Ludlow Street Healthcare Group Limited

Private and voluntary organisations · Private limited company

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First report 5 Dec 2017•Latest report 5 Dec 2017

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
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Ludlow Street Healthcare Group Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Wales Central

    AI-generated summary

    Stephanie Cave · 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

    Stephanie Cave had a history of deteriorating mental health, self-harm and attempts to end her life, and died after being found with a ligature around her neck on 17 August 2017 while in hospital care. The concerns identified included inconsistent enhanced observations, lack of training and written guidance for conducting and recording observations, and failure to routinely record precise observation times.

    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 Ludlow Street Healthcare Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training on completing and recording enhanced observations

    Wider context from the report

    “(2) The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms. ”
    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 Ludlow Street Healthcare Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of written guidelines for completing and recording enhanced observations

    Wider context from the report

    “(2) The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms. ”
    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 Ludlow Street Healthcare Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent conduct of enhanced observations

    Wider context from the report

    “(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep. ”
    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 Ludlow Street Healthcare Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent recording of enhanced observations

    Wider context from the report

    “(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep. ”
    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 Ludlow Street Healthcare Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely record precise times of enhanced observations

    Wider context from the report

    “(3) The evidence also revealed that precise times of such observations were not routinely being recorded. ”
    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

Data last updated 7 September 2026