9 May 2025 Caroline Cleall and Bernard Cleall · Prevention of Future Deaths report South London
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Concerns raised 2 Inability of adult social care professionals to access hospital assessment and advice records when reviewing telecare needs View source Failure to record the assessment, discussion and advice about the appropriate telecare package 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
Caroline Cleall and Bernard Cleall · 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
Caroline and Bernard Cleall, a husband and wife, died together in a house fire at home on 5 January 2022. The report raises concerns that Adult Social Care could not access the earlier assessment and advice about Caroline’s needs and telecare package, limiting proper review of whether an enhanced package with an automatic smoke detector was required.
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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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Inability of adult social care professionals to access hospital assessment and advice records when reviewing telecare needs
Wider context from the report “(1) The senior manager from LB Croydon Adult Social Care who gave evidence told me that he and his team were unable to access the record of the assessment carried out with Mrs Cleall at Croydon University Hospital for her discharge back to the community . I was told that the record was held by the LIFE team on an NHS system to which LB Croydon Adult Social Care did not have access .
(2) The evidence was that what should take place at that assessment is an adequate risk assessment and a discussion with the client about which level of telecare package is appropriate. If the client declines a more expensive package against advice, this should be documented. There was no evidence in this case of the content of any assessment, discussion or advice as to the appropriate level of telecare package for Mrs Cleall.
(3) It appears that LB Croydon's Adult Services would also not have access to the record and the assessment when reviewing the client’s situation once the package is in place and underway .
(4) A review by LB Croydon Adult Social Care was due 4-6 weeks after hospital discharge but it appears that the reviewers had no access to the assessment, advice and response from the client which took place at the hospital . This would mean that the review was missing vital information which might have had a bearing on whether the telecare package should have been revised to include the enhanced service with an automatic smoke detector facility.
(5) In summary, I am concerned that the inability of LB Croydon Adult Social Care professionals to access records of an earlier assessment undertaken (and advice given) by their colleagues, together with the NHS LIFE team, deprives LB Croydon Adult Social Care of the ability to review the client’s needs properly (with the necessary information) following discharge into the community .
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Failure to record the assessment, discussion and advice about the appropriate telecare package
Wider context from the report “(1) The senior manager from LB Croydon Adult Social Care who gave evidence told me that he and his team were unable to access the record of the assessment carried out with Mrs Cleall at Croydon University Hospital for her discharge back to the community. I was told that the record was held by the LIFE team on an NHS system to which LB Croydon Adult Social Care did not have access.
(2) The evidence was that what should take place at that assessment is an adequate risk assessment and a discussion with the client about which level of telecare package is appropriate. If the client declines a more expensive package against advice, this should be documented. There was no evidence in this case of the content of any assessment, discussion or advice as to the appropriate level of telecare package for Mrs Cleall.
(3) It appears that LB Croydon's Adult Services would also not have access to the record and the assessment when reviewing the client’s situation once the package is in place and underway.
(4) A review by LB Croydon Adult Social Care was due 4-6 weeks after hospital discharge but it appears that the reviewers had no access to the assessment, advice and response from the client which took place at the hospital. This would mean that the review was missing vital information which might have had a bearing on whether the telecare package should have been revised to include the enhanced service with an automatic smoke detector facility.
(5) In summary, I am concerned that the inability of LB Croydon Adult Social Care professionals to access records of an earlier assessment undertaken (and advice given) by their colleagues, together with the NHS LIFE team, deprives LB Croydon Adult Social Care of the ability to review the client’s needs properly (with the necessary information) following discharge into the community.
” Open source report
28 Feb 2019 Yong Keng Hong · Prevention of Future Deaths report South London
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Concerns raised 7 Failure to seek further advice from an appropriate clinician View source Failure to implement the advised observation regime View source Failure to provide therapeutic engagement View source Failure to carry out a risk assessment before returning the call bell View source Failure to obtain interpreter support for assessment of needs View source Lack of training for care home staff in carrying out risk assessments View source Failure to provide a safety net View source See 4 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.
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AI-generated summary
Yong Keng Hong · 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
Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.
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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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Failure to seek further advice from an appropriate clinician
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the advised observation regime
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Failure to provide therapeutic engagement
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out a risk assessment before returning the call bell
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell .
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain interpreter support for assessment of needs
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Lack of training for care home staff in carrying out risk assessments
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a safety net
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report
16 Oct 2014 Roger William Maurice De Klerk · Prevention of Future Deaths report South London
View report summary
Concerns raised 7 Cycle route passing over tactile paving areas View source Confusing signage misrepresenting the tram route as a cycle route View source Confusing bicycle-lane design and appearance at the junction View source Cycle-path geometry forcing cyclists to parallel tramlines at the junction View source Cycle route conflicting with pedestrians crossing at the junction View source Tramline hazards for cyclists View source Tramlines located close to pavement alongside the cycle route View source See 4 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
Roger William Maurice De Klerk · 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
On 12 November 2013, Roger William Maurice De Klerk was cycling along Addiscombe Road when his bicycle wheels contacted tramlines, causing him to fall into the path of a bus. The bus collided with him and his bicycle. Concerns included the danger posed by tramlines to cyclists, confusing cycle-lane design and signage, and the intended route across tactile paving and pedestrian areas.
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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Cycle route passing over tactile paving areas
Wider context from the report “(3) For cyclists who do go onto the pavement, the intended route goes over two tactile paving areas and involves contact with pedestrians crossing at the 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Confusing signage misrepresenting the tram route as a cycle route
Wider context from the report “(4) The signage at the junction is confusing and appears to suggest that the tram route is a cycle route , yet the lines are frequently close to pavement at the junction and at other areas further along Addiscombe Road
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Confusing bicycle-lane design and appearance at the junction
Wider context from the report “(2) The design and appearance of the bicycle lane at the junction of Addiscombe Road and Cherry Orchard Road may cause confusion for cyclists who are apparently required to go on to the pavement before the junction in order to cross it safely. The cycle path continues into the junction so that cyclists turning left will be forced to parallel with the lines, rather than crossing at 90 degrees, which is safer.
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Cycle-path geometry forcing cyclists to parallel tramlines at the junction
Wider context from the report “(2) The design and appearance of the bicycle lane at the junction of Addiscombe Road and Cherry Orchard Road may cause confusion for cyclists who are apparently required to go on to the pavement before the junction in order to cross it safely. The cycle path continues into the junction so that cyclists turning left will be forced to parallel with the lines, rather than crossing at 90 degrees, which is safer.
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Cycle route conflicting with pedestrians crossing at the junction
Wider context from the report “(3) For cyclists who do go onto the pavement, the intended route goes over two tactile paving areas and involves contact with pedestrians crossing at the 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Tramline hazards for cyclists
Wider context from the report “(1) Tramlines present a significant danger for cyclists , either by being caught in the lines or slipping on the metal, particularly in the wet .
” 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 London Borough of Croydon; that does not assign responsibility.
PFD Monitor interpretation Tramlines located close to pavement alongside the cycle route
Wider context from the report “(4) The signage at the junction is confusing and appears to suggest that the tram route is a cycle route, yet the lines are frequently close to pavement at the junction and at other areas further along Addiscombe Road
” 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 Review signing and markings at Croydon sites where cyclists cross tram tracks and rectify confusing arrangements.
Verbatim wording from the response “The council also appreciates that the issues for cyclists when crossing the tram tracks may exist at other locations along the tram network. For this reason the Council has discussed with TfL Tramlink the possible application of proprietary products which fill the gap in but to date have not found anything that is suitable for in street application and that do not have a significant risk to the operation. However Tramlink are committed to researching other solutions and have meetings set up in the New Year with railway suppliers and plastic suppliers. We will review signing and markings at all other sites in Croydon where cyclists cross the tram tracks to check for and rectify any other potentially confusing signing and marking.” Source location 2014-0448-Response-De-Klerk
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 Conduct the junction safety review with TfL designers and obtain short- and long-term improvement options.
Verbatim wording from the response “Following the findings of your Coroner’s inquest, the council has agreed to carry out a detailed review of the junction of Addiscombe Road / Cherry Orchard Road with the aim of finding any improvements that will assist cyclist and improve road safety at this site. To this end, the council is requesting TfL’s design team (with expertise employed on TfL’s cycling better junction review and central London cycle Superhighway design) to carry out this review and provide the council with a range of workable options. These will include both short term options that can be implemented quickly, and more extensive improvement. We are entering into discussions with TfL regarding cycling Quietway funding with a view to making such more extensive improvement by 2016.” Source location 2014-0448-Response-De-Klerk
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 No suitable proprietary product has been found to fill tram-track gaps without creating a significant operational risk.
Verbatim wording from the response “The council also appreciates that the issues for cyclists when crossing the tram tracks may exist at other locations along the tram network. For this reason the Council has discussed with TfL Tramlink the possible application of proprietary products which fill the gap in but to date have not found anything that is suitable for in street application and that do not have a significant risk to the operation. However Tramlink are committed to researching other solutions and have meetings set up in the New Year with railway suppliers and plastic suppliers. We will review signing and markings at all other sites in Croydon where cyclists cross the tram tracks to check for and rectify any other potentially confusing signing and marking.” Source location 2014-0448-Response-De-Klerk
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations