26 Jul 2024 Zara Natasha Aleena · Prevention of Future Deaths report East London
View report summary
Concerns raised 25 Failure to provide prison risk intelligence to Integrated Offender Management meetings View source Threshold for reflective practice set too high View source Unclear understanding of when to request emergency recall View source Lack of mandatory and refreshed risk assessment training View source Lack of supervision for prison offender managers View source Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail View source Lack of systems to support staff supervising key decisions View source Lack of alerts for handover from prison to community offender managers View source Lack of checks on sharing up-to-date and accurate risk assessments View source Failure of prison offender managers to implement sentence plans and facilitate rehabilitation View source Lack of focused risk assessment training for prison offender managers View source Lack of rigour, detail and independence in MPS investigations View source Unclear and incomplete sharing of risk information between probation and the MPS View source Failure to conduct timely risk assessments with complementary risk management plans View source Societal acceptance of unreported following behaviour View source Unclear CCTV operator training on identifying sexual predators and stalking behaviour View source Lack of assurance and refresher training for CCTV operators View source Failure to holistically assess indicators of serious harm View source Failure of alert systems to highlight restraining orders View source Lack of reporting guidance and training for business owners on sexualised or predatory behaviour View source OASYS risk assessment tool failing to support extraction and analysis of key risk areas View source Understaffing of probation delivery units View source Failure to probe information relevant to risk View source Obstacles inhibiting increases in assessed risk levels View source Failure of prison offender managers to gather and share evidence relevant to risk formulation View source See 22 more concerns
Responses linked to these concerns
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AI-generated summary
Zara Natasha Aleena · 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
Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.
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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prison risk intelligence to Integrated Offender Management meetings
Wider context from the report “(15)The Integrated Offender Management meetings did not receive the necessary intelligence from the prison setting . There was no system in place to ensure that either the prison offender manager was invited to attend, or that the prison offender manager was asked to provide written information around risk incidents .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Threshold for reflective practice set too high
Wider context from the report “(18)There were clearly learning points for the police constables, police sergeants and the local intelligence team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in performance or conduct”. It is of concern that the threshold for reflective practice is set too high .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Unclear understanding of when to request emergency recall
Wider context from the report “(10) The evidence revealed a difference of opinion and understanding around when an emergency recall should be requested . A senior probation officer and probation services officer erroneously believed that an emergency recall could only be requested out of hours .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and refreshed risk assessment training
Wider context from the report “(4) Risk assessment training is not part of the mandatory training framework within the probation service. Risk assessment training is not refreshed .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of supervision for prison offender managers
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender. They did not attempt to facilitate any rehabilitative interventions. There was no evidence of supervision for the prison offender manager .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail
Wider context from the report “(17)The Fast Time Review did not probe into sufficient detail into the systems of the local intelligence team and the Computer Aided Dispatch process . A more detailed, independent review should have been carried out.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of systems to support staff supervising key decisions
Wider context from the report “(2) There were no systems in place devised to assist the staff working in these stretched circumstances , such as easy reference checklists for supervising key decisions .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of alerts for handover from prison to community offender managers
Wider context from the report “(13)There was no system in place to alert the prison offender manager to handover an offender to the community offender manager when a period of sentence ended and where the offender remained in prison, on remand.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of checks on sharing up-to-date and accurate risk assessments
Wider context from the report “(5) There were no checks to ensure the provision of up to date and accurate risk assessments to partner agencies (such as the housing team).
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure of prison offender managers to implement sentence plans and facilitate rehabilitation
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender . They did not attempt to facilitate any rehabilitative interventions . There was no evidence of supervision for the prison offender manager.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of focused risk assessment training for prison offender managers
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training . Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk. There were multiple intelligence logs and records that should have been obtained by them. The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of rigour, detail and independence in MPS investigations
Wider context from the report “(16)I am concerned about the lack of rigour, detail and independence of the MPS investigation into this case. The unit involved in this case was the East Area BCU. An independent, rapid investigation (Fast Time Review) was carried out by the Directorate of Professional Standards. Despite the very limited time to complete the review, the DPS officer reached clear and valuable findings. The findings of the DPS investigator were however rejected by more senior officers within the MPS. The officers who rejected the findings were not independent and all worked within the East Area BCU. This lack of independence is of concern.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Unclear and incomplete sharing of risk information between probation and the MPS
Wider context from the report “(14)The system in place for sharing risk information between the probation service and the MPS was unclear . Only very limited intelligence was shared with the MPS . There was no explanation as to why that information was shared, when more concerning risk related information was not shared .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely risk assessments with complementary risk management plans
Wider context from the report “(3) The understanding around risk assessment was poor , at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times , and the assessment of risk was not accompanied by a complementary risk management plan . Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Societal acceptance of unreported following behaviour
Wider context from the report “(21) At least two other members of the public were followed by the offender before he attacked Zara Aleena. The members of the public appear to have seen the offender and appear to be aware that he was following them. This was not brought to the attention of the emergency services. I am concerned that there is a societal acceptance that such conduct does not need to be reported .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Unclear CCTV operator training on identifying sexual predators and stalking behaviour
Wider context from the report “(19)The details of training for CCTV operators includes “training on sexual harassment”, but it is not clear whether this includes identifying sexual predators and stalking type behaviour .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance and refresher training for CCTV operators
Wider context from the report “(20)I am unclear from the evidence provided, whether LBR have a system for checking that training provided to CCTV operators is fully understood , or whether refresher training is provided to them .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to holistically assess indicators of serious harm
Wider context from the report “(3) The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm , to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure of alert systems to highlight restraining orders
Wider context from the report “(8) The globe system and alert systems did not work effectively in this case. A restraining order had been put in place against the offender, but this was not highlighted , as it should have been. Key staff involved in assessing and managing the offender were unaware of the restraining order .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of reporting guidance and training for business owners on sexualised or predatory behaviour
Wider context from the report “(22)Business owners were aware of the offender’s concerning conduct on the night of Zara Aleena’s murder. For example, a public house had refused to provide more drinks to him. It is not clear whether business owners are encouraged to report such concerning behaviour to the authorities or whether they are offered any training to assist them and their staff to recognise sexualised or predatory behaviour .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation OASYS risk assessment tool failing to support extraction and analysis of key risk areas
Wider context from the report “(7) The OASYS risk assessment tool is unwieldy and difficult to navigate . It was challenging to extract the most relevant material. The content of the OASYS assessment was so dense that the probation officers seemed to get lost in the detail and failed to pull together and formulate/analyse key risk areas . One senior probation officer stated that she would not look at the OASYS when allocating cases, because OASYS assessments were “not always accurate and up to date”. It is noted that a new risk assessment tool within the probation service is a work in progress. It is hoped that the new tool will take into account the above concerns.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Understaffing of probation delivery units
Wider context from the report “(1) The probation delivery unit responsible for the offender was understaffed at the time of relevant oversight. The staffing levels were 61% in 2022 . The staffing levels at the time of the inquest in June 2024 was 58% . The inquest heard that this is a national problem and that there are other probation delivery units that have even lower levels of staffing. The low staffing level had an impact upon quality and depth of assessments; quality of supervision of junior staff (supervision was wholly reactive); excessively high workloads for probation officers and senior probation officers; lack of cover during annual leave for probation officers and poor record keeping.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to probe information relevant to risk
Wider context from the report “(6) There was a lack of professional curiosity and a lack of sufficient probing into information relevant to risk .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Obstacles inhibiting increases in assessed risk levels
Wider context from the report “(9) There may be obstacles to increasing risk levels . The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team . The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase risk .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure of prison offender managers to gather and share evidence relevant to risk formulation
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training. Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk . There were multiple intelligence logs and records that should have been obtained by them . The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately .
” 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 Audit CCTV operators’ work and provide mentoring, additional training or guidance where knowledge or performance gaps are identified.
Verbatim wording from the response “LBR ensures that the training provided to CCTV operators is fully comprehensive and regularly reinforced through evaluation and ongoing professional development. After completing the Tavcom training, all operators must pass an exam to obtain their SIA (Security Industry Authority) licence, confirming their understanding of the training content. Additionally, LBR implements a performance management system, including mentoring from experienced operators and regular audits of work to identify any gaps in knowledge or performance. These audits inform whether additional training or guidance is needed, ensuring operators maintain high proficiency standards. Once operatives have had official training, they are regularly audited on their CCTV viewing footage and any further training needs are picked up and implemented on a case by case basis.” Source location Response from London Borough of Redbridge
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 CCTV operator training covering suspicious, predatory, stalking and sexual harassment behaviours.
Verbatim wording from the response “The training for CCTV operators encompasses modules that cover behavioural body language training and are specifically designed to detect behaviours that would fall under the remit of ‘suspicious’. The training is based on established principles and techniques outlined in Tavcom training programs – suspicious behaviours can include gestures, mannerisms, alone or in a group, time, location, how someone is acting (i.e. drunk/disorientated), approaching people, being aggressive etc. The training given to all LBR CCTV officers to assist them in making inferences regarding suspicious behaviours that lend themselves to multiple situations (including drug dealing, knife attacks, theft, robbery, stalking, sexual harassment and intimidation).” Source location Response from London Borough of Redbridge
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 Require CCTV operators to pass an examination for SIA licensing to confirm understanding of training.
Verbatim wording from the response “LBR ensures that the training provided to CCTV operators is fully comprehensive and regularly reinforced through evaluation and ongoing professional development. After completing the Tavcom training, all operators must pass an exam to obtain their SIA (Security Industry Authority) licence, confirming their understanding of the training content. Additionally, LBR implements a performance management system, including mentoring from experienced operators and regular audits of work to identify any gaps in knowledge or performance. These audits inform whether additional training or guidance is needed, ensuring operators maintain high proficiency standards. Once operatives have had official training, they are regularly audited on their CCTV viewing footage and any further training needs are picked up and implemented on a case by case basis.” Source location Response from London Borough of Redbridge
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 direct managerial observation, documented one-to-ones and appraisals addressing CCTV staff’s operational and training objectives.
Verbatim wording from the response “Operatives’ line managers are regularly based within the CCTV control room so are able to directly observe behaviour and working practices during shifts, with regular communication and feedback. This is in addition to regular, documented 1:1s with each staff member and regular appraisals following LBR’s One Brilliant You appraisal process which set and review operational and personal training and development objectives. All CCTV team One Brilliant You conversations are up to date and logged in the Council’s trent HR system.” Source location Response from London Borough of Redbridge
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 CCTV operator training already covers recognising suspicious, predatory, stalking, sexual harassment and intimidation behaviours.
Verbatim wording from the response “The training for CCTV operators encompasses modules that cover behavioural body language training and are specifically designed to detect behaviours that would fall under the remit of ‘suspicious’. The training is based on established principles and techniques outlined in Tavcom training programs – suspicious behaviours can include gestures, mannerisms, alone or in a group, time, location, how someone is acting (i.e. drunk/disorientated), approaching people, being aggressive etc. The training given to all LBR CCTV officers to assist them in making inferences regarding suspicious behaviours that lend themselves to multiple situations (including drug dealing, knife attacks, theft, robbery, stalking, sexual harassment and intimidation).” Source location Response from London Borough of Redbridge
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing examinations, mentoring, audits and performance management verify CCTV operators’ understanding and identify further training needs.
Verbatim wording from the response “LBR ensures that the training provided to CCTV operators is fully comprehensive and regularly reinforced through evaluation and ongoing professional development. After completing the Tavcom training, all operators must pass an exam to obtain their SIA (Security Industry Authority) licence, confirming their understanding of the training content. Additionally, LBR implements a performance management system, including mentoring from experienced operators and regular audits of work to identify any gaps in knowledge or performance. These audits inform whether additional training or guidance is needed, ensuring operators maintain high proficiency standards. Once operatives have had official training, they are regularly audited on their CCTV viewing footage and any further training needs are picked up and implemented on a case by case basis.” Source location Response from London Borough of Redbridge
Open published response
26 Mar 2024 Mark Wolfe Kinzley · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Lack of formal capacity assessment for nursing-home residents View source Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state View source Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness 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
Mark Wolfe Kinzley · 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
Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.
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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Lack of formal capacity assessment for nursing-home residents
Wider context from the report “2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
Wider context from the report “3. During the same period, Mr Kinzley was not referred for a mental health assessment despite.
a. His history of mental illness.
b. His history of deliberate self-harm.
c. His history of accidental self-harm when agitated.
d. His deteriorating mental state during the month prior to his death.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness
Wider context from the report “1. I have doubts that the location of Mr Kinzley’s care was appropriate. Mr Kinzley was a socially isolated adult suffering from a profound neurological disorder and mental illness.
” Open source report
31 Aug 2023 Donna Levy · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to escalate care in response to deteriorating health and self-neglect risks View source Failure to undertake an adequately scoped serious investigation of community care incidents View source Domiciliary care visits failing to provide personal care View source Failure to undertake or consider a formal Mental Capacity Act assessment View source Failure to make formal mental health referrals for reluctance to accept offered care View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Donna Levy · 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
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.
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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate care in response to deteriorating health and self-neglect risks
Wider context from the report “2. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake an adequately scoped serious investigation of community care incidents
Wider context from the report “6. The Trust responsible for community care did not undertake a Serious Investigation . The decision was justified on the basis that Ms Levy’s pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Domiciliary care visits failing to provide personal care
Wider context from the report “1. Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken . Ms Levy was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided . Carers had escalated to the local authority Ms Levy’s reluctance to accept personal care and raised safeguarding reports regarding Ms Levy’s living conditions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake or consider a formal Mental Capacity Act assessment
Wider context from the report “3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her.
4. No formal Mental Capacity Act assessment was ever undertaken or considered .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to make formal mental health referrals for reluctance to accept offered care
Wider context from the report “5. No formal referral was made to mental health services regarding Ms Levy’s reluctance to take advantage of offered care .
” Open source report
12 Oct 2021 Mrs Helena Opoku · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to assess the suitability of vulnerable residents' homes View source Delays in appointing social workers to vulnerable persons View source Failure to properly investigate safeguarding referrals 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
Mrs Helena Opoku · 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 Helena Opoku was pronounced deceased at home on 4 April 2021 after dying from carbon monoxide toxicity associated with using charcoal braziers for cooking and heating after her gas and electricity had been disconnected. The report raised concerns about social services’ failure to investigate safeguarding referrals, appoint social workers within a reasonable timeframe, and assess vulnerable residents’ homes during January to March 2021.
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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the suitability of vulnerable residents' homes
Wider context from the report “2. During the same period the team was unable to appoint social workers to vulnerable persons within a reasonable timeframe or carry out assessments of the suitability of the homes of vulnerable residents .
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Delays in appointing social workers to vulnerable persons
Wider context from the report “2. During the same period the team was unable to appoint social workers to vulnerable persons within a reasonable timeframe or carry out assessments of the suitability of the homes of vulnerable residents.
” 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 Redbridge; that does not assign responsibility.
PFD Monitor interpretation Failure to properly investigate safeguarding referrals
Wider context from the report “1. During January- March 2021 the London Borough of Redbridge social services adult social care team in Cranbrook and Loxford were unable to; properly investigate all but the most acute safeguarding referrals made to them ;
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations