieve this we have created a range of highly personalised risk assessment tools and Individual Support Plans which are bespoke to each of our customers.” Source location 2015-0074-Response-by-Leeds-City-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 The existing first-aid training regime adequately addresses concerns about staff first-aid competence, so additional training is unnecessary.
Verbatim wording from the response “The Council provides staff with First Aid Training as part of its on-going programme of continuing professional development. The courses which are provided are First Aid in Work and Fundamental First Aid.” Source location 2015-0074-Response-by-Leeds-City-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 There is no need to engage health support workers because customers generally do not have complex or additional medical needs.
Verbatim wording from the response “As previously mentioned, the customers that are served by the Learning Disability Community Support Service do not generally present with complex and additional medical needs. There is therefore no need for the service to engage the services of “health support workers” as mentioned in the Coroner’s report.” Source location 2015-0074-Response-by-Leeds-City-Council
Open published response
17 Nov 2014 Mrs Gladys Smith · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 16 Failure to fully record wound dimensions and presenting features on each District Nurse visit View source Failure to regularly and fully record residents' weights View source Lack of Care Home staff knowledge of dementia care View source Lack of comprehensive national guidance on prevention and treatment of impact-injury wounds and ulcers View source Delays in District Nurse referrals to the Tissue Viability Nurse Service View source Failure to regularly monitor residents' weights View source Failure to body map residents' bruises View source Failure to complete turning and repositioning charts View source Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service View source Failure to implement nutrition charts for residents with significant weight loss View source Failure to proactively seek medical practitioners' care advice for residents with recognised medical conditions View source Failure to undertake regular falls assessments for residents View source Delays in seeking medical advice after apparent impact injury bruising View source Failure to implement medical practitioners' advice and instruction on resident turning and repositioning View source Failure to consider the appropriate location of residents' rooms View source Delays in seeking medical advice after significant resident weight loss View source See 13 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
Mrs Gladys Smith · 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
Mrs Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to fully record wound dimensions and presenting features on each District Nurse visit
Wider context from the report “(a) Members of the District Nursing Team who attended upon Mrs Smith did not, upon each visit, fully record and document the dimensions and presenting features of the wound . In the circumstances, the Trust should ensure District Nurses do record and document all bruises and/or wounds, in particular the dimensions of the same together with a detailed description as to all presenting features;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly and fully record residents' weights
Wider context from the report “(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded . In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights';
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of Care Home staff knowledge of dementia care
Wider context from the report “(g) Mrs Smith suffered from vascular dementia and had done so since the commencement of her residency at the Care Home. A number of other residents suffer from dementia. Care Assistants at the said Care Home have little or no knowledge of dementia and, consequently, how to care for residents suffering from such a condition . In the circumstances, all Care Home staff should undergo more indepth training in relation to dementia;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive national guidance on prevention and treatment of impact-injury wounds and ulcers
Wider context from the report “(a) There are no NICE guidelines which provide any comprehensive guidance to Medical Practitioners in relation to the prevention and treatment of wounds and ulcers caused by impact injuries . Clinical Guideline 29 – The prevention and treatment of pressure ulcers, does not give guidance in respect of wounds/ulcers caused by impact injuries . In the circumstances there should be national guidelines which deal with such
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in District Nurse referrals to the Tissue Viability Nurse Service
Wider context from the report “(b) Mrs Smith was referred to the Tissue Viability Nurse Service on or around 25 June 2012, some 12 days after a referral ought to have been made according to expert evidence adduced in the course of the Inquest. In the circumstances, the Trust should ensure District Nurses make referrals to the Tissue Viability Nurse Service timeously;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly monitor residents' weights
Wider context from the report “(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded. In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights';
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to body map residents' bruises
Wider context from the report “(b) None of the bruises sustained by Mrs Smith, in particular the one which was noticed on the 25 May 2012, were body mapped by Care Home staff. In the circumstances, staff should ensure that all bruises sustained by residents are carefully body mapped at the first available opportunity;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete turning and repositioning charts
Wider context from the report “(a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs Smith was not followed and repositioning charts were not completed . In the circumstances, all Care Home staff should ensure that all advice and instruction given by medical practitioners, that is to say by General Practitioners and District Nurses, in relation to residents is appropriately implemented and that turning/repositioning charts are completed;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service
Wider context from the report “(c) The Trusts Clinical Guidelines for Wound Management in Adults and Children omits to provide guidance as to when District Nurses should refer patients to the Tissue Viability Nurse Service . In the circumstances, the Trust should amend the said Clinical Guidelines in order to provide comprehensive guidance as to when such a referral to the said Service should be 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement nutrition charts for residents with significant weight loss
Wider context from the report “(f) Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a nutrition chart implemented in order to monitor Mrs Smith's nutritional intake . Moreover, medical advice in relation to Mrs Smith's weight loss was only sought a number of weeks after the commencement of the said weight loss. In the circumstances, Care Home staff should ensure nutrition charts are completed in respect of any resident whose weight falls significantly and should ensure appropriate medical advice is sought at the first available opportunity following such a fall in weight;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively seek medical practitioners' care advice for residents with recognised medical conditions
Wider context from the report “(h) Care Home staff do not proactively enquire of medical practitioners as to how to care for residents with certain medical conditions – for example, hiatus hernias, dementia. In the circumstances, Care Home staff should ensure proactive enquiries are made of relevant medical practitioners at the earliest opportunity as to the appropriate care for residents suffering from recognised medical conditions.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake regular falls assessments for residents
Wider context from the report “(d) Falls assessments in respect of Mrs Smith whilst a resident at the Care Home were not regularly undertaken and no consideration was at any time given by Care Home staff as to the most appropriate location for Mrs Smith's room within the Care Home. In the circumstances, falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking medical advice after apparent impact injury bruising
Wider context from the report “(c) On or around 25 May 2012 bruising on the left side of Mrs Smith's bottom cheek was noted by a Care Home staff together with a blister. However, District Nurse attendance in respect of an open area on Mrs Smith's bottom on her left side took place 7 (seven) days later on 11 June 2012. In the circumstances, Care Home staff should ensure appropriate medical advice is sought at the first available opportunity upon noticing a bruise to a resident following an apparent impact injury;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement medical practitioners' advice and instruction on resident turning and repositioning
Wider context from the report “(a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs Smith was not followed and repositioning charts were not completed. In the circumstances, all Care Home staff should ensure that all advice and instruction given by medical practitioners, that is to say by General Practitioners and District Nurses, in relation to residents is appropriately implemented and that turning/repositioning charts are completed;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the appropriate location of residents' rooms
Wider context from the report “(d) Falls assessments in respect of Mrs Smith whilst a resident at the Care Home were not regularly undertaken and no consideration was at any time given by Care Home staff as to the most appropriate location for Mrs Smith's room within the Care Home . In the circumstances, falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home;
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking medical advice after significant resident weight loss
Wider context from the report “(f) Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a nutrition chart implemented in order to monitor Mrs Smith's nutritional intake. Moreover, medical advice in relation to Mrs Smith's weight loss was only sought a number of weeks after the commencement of the said weight loss . In the circumstances, Care Home staff should ensure nutrition charts are completed in respect of any resident whose weight falls significantly and should ensure appropriate medical advice is sought at the first available opportunity following such a fall in weight;
” Open source report
17 Jan 2014 Julie Ann Camm · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to ensure smoke detectors are fitted in housing properties View source Unavailability of home fire safety check referral arrangements for housing tenants 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
Julie Ann Camm · 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
Julie Ann Camm, aged 49, was found dead at her home after deliberately starting a fire and sustaining multiple deep incised wounds. The principal concern was that the property had no smoke detectors, despite her vulnerability as a tenant; the report stated that a detector might have alerted others in time for her to be rescued.
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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure smoke detectors are fitted in housing properties
Wider context from the report “The Fire Service Report revealed that there were no smoke alarms fitted to the property . This property was originally in the ownership of a Housing Association and it was established that there had been a partial re-wire, kitchen sockets only in 2008. Had it been due for a full re-wire then hard-wired smoke detectors would have been installed. The Housing Association’s procedure at the time was to encourage their tenants to refer to the West Yorkshire Fire and Rescue Service to have a home fire safety check, but this was not in place when Miss Camm took out this tenancy. I am aware that the Fire Service provide fire safety advice to all members of the community and will provide and fix smoke detectors free of charge where necessary. A considerable amount of work has been carried out to forge links with other agencies and provide them with education in risk identification with regard to fire safety. The Fire and Rescue Service would encourage individuals or agencies to refer any member of the community to them, particularly those most vulnerable in the first instance through their local Fire Service. This property is now within the ownership of Leeds City council. Originally it was owned by a Housing Association - Leeds West North Homes. The Council took over on 1 October 2013.
It is a matter of grave concern to me that there were no smoke detectors in the property , notwithstanding the vulnerability of Miss Camm as a tenant. I, therefore, recommend that the owner of this property inspect all their housing stock and arrange for either hard-wired detectors to be fitted at the earliest opportunity. Until this can be achieved I further recommend that the landlord contact the West Yorkshire Fire and Rescue Service for home assessment teams to carry out the necessary assessment and, where appropriate, fit battery operated smoke detectors until such time as permanent hard-wired detectors can be installed.
Had a smoke detector been in place, it is likely that neighbours and members of the public in the vicinity would have been alerted to the fire in sufficient time for Miss Camm to be rescued and her death could have been avoided.
” 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 Leeds City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of home fire safety check referral arrangements for housing tenants
Wider context from the report “The Fire Service Report revealed that there were no smoke alarms fitted to the property. This property was originally in the ownership of a Housing Association and it was established that there had been a partial re-wire, kitchen sockets only in 2008. Had it been due for a full re-wire then hard-wired smoke detectors would have been installed. The Housing Association’s procedure at the time was to encourage their tenants to refer to the West Yorkshire Fire and Rescue Service to have a home fire safety check, but this was not in place when Miss Camm took out this tenancy . I am aware that the Fire Service provide fire safety advice to all members of the community and will provide and fix smoke detectors free of charge where necessary. A considerable amount of work has been carried out to forge links with other agencies and provide them with education in risk identification with regard to fire safety. The Fire and Rescue Service would encourage individuals or agencies to refer any member of the community to them, particularly those most vulnerable in the first instance through their local Fire Service. This property is now within the ownership of Leeds City council. Originally it was owned by a Housing Association - Leeds West North Homes. The Council took over on 1 October 2013.
It is a matter of grave concern to me that there were no smoke detectors in the property, notwithstanding the vulnerability of Miss Camm as a tenant. I, therefore, recommend that the owner of this property inspect all their housing stock and arrange for either hard-wired detectors to be fitted at the earliest opportunity. Until this can be achieved I further recommend that the landlord contact the West Yorkshire Fire and Rescue Service for home assessment teams to carry out the necessary assessment and, where appropriate, fit battery operated smoke detectors until such time as permanent hard-wired detectors can be installed.
Had a smoke detector been in place, it is likely that neighbours and members of the public in the vicinity would have been alerted to the fire in sufficient time for Miss Camm to be rescued and her death could have been avoided.
” 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