11 Nov 2024 Alison BINYON · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 4 Failure to manage communication with service users about moving accommodation carefully and accurately View source Lack of clear communication to community supporters about the moving-accommodation process View source Failure to conduct internal reviews following deaths View source Uncertainty in moving-accommodation timescales creating a potential self-harm trigger View source See 1 more concern
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Alison BINYON · 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 Binyon, who had a history of mental health difficulties and self-harm involving ligation, was found unresponsive at her residential home on 11 September 2019 and died on 13 September 2019 after developing a hypoxic brain injury. The report identified concerns about communication and uncertainty around her planned move to step-down accommodation, and about the absence of an internal review after her death.
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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 Leicestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to manage communication with service users about moving accommodation carefully and accurately
Wider context from the report “The court heard evidence from the Adult Social Care Team that communication with service users around moving accommodation needs to be managed carefully as false assurances can undermine trust between the service user and the supporting team . The court further heard that uncertainty can be a potential stressor or trigger for self-harm for those with a diagnosis of Emotionally Unstable Personality Disorder. There is an inherent uncertainty in the timescales for moving as it depends on the availability of suitable accommodation and the situation therefore requires careful management and communication.
Whilst consideration had been given to conversations with the service user in this situation, the court heard evidence from those supporting Alison (including community mental health nurses) that they were unclear on the stage the process had reached, the specific steps of the process and the likely timescales involved. This affected the type of support they could provide. There was a lack of evidence of a specific approach or policy addressing how the process can be clearly communicated to those supporting service users in the community.
Further, no internal review was carried out at Leicestershire County Council following Alison's death. If such reviews are not conducted this could lead to inadequate learning from deaths which creates a risk of further deaths.
” 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 Leicestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear communication to community supporters about the moving-accommodation process
Wider context from the report “The court heard evidence from the Adult Social Care Team that communication with service users around moving accommodation needs to be managed carefully as false assurances can undermine trust between the service user and the supporting team. The court further heard that uncertainty can be a potential stressor or trigger for self-harm for those with a diagnosis of Emotionally Unstable Personality Disorder. There is an inherent uncertainty in the timescales for moving as it depends on the availability of suitable accommodation and the situation therefore requires careful management and communication.
Whilst consideration had been given to conversations with the service user in this situation, the court heard evidence from those supporting Alison (including community mental health nurses) that they were unclear on the stage the process had reached, the specific steps of the process and the likely timescales involved . This affected the type of support they could provide . There was a lack of evidence of a specific approach or policy addressing how the process can be clearly communicated to those supporting service users in the community .
Further, no internal review was carried out at Leicestershire County Council following Alison's death. If such reviews are not conducted this could lead to inadequate learning from deaths which creates a risk of further deaths.
” 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 Leicestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct internal reviews following deaths
Wider context from the report “The court heard evidence from the Adult Social Care Team that communication with service users around moving accommodation needs to be managed carefully as false assurances can undermine trust between the service user and the supporting team. The court further heard that uncertainty can be a potential stressor or trigger for self-harm for those with a diagnosis of Emotionally Unstable Personality Disorder. There is an inherent uncertainty in the timescales for moving as it depends on the availability of suitable accommodation and the situation therefore requires careful management and communication.
Whilst consideration had been given to conversations with the service user in this situation, the court heard evidence from those supporting Alison (including community mental health nurses) that they were unclear on the stage the process had reached, the specific steps of the process and the likely timescales involved. This affected the type of support they could provide. There was a lack of evidence of a specific approach or policy addressing how the process can be clearly communicated to those supporting service users in the community.
Further, no internal review was carried out at Leicestershire County Council following Alison's death . If such reviews are not conducted this could lead to inadequate learning from deaths which creates a risk of further deaths .
” 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 Leicestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Uncertainty in moving-accommodation timescales creating a potential self-harm trigger
Wider context from the report “The court heard evidence from the Adult Social Care Team that communication with service users around moving accommodation needs to be managed carefully as false assurances can undermine trust between the service user and the supporting team. The court further heard that uncertainty can be a potential stressor or trigger for self-harm for those with a diagnosis of Emotionally Unstable Personality Disorder. There is an inherent uncertainty in the timescales for moving as it depends on the availability of suitable accommodation and the situation therefore requires careful management and communication.
Whilst consideration had been given to conversations with the service user in this situation, the court heard evidence from those supporting Alison (including community mental health nurses) that they were unclear on the stage the process had reached, the specific steps of the process and the likely timescales involved. This affected the type of support they could provide. There was a lack of evidence of a specific approach or policy addressing how the process can be clearly communicated to those supporting service users in the community.
Further, no internal review was carried out at Leicestershire County Council following Alison's death. If such reviews are not conducted this could lead to inadequate learning from deaths which creates a risk of further deaths.
” 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 Create and introduce a visual accommodation-process flowchart showing steps, timescales, MDT involvement and information-sharing responsibilities.
Verbatim wording from the response “The Adult Social Care team have carefully considered this matter and reviewed my department’s current processes and policies around communication with individuals and other agencies supporting accommodation moves proposed and actual. As a result, the team are improving our current processes by creating a visual flowchart of the accommodation process from beginning to end so that all those involved can clearly see what the next steps are and how close the individual is to any proposed move. Within the flow chart, Adult Social Care workers will be reminded that they must include the MDT working with the individual concerned (including care providers and Community Mental Health Teams) so that accurate information can be shared regarding future plans, and appropriate actions taken.” Source location Response from Leicestershire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue staff guidance through the weekly newsletter on reassuring individuals, checking understanding, sharing information, managing anxiety and considering move timescales.
Verbatim wording from the response “The Adult Social Care Workers will be provided with communication from the department within our weekly internal newsletter, which directs them to our key goal: that staff are aware of the need to reassure individuals at each stage of the process, check for clarification of understanding, and ensure that providers and other professionals are made aware of any raised anxiety levels. The newsletter will also direct staff to be person-centred when considering the date or timescales of a move and to avoid any periods of time where an individual may already be experiencing stress or anxiety. This information will be included in the newsletter circulated week commencing 13th January 2025.” Source location Response from Leicestershire County Council
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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 implement a procedure requiring Adult Social Care managers to conduct internal reviews after unexpected deaths and identify learning or required policy changes.
Verbatim wording from the response “Nevertheless, in light of this concern being raised in the RPRD, I have considered this matter and consultation has occurred within the department around the internal review process for when an unexpected death occurs.” Source location Response from Leicestershire County Council
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Concerns raised 3 Failure to reduce the speed limit at the junction View source Lack of signage indicating the junction View source Failure to maintain clear visibility into and approaching the junction View source
Responses linked to these concerns
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AI-generated summary
Kian Singh GILL · 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
Kian Singh GILL, aged 15, died at the scene of a road traffic accident while cycling into the path of a car at a junction in Gilmorton, Leicestershire, on 5 May 2015. Concerns included overgrown hedgerows obscuring visibility, a lack of junction signage, and the national speed limit remaining in place despite the junction.
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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 Leicestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reduce the speed limit at the junction
Wider context from the report “(3) The speed limit is not curtailed from the national speed limit despite there being a junction .
” 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 Leicestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage indicating the junction
Wider context from the report “(2) There is no signage to indicate that there is a junction there and
” 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 Leicestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain clear visibility into and approaching the junction
Wider context from the report “(1) The hedgerows by the side of both roads are overgrown and obscure a driver's view into the junction and the road leading up to it . This meant that neither the rider nor the driver had view of each other until the final moments prior to impact.
” 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 Place “Slow” road markings on Ullesthorpe Road to encourage drivers to reduce speed near the junction.
Verbatim wording from the response “b) It is proposed to place “Slow” markings on Ullesthorpe Road to advise drivers of the presence of a junction with a view to encouraging them to reduce their speed.” Source location Response from Leicestershire County Council
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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 Place give-way road markings on Bonehams Lane.
Verbatim wording from the response “a) It is proposed to place give way road markings on Bonehams lane;” Source location Response from Leicestershire County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reducing the speed limit was not considered necessary because the junction showed no elevated risk and speed limits should not address isolated hazards alone.
Verbatim wording from the response “47. It is relevant in this context, that the Council has checked its safety records dating back to 1 January 1979 and it has not identified any previous reported injury road traffic accidents (let alone fatalities) at the junction between Bonehams Road and Ullesthorpe Road.” Source location Response from Leicestershire County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional junction signage was considered unnecessary because existing visual cues should alert reasonably careful road users to the junction.
Verbatim wording from the response “34. Although the Council is prepared to take further measures to enhance road safety, the Council does not believe that the presence of additional signage was necessary to alert a reasonably careful road user on Bonehams Lane of the existence of a junction.” Source location Response from Leicestershire County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hedgerow-cutting enforcement was considered unnecessary because the hedgerows were already situated a safe distance from the carriageway.
Verbatim wording from the response “17. Hedgerows are generally owned by the owners of neighbouring land and not therefore the property of the Council. I acknowledge that the Council may enforce restrictions on the expansion of hedgerows under Section 152 of the Highways Act 1980.” Source location Response from Leicestershire County Council
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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 Visibility at the junction exceeded applicable national guidance, so restricted sight lines were not considered the cause of delayed evasive action.
Verbatim wording from the response “11. For traffic positioned at a setback distance of 2.4 metres from the edge of the junction, the minimum visibility distance required for a 60 m.p.h. design speed is 215 metres (please see the table at page “2/4” of Tab 1). The measured visibility from Bonehams Lane was 270 metres looking west and 250m looking east. Relevant photographic evidence arising from the inspections is enclosed at tab 7 of the bundle.” Source location Response from Leicestershire County Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations