London Borough of Redbridge

Local government · London borough council

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First report 12 Oct 2021•Latest report 26 Jul 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 4
Published responses: 25%
Concerns addressed: 2
Stated actions: 6

Concerns and recipient responses

Statements from London Borough of Redbridge linked to the concerns in each report. Select any concern, action or position to view the source wording.

26 Jul2024
East London
Concerns raised25
1. Failure to provide prison risk intelligence to Integrated Offender Management meetings
2. Threshold for reflective practice set too high
3. Unclear understanding of when to request emergency recall
1. Lack of mandatory and refreshed risk assessment training
2. Lack of supervision for prison offender managers
3. Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail
4. Lack of systems to support staff supervising key decisions
5. Lack of alerts for handover from prison to community offender managers
6. Lack of checks on sharing up-to-date and accurate risk assessments
7. Failure of prison offender managers to implement sentence plans and facilitate rehabilitation
8. Lack of focused risk assessment training for prison offender managers
9. Lack of rigour, detail and independence in MPS investigations
10. Unclear and incomplete sharing of risk information between probation and the MPS
11. Failure to conduct timely risk assessments with complementary risk management plans
12. Societal acceptance of unreported following behaviour
13. Unclear CCTV operator training on identifying sexual predators and stalking behaviour
14. Lack of assurance and refresher training for CCTV operators
15. Failure to holistically assess indicators of serious harm
16. Failure of alert systems to highlight restraining orders
17. Lack of reporting guidance and training for business owners on sexualised or predatory behaviour
18. OASYS risk assessment tool failing to support extraction and analysis of key risk areas
19. Understaffing of probation delivery units
20. Failure to probe information relevant to risk
21. Obstacles inhibiting increases in assessed risk levels
22. Failure of prison offender managers to gather and share evidence relevant to risk formulation
Actions described in response 4
1. Action
  Audit CCTV operators’ work and provide mentoring, additional training or guidance where knowledge or performance gaps are identified.
2. Action
  Deliver CCTV operator training covering suspicious, predatory, stalking and sexual harassment behaviours.
3. Action
  Require CCTV operators to pass an examination for SIA licensing to confirm understanding of training.
1. Action
  Provide direct managerial observation, documented one-to-ones and appraisals addressing CCTV staff’s operational and training objectives.
Respondent positions 2
1. Position
  CCTV operator training already covers recognising suspicious, predatory, stalking, sexual harassment and intimidation behaviours.
  Disputes the concern
1. Position
  Existing examinations, mentoring, audits and performance management verify CCTV operators’ understanding and identify further training needs.
  Existing arrangements considered sufficient
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
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
Page 1 · response
Published 2 August 2024
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 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
Page 1 · response
Published 2 August 2024
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
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
Page 1 · response
Published 2 August 2024
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
Page 1 · response
Published 2 August 2024
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
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
Page 1 · response
Published 2 August 2024
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
Page 1 · response
Published 2 August 2024
Open published response
26 Mar2024
East London
Concerns raised3
1. Lack of formal capacity assessment for nursing-home residents
2. Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
3. Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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 Aug2023
East London
Concerns raised5
1. Failure to escalate care in response to deteriorating health and self-neglect risks
2. Failure to undertake an adequately scoped serious investigation of community care incidents
3. Domiciliary care visits failing to provide personal care
1. Failure to undertake or consider a formal Mental Capacity Act assessment
2. Failure to make formal mental health referrals for reluctance to accept offered care
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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 Oct2021
East London
Concerns raised3
1. Failure to assess the suitability of vulnerable residents' homes
2. Delays in appointing social workers to vulnerable persons
3. Failure to properly investigate safeguarding referrals
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised25

Failure to provide prison risk intelligence to Integrated Offender Management meetings

Threshold for reflective practice set too high

Unclear understanding of when to request emergency recall

Lack of mandatory and refreshed risk assessment training

Lack of supervision for prison offender managers

Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail

Lack of systems to support staff supervising key decisions

Lack of alerts for handover from prison to community offender managers

Lack of checks on sharing up-to-date and accurate risk assessments

Failure of prison offender managers to implement sentence plans and facilitate rehabilitation

Lack of focused risk assessment training for prison offender managers

Lack of rigour, detail and independence in MPS investigations

Unclear and incomplete sharing of risk information between probation and the MPS

Failure to conduct timely risk assessments with complementary risk management plans

Societal acceptance of unreported following behaviour

Unclear CCTV operator training on identifying sexual predators and stalking behaviour

Lack of assurance and refresher training for CCTV operators

Failure to holistically assess indicators of serious harm

Failure of alert systems to highlight restraining orders

Lack of reporting guidance and training for business owners on sexualised or predatory behaviour

OASYS risk assessment tool failing to support extraction and analysis of key risk areas

Understaffing of probation delivery units

Failure to probe information relevant to risk

Obstacles inhibiting increases in assessed risk levels

Failure of prison offender managers to gather and share evidence relevant to risk formulation

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Concerns raised3

Lack of formal capacity assessment for nursing-home residents

Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state

Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness

Actions described in response 4

Respondent positions 2