30 Jan 2025 Liam Stephen Allan · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Delays in police alerting of the LFB and subsequent emergency response View source Inadequate visibility of riverside buoyancy aids 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
Liam Stephen Allan · 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
Liam Stephen Allan was arrested alongside the River Thames on the evening of 26 August 2022, entered the river, and drowned. The report identified concerns about inadequate lighting and visibility of riverside buoyancy aids, and about delays in alerting the London Fire Brigade because notification was made by telephone rather than through the faster CAD-mediated 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 London Borough of Newham; that does not assign responsibility.
PFD Monitor interpretation Delays in police alerting of the LFB and subsequent emergency response
Wider context from the report “The process for alerting the LFB by the Metropolitan Police Service (MPS) uses a telephone to transmit information from the MPS to the LFB , rather than using a CAD-mediated system to transfer information electronically from the Police to the LFB which is faster than transmitting information by telephone . This delay means that there is a risk that future deaths could occur due to a delay in the LFB being alerted by the Police and a corresponding delay to the LFB's subsequent response to an emergency incident .
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility of riverside buoyancy aids
Wider context from the report “The lighting of buoyancy aids on the riverside is not adequate , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
Buoyancy aids are more visible when painted with white stripes and/or reflective white stripes. However, not all buoyancy aids are so painted , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
” Open source report
5 Dec 2024 Mazeedat Adeoye · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Inadequate supervision of social workers View source Failure to properly record the rationale for critical NRPF decisions View source Failure to communicate observed heat signatures during searches View source Culture tolerating unprofessional and antagonistic behaviour towards vulnerable people View source Failure to oversee arbitrary decisions made by junior staff View source Failure to periodically review social workers’ caseloads View source Failure to constrain inappropriate behaviour within the NRPF team View source Failure to appropriately assess heat signatures during searches 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. 15
Action
Conduct monthly Practice Learning Conversation audits across services and moderate samples through senior management.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2024. View source
Action
Develop Integrated Children’s System changes to strengthen recording of notes and management decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2024. View source
Action
Undertake focused case audits covering supervision, management oversight, recording, plans and children’s voices.
Stated plannedThe respondent said that this action was planned when they made their response on 6 December 2024. View source
Action
Strengthen supervision compliance through monthly management performance meetings, data monitoring and practice-outcome review.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2024. View source
Action
Provide ongoing specialist consultation, reflective supervision and practice-development support focused on compassionate, relational work with families.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2024. View source
Action
Embed purposeful, child-centred and compassionate recording standards through training and quality-assurance reviews.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2024. View source
Action
Deliver trauma-informed and domestic-abuse training for the NRPF team through the London Black Women’s Project.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2024. View source
Action
Deliver scheduled NRPF refresher training on assessments, relational practice, compassionate recording, human-rights assessments, supervision and Section 20 processes.
Stated plannedThe respondent said that this action was planned when they made their response on 6 December 2024. View source
Action
Monitor and review leadership, systems, processes, caseloads, performance, practice, conduct and team culture through the new service quality-assurance programme.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2024. View source
Action
Increase permanent staffing across Children’s Services to replace agency workers and improve workforce stability.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2024. View source
Action
Operate twice-monthly NRPF panels to scrutinise family circumstances and prevent drift or delay in decision-making.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2024. View source
Action
Embed the Circles of Support practice model across Children’s Services to promote compassionate, relational and collaborative interventions.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2024. View source
Action
Provide continuing language, relational, systemic, legal and specialist practice training for social workers and managers.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2024. View source
Action
Provide ongoing NRPF practice-development coaching, including workshops, individual coaching, joint visits, observation, record review and reflective feedback.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2024. View source
Action
Review supervision policy to clarify supervision and management-oversight requirements for different family circumstances.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2024. View source See 12 more actions
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AI-generated summary
Mazeedat Adeoye · 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
Mazeedat Adeoye, a two-year-old girl, drowned on 29 January 2022 after falling into a water-filled plastic refuse bin while playing alone and inadequately supervised in a volunteer carer’s garden. The report identifies concerns about failures by local authority child services to arrange appropriate temporary care, as well as concerns regarding police search procedures, social-worker conduct and supervision, and inadequate record-keeping.
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 Newham; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of social workers
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised , and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record the rationale for critical NRPF decisions
Wider context from the report “4. Inadequate standards of note-keeping meant that the rationale for critical decisions made by the NRPF were not properly recorded . The absence of clear records diminished both communication within the team and accountability.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate observed heat signatures during searches
Wider context from the report “1. NPAS helicopter resources were utilised in the search for Mazeedat on 29th January 2022. At 16.40, a small circular heat signature was observed by a tactical flight officer within the garden where Mazeedat’s body was ultimately located. The shape and size of the object meant that the object was “discounted” in the search and its presence was not communicated to anyone . Mazeedat was discovered 11 minutes later by a police dog unit on the ground. Whereas the delay in locating Mazeedat did not contribute to her tragic death, the decision to discount such a heat signature could, in another case, amount to a risk of fatal harm.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Culture tolerating unprofessional and antagonistic behaviour towards vulnerable people
Wider context from the report “2. The Adeoye family interactions with the local authority, child services team were characterised by unprofessional behaviour from social workers . A culture existed within the team that tolerated and therefore encouraged overtly antagonistic behaviour towards vulnerable people . Should this hostile environment continue to be enabled, sub-optimal care outcomes will result with an ongoing risk of fatal harm.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to oversee arbitrary decisions made by junior staff
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked .
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to periodically review social workers’ caseloads
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed . The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to constrain inappropriate behaviour within the NRPF team
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately assess heat signatures during searches
Wider context from the report “1. NPAS helicopter resources were utilised in the search for Mazeedat on 29th January 2022. At 16.40, a small circular heat signature was observed by a tactical flight officer within the garden where Mazeedat’s body was ultimately located. The shape and size of the object meant that the object was “discounted” in the search and its presence was not communicated to anyone. Mazeedat was discovered 11 minutes later by a police dog unit on the ground. Whereas the delay in locating Mazeedat did not contribute to her tragic death, the decision to discount such a heat signature could, in another case, amount to a risk of fatal harm.
” 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 Conduct monthly Practice Learning Conversation audits across services and moderate samples through senior management.
Verbatim wording from the response “The Local Authority introduced a Quality Assurance process whereby audits (Practice Learning Conversations – PLC’s) were completed by managers, senior managers and the Quality Assurance Unit on a monthly basis across all services. A sample of which were then moderated by a more Senior Manager to ensure the quality of the audit as well as the accuracy of the finding. This brought about a constant, robust check on services and decision making with families.” Source location Response from London Borough of Newham
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 Integrated Children’s System changes to strengthen recording of notes and management decisions.
Verbatim wording from the response “We are working closely with our IT support team to make further changes to our Integrated Children’s System (ICS) in order to support with further strengthening all note-keeping and recording including the recording of management decision making.” Source location Response from London Borough of Newham
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 Undertake focused case audits covering supervision, management oversight, recording, plans and children’s voices.
Verbatim wording from the response “The Service has a bi-monthly sample review schedule of case audits by the Service Manager. This is alongside Practice Learning Conversations undertaken by the Quality Assurance Service. In light of the findings made by the Coroner, there will be a particular focus on the following areas in our audit schedule:” Source location Response from London Borough of Newham
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 Strengthen supervision compliance through monthly management performance meetings, data monitoring and practice-outcome review.
Verbatim wording from the response “As part of our ongoing learning and practice development in 2022, a Family Therapist and Practice Development Social Worker held 1:1 reflective supervision sessions with named team managers to support with improving the quality of supervision, recording and reflecting language that cares in management oversight and supervision records. We are continuing to strengthen and ensure compliance with supervision standards through monthly performance management meetings with the NRPF management team. These meetings are chaired by the Head of MASH, NRPF and Early Help Services. As part of our performance management schedule, a monthly Practice and Outcome Meeting of Head of Services also takes place and is chaired by the Director of Early Help and Safeguarding. This meeting scrutinises the plethora of data collated, hypothesises the reason for the data being what it is and directs improvements.” Source location Response from London Borough of Newham
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 Provide ongoing specialist consultation, reflective supervision and practice-development support focused on compassionate, relational work with families.
Verbatim wording from the response “• Monthly practice improvement reflective supervision sessions for 9 months from March to December 2022. This was completed as a specific development plan for the NRPF Team following the complaint made by the Alternative Trust. These sessions used case examples to help workers think about language, the importance of the first contact and developing first impressions with families to ensure mutual warmth and trust. This was used to challenge practice and monitor staff’s practice improvement. The sessions were facilitated by a Family and Systemic Psychotherapist, and attended by Social Workers, Project Workers and the Team Managers in the NRPF Team.” Source location Response from London Borough of Newham
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 Embed purposeful, child-centred and compassionate recording standards through training and quality-assurance reviews.
Verbatim wording from the response “Significant improvements have already been made to note-keeping and the recording of actions and decisions.” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver trauma-informed and domestic-abuse training for the NRPF team through the London Black Women’s Project.
Verbatim wording from the response “In addition, The London Black Women’s Project conducted training with the NRPF Team. The aim was to further enhance their understanding of the journey of migrant families with No Recourse to Public Funds focussing on trauma-informed practice and domestic abuse. This has resulted in an improved awareness and knowledge in relation to trauma informed practice by the NRPF team and further enhanced working in partnership with the Voluntary and Community Sector,” Source location Response from London Borough of Newham
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 Deliver scheduled NRPF refresher training on assessments, relational practice, compassionate recording, human-rights assessments, supervision and Section 20 processes.
Verbatim wording from the response “Since the Coroner’s findings a further Training Plan for the NRPF team has been created to ensure staff have refresher training and that what occurred to Mazeedat will not occur again.” Source location Response from London Borough of Newham
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 Monitor and review leadership, systems, processes, caseloads, performance, practice, conduct and team culture through the new service quality-assurance programme.
Verbatim wording from the response “With the launch of the new team on 20th January 2025, we have identified a quality assurance action plan (see below), to be undertaken over the course of the next 3 to 6 months. As part of the quality assurance programme for the newly reconfigured service, leadership, systems and processes in the NRPF Team will be monitored and reviewed. This will ensure further enhanced operational management and leadership oversight of the NRPF Team, including continuing to ensure manageable caseloads for workers. It will also support us to further review our performance, practice, conduct of staff, team culture, and any patterns of behaviours that may give cause for concern.” Source location Response from London Borough of Newham
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 Increase permanent staffing across Children’s Services to replace agency workers and improve workforce stability.
Verbatim wording from the response “A focused campaign was launched in 2022 to ensure that social workers and managers were recruited permanently and replaced agency staff who did not provide consistent Relational Practice to families. These improvements can be seen in our staff retention and turnover rates since 2021. In 2021 we had 30% permanent staff (Social Workers and managers) in Children's Services and 70% agency staff. Currently we have 80% permanent staff (Social Workers and managers). Our 20% agency staff receive the same training that permanent staff do as we can invest in them given the lower numbers of them. Many of these agency staff are longstanding. Our turnover rate is now very low and has been on a downward trajectory from 2019-20 where our turnover rate for social workers was 30.2%. In 2023-24 the turnover rate for social workers was 11%.” Source location Response from London Borough of Newham
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 Operate twice-monthly NRPF panels to scrutinise family circumstances and prevent drift or delay in decision-making.
Verbatim wording from the response “In addition to the launch of our Practice Learning Conversations in 2022, which ensures heightened oversight of cases and practice by all managers including Senior Management, the Head of Service also chairs the NRPF panel twice a month, which allows for greater scrutiny of families’ situations. The purpose of the panel is to scrutinise the work with families and prevent any drift and delay in decision making for the children and families allocated to the service. The panel also ensure the oversight of the family’s circumstances such as their immigration journey, their accommodation needs and the level of support they are receiving. The panel consists of practitioners from Newham Children’s Social Care, Housing and the Legal department.” Source location Response from London Borough of Newham
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 Embed the Circles of Support practice model across Children’s Services to promote compassionate, relational and collaborative interventions.
Verbatim wording from the response “Newham Children’s Services has been on an improvement journey since 2019, recognising that improvements in practice are crucial to positive outcomes for the children and families we work alongside. In light of this the service had developed an overarching approach to the practice of social work, that is informed by Systemic Psychotherapy, Relational and Restorative Practice. We have built this into an approach we call “Circles of Support”. This is characterised by the idea that all practice is held by Six Key components: Compassion, Curiosity, Collaboration, Community, Confidence and Clarity. This work has directly improved the culture of the NRPF team by collaborative work” Source location Response from London Borough of Newham
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 Provide continuing language, relational, systemic, legal and specialist practice training for social workers and managers.
Verbatim wording from the response “Training around the use of language and the impact of early conversations on positive outcomes was rolled out in February 2022 - “The power of the 1st Utterance”. “The Power of the 1st Utterance” is an approach developed within the Family and Systemic Psychotherapy field and adapted to social care contexts. It invites the worker (Social Workers in this case) to be mindful about how they start conversations and how these conversational starters construct what follows. The invitation is to start conversations in ways that are appreciative rather than starting from the point of concern. In this way relationships are more likely to be constructive, trusting, collaborative and enabling.” Source location Response from London Borough of Newham
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 Provide ongoing NRPF practice-development coaching, including workshops, individual coaching, joint visits, observation, record review and reflective feedback.
Verbatim wording from the response “A named Practice Development Social Worker (PDSW) has been aligned to the team, to further monitor and support ongoing practice development in the service. The PDSW will follow a coaching model that includes the delivery of training workshops covering the above topics and different practice subject matters. This will be followed by 1 to 1 coaching with each worker, including joint visits, practice role modelling, observation of practice, reviewing written records and providing feedback and reflective spaces. We consider that this will directly impact a continuing” Source location Response from London Borough of Newham
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 Review supervision policy to clarify supervision and management-oversight requirements for different family circumstances.
Verbatim wording from the response “The 2024 audit which reviewed all PLCs (audits) undertaken from 2022 to 2024 recommended that management oversight should be further strengthened and the supervision policy reviewed. We are in the process of reviewing our supervision policy to be more specific and clear regarding the frequency of supervision and management oversight for different types of children and family’s circumstances.” Source location Response from London Borough of Newham
Open published response
3 Oct 2024 Mrs Gabrielle Sarah Anne Steel · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to leave or share written fire risk management plans with relevant recipients View source Failure to convey home fire safety findings to responsible carers View source Absence of a risk management plan to reduce fire harm View source Failure to enquire into the outcome of home fire safety visits View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Gabrielle Sarah Anne Steel · 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 Gabrielle Sarah Anne Steel, who was bed bound and known to smoke in bed and drink alcohol, died after a fire on her bed at her home on 17 October 2023. The fire investigation identified the likely cause as unsafe disposal of smoking materials, and the flame-retardant duvet cover was not on the bed. The principal concerns were poor communication of the fire safety assessment and the absence of a shared written fire risk management plan for those caring for her.
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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to leave or share written fire risk management plans with relevant recipients
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check .
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to convey home fire safety findings to responsible carers
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her .
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check.
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Absence of a risk management plan to reduce fire harm
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check.
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel . Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire into the outcome of home fire safety visits
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit , so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check.
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” 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 Conduct enhanced monitoring for people known to Adult Social Care who have an established fire risk, for one year.
Verbatim wording from the response “4. Action: Enhanced monitoring where there is an established risk of fire for people known to Adult Social Care. The monitoring will take place for the next year with the objective of ensuring learning is embedded.
Who: Strategic Safeguarding
When: Monitoring to start from 2025” Source location Response from London Borough of Newham
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 Hold training for social care staff on fire safety risk assessment and risk management plans.
Verbatim wording from the response “2. Action: To further improve training for social care staff by holding a training session on fire safety risk assessment and risk management plans. This session will complement the joint training session which took place on 25/04/24.
Who: Workforce Development and Strategic Safeguarding
When: 30/01/25” Source location Response from London Borough of Newham
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 Produce a briefing on developing fire safety risk management plans, covering escalation, LFB feedback, and plan reviews.
Verbatim wording from the response “3. Action: Produce a ‘7 minute briefing on the development of fire safety risk management” Source location Response from London Borough of Newham
Open published response
22 Jul 2024 Omar Abdi Ahmed · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure of district nursing staff to identify risks when patients disengage from treatment View source Failure to challenge refusal to use central heating View source Under-resourcing of the district nursing team View source Failure of domiciliary care to provide essential cleaning, personal care and meal support View source Failure of communication between care providers and public services to identify deterioration in living conditions and health View source Failure to challenge unsafe budgeting decisions affecting access to food and cleaning materials View source See 3 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. 10
Action
Conduct welfare checks for Sunlight Care residents who live alone.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Produce and distribute a briefing on non-adherence with care plans and present it at the provider forum.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Develop an escalation procedure for partners to flag high unmitigated risk or differing risk assessments, including reviews of no-reply and refusal-of-care protocols.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Deliver reflective sessions for Adult Social Care staff and selected partner staff on safeguarding decision-making, multi-agency working and Making Safeguarding Personal.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Produce and distribute a briefing on developing risk management plans and present it at the provider forum.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Implement and continue the quality improvement plan for Sunlight Care.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Provide enhanced monitoring of all residents receiving care and support from Sunlight Care.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Meet with Sunlight Care to address and mitigate risks to residents receiving its care and support.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Deliver a joint learning event for Adult Social Care, Sunlight Care and ELFT staff on professional curiosity, resistance, non-adherence and executive decision-making.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Deliver reflective sessions for Adult Social Care staff and selected partner staff on risk assessment and management, information sharing, coordinated intervention, thresholds and social isolation.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source See 7 more actions
×
AI-generated summary
Omar Abdi Ahmed · 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
Omar Abdi Ahmed, who had significant comorbidity and bilateral lower-limb amputations, was found unresponsive and severely hypothermic at home on 15 November 2023 after receiving domiciliary and district nursing care. He died in hospital on 20 November 2023; the inquest concluded that hypothermia, with pneumonia and ischaemic heart disease contributing, was the medical cause of death. Concerns included poor communication between care organisations, shortcomings in district nursing oversight, and domiciliary care arrangements that did not adequately address his personal care, nutrition, cleaning, and heating needs.
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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure of district nursing staff to identify risks when patients disengage from treatment
Wider context from the report “2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment .
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge refusal to use central heating
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating , a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death .
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of the district nursing team
Wider context from the report “2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure of domiciliary care to provide essential cleaning, personal care and meal support
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café .
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between care providers and public services to identify deterioration in living conditions and health
Wider context from the report “1. Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed’s living conditions and health .
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge unsafe budgeting decisions affecting access to food and cleaning materials
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged , this led to a lack of nutritious food and cleaning materials in his home . Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct welfare checks for Sunlight Care residents who live alone.
Verbatim wording from the response “• Welfare checks of all residents Sunlight Care provide care and support to who live alone has taken place
By who: Commissioning Team” Source location Response from London Borough of Newham
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 Produce and distribute a briefing on non-adherence with care plans and present it at the provider forum.
Verbatim wording from the response “8. Produce a ‘7 minute briefing with a focus on the issue of non-adherence with care plans. This will be distributed across all Adults and Health staff groups and presented at the provider forum
By who: Workforce Development and Strategic Safeguarding
By when: 30/01/24” Source location Response from London Borough of Newham
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 Develop an escalation procedure for partners to flag high unmitigated risk or differing risk assessments, including reviews of no-reply and refusal-of-care protocols.
Verbatim wording from the response “4. Adult Social Care will lead on the development of an escalation procedure which will enable partners to flag cases where there is concern about a high level of unmitigated risk or differences of opinion about level of risk. This procedure will involve reviews of the following protocols:” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver reflective sessions for Adult Social Care staff and selected partner staff on safeguarding decision-making, multi-agency working and Making Safeguarding Personal.
Verbatim wording from the response “5. The issues regarding the safeguarding activity in this case will be addressed by reflective sessions which cover the following areas” Source location Response from London Borough of Newham
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 Produce and distribute a briefing on developing risk management plans and present it at the provider forum.
Verbatim wording from the response “7. Produce a ‘7 minute briefing on the development of risk management plans. This will be distributed across all Adults and Health staff groups and presented at the provider forum
By who: Workforce Development and Strategic Safeguarding
By when: 30/12/2024” Source location Response from London Borough of Newham
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 Implement and continue the quality improvement plan for Sunlight Care.
Verbatim wording from the response “2. Action: A meeting with the Sunlight Care to ensure that any risks to residents they provide care and support to is mitigated. This will be achieved by the following actions
By who: Strategic Safeguarding and Quality Assurance and
By when: Meeting held on 17/07/24 although the QIP is ongoing” Source location Response from London Borough of Newham
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 Provide enhanced monitoring of all residents receiving care and support from Sunlight Care.
Verbatim wording from the response “• Enhanced monitoring of all residents Sunlight Care provide care and support to is in place” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with Sunlight Care to address and mitigate risks to residents receiving its care and support.
Verbatim wording from the response “2. Action: A meeting with the Sunlight Care to ensure that any risks to residents they provide care and support to is mitigated. This will be achieved by the following actions
By who: Strategic Safeguarding and Quality Assurance and
By when: Meeting held on 17/07/24 although the QIP is ongoing” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a joint learning event for Adult Social Care, Sunlight Care and ELFT staff on professional curiosity, resistance, non-adherence and executive decision-making.
Verbatim wording from the response “9. Adult Social Care will lead on a joint learning event involving staff from ASC, staff from Sunlight Care and staff from ELFT. The learning event will focus on the following issues:” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver reflective sessions for Adult Social Care staff and selected partner staff on risk assessment and management, information sharing, coordinated intervention, thresholds and social isolation.
Verbatim wording from the response “6. The issues regarding risk assessment and risk management will be addressed by a reflective session which covers the following areas:” Source location Response from London Borough of Newham
Open published response
22 Mar 2024 Regina Olufunmilola Ademiluyi · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to formally assess mental capacity View source Insufficiently detailed safeguarding reports failing to trigger further investigation View source Failure to offer a carers assessment in response to concerns about carer capacity View source Failure of the local authority to seek further information or clarification from the Trust View source Failure of the local authority to undertake meaningful significant event analysis of care failings View source See 2 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. 14
Action
Create and circulate an anonymised seven-minute briefing on lessons learned from the case across Adults and Health staff groups.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Convene a multi-disciplinary shared learning event with ELFT staff to explore the case themes from clinician and practitioner perspectives.
Stated in progressThe respondent said that this action was in progress when they made their response on 25 March 2024. View source
Action
Review the Direct Payment Policy and develop practice guidance and a practitioner checklist covering capacity, best interests, double-handed care, hospital discharge, quality concerns and safeguarding thresholds.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Complete and submit the section 44 Safeguarding Adult Review referral for consideration by the Safeguarding Adults Board subcommittee.
Stated completedThe respondent said that this action was complete when they made their response on 25 March 2024. View source
Action
Share case themes with the borough’s Mental Capacity Act Oversight Group.
Stated in progressThe respondent said that this action was in progress when they made their response on 25 March 2024. View source
Action
Review meeting attendance to consider involving the Council’s Safeguarding Adults Team in safeguarding discussions.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Update carer definitions, recording processes and frontline documentation under the borough’s established all-age Carers Strategy and delivery board.
Stated completedThe respondent said that this action was complete when they made their response on 25 March 2024. View source
Action
Develop specific Mental Capacity Act training for occupational therapy staff through peer learning and a separately planned formal training session.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Convene reflective-practice sessions for frontline operational staff on professional curiosity, cultural needs and risk management in light of the case.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Add mandatory pressure-care refresher training, including reporting, notification and safeguarding interfaces, to the 2024/25 training plan for operational adult social care staff.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Review and improve Mental Capacity Act training and refresher provision for all adult social care professional groups.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Roll out refresher carer-awareness training for all frontline adult social care staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 25 March 2024. View source
Action
Develop guidance for frontline adult social care staff on informal and family carers and safeguarding adults.
Stated plannedThe respondent said that this action was planned when they made their response on 25 March 2024. View source
Action
Maintain regular safeguarding meetings between ELFT Community Health Newham and Council neighbourhood teams to address referral quality, thresholds and recurring safeguarding themes.
Stated completedThe respondent said that this action was complete when they made their response on 25 March 2024. View source See 11 more actions
×
AI-generated summary
Regina Olufunmilola Ademiluyi · 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
Regina Olufunmilola Ademiluyi was an 83-year-old woman who was bed-bound following surgery for a broken hip and died in March 2024 after declining cognition and physical health, malnutrition, a grade 4 sacral pressure ulcer and an aspiration incident. The report raised concerns that state-funded domiciliary care was not provided, and that the NHS Trust and local authority did not adequately assess or respond to safeguarding, mental-capacity and carer-support concerns.
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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess mental capacity
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity , had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed safeguarding reports failing to trigger further investigation
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure to offer a carers assessment in response to concerns about carer capacity
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure of the local authority to seek further information or clarification from the Trust
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 Newham; that does not assign responsibility.
PFD Monitor interpretation Failure of the local authority to undertake meaningful significant event analysis of care failings
Wider context from the report “2. Despite the death of Mrs Ademiluyi’s occurring in the spring of 2023 no meaningful reflection or remediation had been undertaken by the Local Authority into the failings in care by the time of the inquest almost a year later. It was suggested by the legal representative of local authority that the inquest hearing itself was the extent of the significant event analysis undertaken by their professional client.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and circulate an anonymised seven-minute briefing on lessons learned from the case across Adults and Health staff groups.
Verbatim wording from the response “1.3 Convene focussed reflective practice sessions for frontline operational staff based around circumstances highlighted in Mrs Ademiluyi’s care, thematically orientated around “professional curiosity” and “cultural needs vs. risks” (reinforcing the message that risk management comes first). | Strategic Safeguarding, Practice and Workforce Development Team | December 2024
1.4 Creation of an anonymised ‘7 minute briefing’ note concerning the lessons learned from this case for circulation across all Adults and Health staff groups at LBN. | Strategic Safeguarding, Practice and Workforce Development Team | June 2024” Source location Response from London Borough of Newham
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 Convene a multi-disciplinary shared learning event with ELFT staff to explore the case themes from clinician and practitioner perspectives.
Verbatim wording from the response “double incontinence). Alongside this we are eager to convene a shared learning event with multi-disciplinary staff from across both organisations to explore the themes identified in Mrs Ademiluyi’s case from a clinician/practitioner perspective. These discussions are being progressed separately with our counterparts at the Trust.” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Direct Payment Policy and develop practice guidance and a practitioner checklist covering capacity, best interests, double-handed care, hospital discharge, quality concerns and safeguarding thresholds.
Verbatim wording from the response “In addition to this, the new DP set up process provides additional ‘hand holding’ support for the first 6 weeks to ensure that DP recipients and their representative(s) fully understand how to utilise their DP. | Direct Payments Team | End of May 2024
2.2 Undertake a review of the Council’s Direct Payment Policy, and develop associated practice guidance (including a practitioner checklist). This will encompass:” Source location Response from London Borough of Newham
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 Complete and submit the section 44 Safeguarding Adult Review referral for consideration by the Safeguarding Adults Board subcommittee.
Verbatim wording from the response “Action: | By who: | By when:
1.1 Immediate s.44 Safeguarding Adult Review (SAR) Referral completed and submitted for presentation at the next SAR subcommittee of Newham’s Safeguarding Adults Board on 7th May 2024 | Team Manager Neighbourhood Team | 27.03.24
1.2 Review and improve training and awareness of pressure care and risks for ASC staff. This will include:” Source location Response from London Borough of Newham
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 Share case themes with the borough’s Mental Capacity Act Oversight Group.
Verbatim wording from the response “Action: | By who: | By when:
3.1 Improve consistency of MCA practice and decision making in the context of best interest decisions which override family where appropriate (including the use of Independent Mental Capacity Advocacy). This will encompass:” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review meeting attendance to consider involving the Council’s Safeguarding Adults Team in safeguarding discussions.
Verbatim wording from the response “In addition to this summary of internal action, we also recognise that further activities need to be considered with our system partners at East London NHS Foundation Trust (ELFT). Regular Safeguarding meetings have now been established between ELFT Community Health Newham and the Council’s Neighbourhood Teams for Older People and Disabilities (mirroring the same processes which are in place in Mental Health services and have been shown to be successful in improving communication between professional groups). This space will be used to address issues such as the quality of referrals, thresholds and reoccurring safeguarding themes. Attendance at these meetings will also be reviewed to consider involvement from the Council’s Safeguarding Adults Team who are responsible for screening referrals.” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update carer definitions, recording processes and frontline documentation under the borough’s established all-age Carers Strategy and delivery board.
Verbatim wording from the response “Action: | By who: | By when:
4.1 An all-age Carers Strategy is in place for the borough and overseen by a multi-agency delivery board. Further work has taken place through 2023/24 to update carer definitions, improve recording processes and enhance documentation used by frontline staff with carers.” Source location Response from London Borough of Newham
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 Develop specific Mental Capacity Act training for occupational therapy staff through peer learning and a separately planned formal training session.
Verbatim wording from the response “• Developing specific training interventions for Occupational Therapy staff regarding the application of the Mental Capacity Act in practice – this has been planned as a topic for the borough’s cross-organisational OT Peer Learning session in May 2024. A separate formal training date is being planned. | Principal Occupational Therapist” Source location Response from London Borough of Newham
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 Convene reflective-practice sessions for frontline operational staff on professional curiosity, cultural needs and risk management in light of the case.
Verbatim wording from the response “1.3 Convene focussed reflective practice sessions for frontline operational staff based around circumstances highlighted in Mrs Ademiluyi’s care, thematically orientated around “professional curiosity” and “cultural needs vs. risks” (reinforcing the message that risk management comes first). | Strategic Safeguarding, Practice and Workforce Development Team | December 2024
1.4 Creation of an anonymised ‘7 minute briefing’ note concerning the lessons learned from this case for circulation across all Adults and Health staff groups at LBN. | Strategic Safeguarding, Practice and Workforce Development Team | June 2024” Source location Response from London Borough of Newham
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 Add mandatory pressure-care refresher training, including reporting, notification and safeguarding interfaces, to the 2024/25 training plan for operational adult social care staff.
Verbatim wording from the response “Action: | By who: | By when:
1.1 Immediate s.44 Safeguarding Adult Review (SAR) Referral completed and submitted for presentation at the next SAR subcommittee of Newham’s Safeguarding Adults Board on 7th May 2024 | Team Manager Neighbourhood Team | 27.03.24
1.2 Review and improve training and awareness of pressure care and risks for ASC staff. This will include:” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve Mental Capacity Act training and refresher provision for all adult social care professional groups.
Verbatim wording from the response “Action: | By who: | By when:
3.1 Improve consistency of MCA practice and decision making in the context of best interest decisions which override family where appropriate (including the use of Independent Mental Capacity Advocacy). This will encompass:” Source location Response from London Borough of Newham
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 Roll out refresher carer-awareness training for all frontline adult social care staff.
Verbatim wording from the response “An updated round of refresher training on carer awareness for all frontline ASC staff is being rolled out in May 2024. | Carers Strategy Delivery Board | End of May 2024
4.2 Develop specific guidance for frontline ASC staff on informal/family carers and Safeguarding Adults. | Strategic Safeguarding, Practice and Workforce Development Team | End of June 2024” Source location Response from London Borough of Newham
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 Develop guidance for frontline adult social care staff on informal and family carers and safeguarding adults.
Verbatim wording from the response “An updated round of refresher training on carer awareness for all frontline ASC staff is being rolled out in May 2024. | Carers Strategy Delivery Board | End of May 2024
4.2 Develop specific guidance for frontline ASC staff on informal/family carers and Safeguarding Adults. | Strategic Safeguarding, Practice and Workforce Development Team | End of June 2024” Source location Response from London Borough of Newham
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 Maintain regular safeguarding meetings between ELFT Community Health Newham and Council neighbourhood teams to address referral quality, thresholds and recurring safeguarding themes.
Verbatim wording from the response “In addition to this summary of internal action, we also recognise that further activities need to be considered with our system partners at East London NHS Foundation Trust (ELFT). Regular Safeguarding meetings have now been established between ELFT Community Health Newham and the Council’s Neighbourhood Teams for Older People and Disabilities (mirroring the same processes which are in place in Mental Health services and have been shown to be successful in improving communication between professional groups). This space will be used to address issues such as the quality of referrals, thresholds and reoccurring safeguarding themes. Attendance at these meetings will also be reviewed to consider involvement from the Council’s Safeguarding Adults Team who are responsible for screening referrals.” Source location Response from London Borough of Newham
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations