Concerns raised 3 Insufficient monitoring of scheduled streetlight repairs View source Delays in repairing reported unlit streetlights View source Insufficient proactive inspection for unreported faulty streetlights 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
John Charles HICKMOTT · 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
John Charles Hickmott died at the scene after stepping from a pedestrian island into the path of a moving car on V11 Tongwell Street, Milton Keynes, on 19 February 2025. The incident occurred in darkness, with several nearby streetlights not working, making pedestrians difficult to see. The principal concerns were the timeliness and monitoring of streetlight repairs and the extent of proactive inspections for faulty lights.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient monitoring of scheduled streetlight repairs
Wider context from the report “I am concerned at:
1) The timeliness of repairs being undertaken when streetlights are reported as not being lit;
2) The extent of monitoring of scheduled repairs to ensure timely repair ;
3) The extent to which proactive inspections are undertaken by the Council to identify faulty streetlights, or blocks of lights, that may not have been reported to the Council.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in repairing reported unlit streetlights
Wider context from the report “I am concerned at:
1) The timeliness of repairs being undertaken when streetlights are reported as not being lit ;
2) The extent of monitoring of scheduled repairs to ensure timely repair;
3) The extent to which proactive inspections are undertaken by the Council to identify faulty streetlights, or blocks of lights, that may not have been reported to the Council.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient proactive inspection for unreported faulty streetlights
Wider context from the report “I am concerned at:
1) The timeliness of repairs being undertaken when streetlights are reported as not being lit;
2) The extent of monitoring of scheduled repairs to ensure timely repair;
3) The extent to which proactive inspections are undertaken by the Council to identify faulty streetlights, or blocks of lights, that may not have been reported to the Council .
” Open source report
28 Aug 2024 Moira FARNELL · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to repair broken pavement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Moira FARNELL · 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
Moira FARNELL fell on a broken pavement outside her home on 18 April 2024, hit her head, and was diagnosed with a traumatic subdural haematoma. Her condition deteriorated and she died in hospital on 6 May 2024; her family had contacted the council about the pavement hazard before her death, but it was not repaired.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to repair broken pavement
Wider context from the report “The deceased's family contacted the council prior to her death concerning the hazard posed by the broken pavement , but no action was taken to repair the pavement .
” Open source report
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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 Routine and responsive inspections found no actionable defect at the location requiring repair.
Verbatim wording from the response “• Utilising our ‘code of practice’ and our qualified and trained inspectors, it was determined that in line with national guidance, during both routine inspections and the ad-hoc responsive inspections following the incident, that there is no actionable defect in this location.” Source location Response from Milton Keynes Council
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 The risk-based inspection code, routine inspections and responsive inspections are considered sufficient to manage highway safety at the location.
Verbatim wording from the response “• The core of our local code of practice, as the national guidance, is that intervention criteria must be applied to justify actions. Routine and reactive inspections did not reveal any actionable defect(s) at Mentieth Close.” Source location Response from Milton Keynes Council
Open published response
23 Aug 2024 Amal Mohamed AHMED · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 5 Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry View source Frequent wrong-way driving down the slip road into oncoming traffic View source Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed View source Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction View source Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amal Mohamed 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
Amal Mohamed Ahmed died at the scene after entering the A5 southbound off slip road in the wrong direction and colliding head-on with another vehicle. The other vehicle’s driver later died in hospital, and a passenger suffered life-threatening injuries. The principal concern was that inadequate, poorly positioned and poorly visible signage and the unlit, wide junction allowed drivers to enter the slip road incorrectly; other drivers were observed making the same manoeuvre.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Frequent wrong-way driving down the slip road into oncoming traffic
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road . Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” 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 Inspect the junction and assess signage and road markings for safety defects.
Verbatim wording from the response “We received a ‘Report-It’ made on 28 May 2023. The records show that in this case a highways inspector visited the location on 2 June 2023 and made the following note ‘Inspection on 02/06/23 enough signage and road marking on road saying no entry. No safety defects found all below investigatory levels’. This reflects his remit to consider the condition of those assets in respect of safety. A standardised response was sent to the customer.” Source location Response from Milton Keynes City Council
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 Reinspect the site after the incident and investigate whether an immediate safety hazard exists.
Verbatim wording from the response “City highways officials visited the site on 20 November after the fatal incident with Thames Valley Police (TVP). TVP then conveyed a video call with MKCC and National Highways on 21 November and National Highways took subsequent actions on their junction. We would” Source location Response from Milton Keynes City Council
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 the junction situation later as part of the planned work programme.
Verbatim wording from the response “We have another ‘Report-It’ made on 21 November 2023 which was made following the incident. The same inspector visited the site again and again found no immediate safety hazard based on condition (of the asset) and highlighted to the resident on 13 January 2024 that we have investigated and intend to review the situation at a later date as part of our planned work programme. A standardised response was sent to the customer.” Source location Response from Milton Keynes City Council
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 Existing signage and road markings appeared adequate under applicable regulations, although illumination might improve the no-entry signage.
Verbatim wording from the response “agree with National Highways that the signage appeared adequate to regulations, although we would suggest that the National Highways no-entry signage at the slip road junction may benefit from illumination (although the Traffic Signs Regulations and General Directions guidance does not require this).” Source location Response from Milton Keynes City Council
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 National Highways is responsible for the slip road junction, its signage and road markings, so it must undertake related improvements.
Verbatim wording from the response “The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.” Source location Response from Milton Keynes City Council
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 The council has no powers to improve the junction mouth, signage or road markings because these are outside its highway authority functions.
Verbatim wording from the response “The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.” Source location Response from Milton Keynes City Council
Open published response
Concerns raised 1 Failure to carry out detailed needs assessments of very vulnerable and elderly patients face-to-face View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Clifford William ROSE · 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
Clifford William Rose died on 10 August 2022 after a serious infection developed from a burn caused by an electric blanket, followed by amputation of his leg. The inquest identified failures in assessing his care needs and escalating concerns about his deteriorating health and self-neglect. It also found that telephone assessments had incorrectly indicated he could dress himself and was eating and drinking regularly.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out detailed needs assessments of very vulnerable and elderly patients face-to-face
Wider context from the report “During the course of the evidence at the inquest it became apparent that detailed assessments of the needs of very vulnerable and perhaps elderly patients are being carried out over the telephone . In this particular case, it lead to the deceased confirming that he was able to dress himself and that he was eating and drinking regularly. This was far from the correct position. I believe that consideration should be given to put in place a system whereby all assessments are carried out face-to-face and where appropriate should involve another member of the family.
” 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 face-to-face assessments following adult social care referrals for care and support.
Verbatim wording from the response “I would like to reassure you that adult social care teams are now conducting face-to-face assessments following referrals for care and support. As you will be aware the Covid-19 pandemic impacted on face-to-face visits, however, we are now operating as we were pre-Covid, so face-to-face assessments are being undertaken. You will appreciate that we do occasionally encounter” Source location Response from Milton Keynes City Council
Open published response
4 Dec 2020 Roy Adrian CURTIS · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure to give urgent adult social care assessment referrals sufficient priority within social services View source Overly bureaucratic procedure for allocating and responding to urgent adult social care assessment referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Roy Adrian CURTIS · 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
Roy Adrian CURTIS, who had an autistic spectrum condition, was admitted after declaring an intention to take his own life and was later discharged without a formal multidisciplinary discharge plan. He died by suicide by hanging on or about 18 November 2018, and his body was discovered on 21 August 2019. The report raises concerns about the failure to complete an adult social care assessment and the overly bureaucratic procedure for urgent referrals, which did not give such referrals sufficient priority.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to give urgent adult social care assessment referrals sufficient priority within social services
Wider context from the report “That the procedure for allocating and responding to a referral for an urgent adult social care assessment is overly bureaucratic and they are not afforded the priority within social services that they so obviously require .
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Overly bureaucratic procedure for allocating and responding to urgent adult social care assessment referrals
Wider context from the report “That the procedure for allocating and responding to a referral for an urgent adult social care assessment is overly bureaucratic and they are not afforded the priority within social services that they so obviously require.
” 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 Employ a link social worker for the acute mental health ward to coordinate required social care assessments before discharge.
Verbatim wording from the response “We recognise that we did not get our response right for Mr Curtis. We have learnt from his untimely death and have reviewed and improved our practice. There is now a link social worker employed to work with the acute mental health hospital ward who is responsible for coordinating social care assessments before discharge when needed.” Source location 2020-0272-Response-from-Milton-Keynes-Council-Redacted
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 identification of inpatients needing social care support in discharge planning to enable timely assessment before discharge.
Verbatim wording from the response “Mr Curtis should have been seen and offered an assessment whilst still an inpatient at the Campbell Centre, an approach that is now well embedded across health and social care. Identifying people who are in patients who need support are in discharge planning meetings and is now straightforward and should not be subject to any delays or unnecessary bureaucracy.” Source location 2020-0272-Response-from-Milton-Keynes-Council-Redacted
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 team practice and monthly performance, including assessment timelines and casework reviews, through the Adult Leadership Team.
Verbatim wording from the response “We will continue to monitor the practice of our teams, with a focus on learning and improving outcomes for vulnerable people. We formally review our performance each month via our Adult Leadership Team meeting, with Heads of Service responsible for the performance in their area. This monitoring includes the timelines for assessments and case work review.” Source location 2020-0272-Response-from-Milton-Keynes-Council-Redacted
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 The out-of-hours team does not complete adult social care assessments; required assessments are referred to the Access Team.
Verbatim wording from the response “Outside of office hours the Milton Keynes Council’s Out of hours Social Care responds to urgent requests for assistance. The team operates between 1700 and 0900 and at all hours over the weekends and bank holidays. The Out of Hours team do not complete ASC assessment but will deal with urgent matters e.g. a missing person, requests for additional care and Mental Health Act assessments. The Out of Hours Team will complete a referral into the Access Team should an adult social care assessment be required.” Source location 2020-0272-Response-from-Milton-Keynes-Council-Redacted
Open published response
Concerns raised 1 Failure to provide counselling to very vulnerable people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neil Stephen David SWAISLAND · 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
Neil Stephen David SWAISLAND died after jumping from the top floor of a multi-storey car park in Milton Keynes on 14 July 2018. Evidence was heard that funding for MIND counselling services had been withdrawn by the Council and the CCG, raising concern that vulnerable people would be at increased risk of self-harm and suicide and that this could result in further suicide deaths.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide counselling to very vulnerable people
Wider context from the report “During the course of the evidence I heard from a senior GP from Milton Keynes and from a senior clinician from mental health services that the funding for counselling services operated by MIND had been withdrawn by both the Council and the CCG . They expressed the view that as a result of this decision it is inevitable that further lives will be put at risk from self-harm and suicide. My concern is that the decision not to provide counselling to some of the very vulnerable people within our society will result in further deaths from suicide.
” 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 Maintain council funding for the counselling services contract through April 2019.
Verbatim wording from the response “Milton Keynes Council (MKC) has a contract for counselling services in place with MIND, Milton Keynes Clinical Commissioning Group (MKCCG) also contributes towards the cost of this provision. This contract was due to end in December 2018 however a continuation of funding from MKC and MKCCG will maintain it until April 2019 whilst MKND develop additional funding opportunities for their services. After April the council will no longer directly commission counselling services, instead focusing our investment into our frontline mental health social care services.” Source location 2018-0385-Response-by-Milton-Keynes-Council
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 Existing NHS counselling and psychological therapy services meet national access and waiting-time requirements in Milton Keynes.
Verbatim wording from the response “The NHS is continuing to provide counselling services in Milton Keynes. MKCCG have continued their commitment to the provision of psychological therapies in Milton Keynes through the Improving Access to Psychological Therapies (IAPT) service provision. The local NHS mental health service provider, Central and North West London Foundation Trust (CNWL), is currently meeting all national access, and waiting time requirements for these services. MIND is working with the IAPT service delivering the triage service.” Source location 2018-0385-Response-by-Milton-Keynes-Council
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 After April 2019, the council will no longer directly commission counselling services, relying on NHS provision instead.
Verbatim wording from the response “Milton Keynes Council (MKC) has a contract for counselling services in place with MIND, Milton Keynes Clinical Commissioning Group (MKCCG) also contributes towards the cost of this provision. This contract was due to end in December 2018 however a continuation of funding from MKC and MKCCG will maintain it until April 2019 whilst MKND develop additional funding opportunities for their services. After April the council will no longer directly commission counselling services, instead focusing our investment into our frontline mental health social care services.” Source location 2018-0385-Response-by-Milton-Keynes-Council
Open published response
Concerns raised 7 Failure to convene senior professionals to consider cases and prepare a plan View source Failure to refer incidents for safeguarding review and learning View source Failure to conduct Serious Incident Reviews after deaths View source Failure to take further action after senior management case reviews View source Failure to respond effectively to safeguarding alerts when the person does not engage View source Lack of effective follow-up to identified problems View source Failure to request an appropriate police concern-for-safety visit View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kevin George Morgan · 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
Kevin George Morgan, who had poorly controlled type 1 diabetes, was found deceased in his flat after family contacted police when they had not heard from him for several weeks. His body was heavily decomposed, and there were no suspicious circumstances. The principal concerns were the lack of effective follow-up by social services and housing, inadequate responses to safeguarding and safety concerns, and the absence of a post-death serious incident or safeguarding review.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to convene senior professionals to consider cases and prepare a plan
Wider context from the report “(5) It was accepted by the Adult Social Care Access Team that a meeting of senior professionals should have been called to consider the case and prepare a plan .
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to refer incidents for safeguarding review and learning
Wider context from the report “(6) Following the death of Kevin Morgan there was no Serious Incident Review conducted by social services and it was not referred for a safeguarding review so that lessons have not been learned from this incident . Without such a review a similar incident could occur in the future .
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct Serious Incident Reviews after deaths
Wider context from the report “(6) Following the death of Kevin Morgan there was no Serious Incident Review conducted by social services and it was not referred for a safeguarding review so that lessons have not been learned from this incident. Without such a review a similar incident could occur in the future.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take further action after senior management case reviews
Wider context from the report “(3) That the case was reviewed by senior managers on at least two occasions and no further action was taken .
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond effectively to safeguarding alerts when the person does not engage
Wider context from the report “(2) That a safeguarding alert was completed by Kevin Morgan’s Mother and, despite her serious concerns, the response was to arrange a visit where Kevin Morgan refused to engage .
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of effective follow-up to identified problems
Wider context from the report “(1)That social services and the housing team were aware of the problems experienced by Kevin Morgan and yet there was no effective follow up .
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to request an appropriate police concern-for-safety visit
Wider context from the report “(4) The police were never requested to conduct a concern for safety visit despite such a visit being recognised as appropriate .
” Open source report
Concerns raised 2 Pedestrian access to fast roads View source Failure to reduce the 70 mph speed limit on Milton Keynes grid roads View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Victoria Elizabeth Rhodes · 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
Victoria Elizabeth Rhodes died after being struck by a Peugeot while attempting to cross the V11 Tongwell Street dual carriageway in Milton Keynes, despite an available footbridge. The concerns raised were the 70 mph speed limit on Milton Keynes grid roads and pedestrian access to fast roads, including a call to review the speed limit.
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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Pedestrian access to fast roads
Wider context from the report “(2) That pedestrians have access to the fast roads despite the attempts to encourage them to use the pedestrian walk ways.
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reduce the 70 mph speed limit on Milton Keynes grid roads
Wider context from the report “(1) That on the grid roads in Milton Keynes the speed limit remains at 70 mph .
” 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 Compile and report on a comprehensive review of road accident casualties, incorporating the identified speed-limit and pedestrian-access concerns.
Verbatim wording from the response “Milton Keynes Council takes a proactive approach to its responsibility to promote the safety of all road users in the Borough and to eliminate or reduce risk to life. 2014 has seen an unexpected rise in serious incidents on the network and as a direct result, Transport and Highways officers met with the Police in May to consider appropriate actions. Following this, Cabinet at their July meeting, endorsed a comprehensive road safety review of the accidents in Milton Keynes with a view to report back to Cabinet at the end of 2014. A copy of this report is attached.” Source location Response from Milton Keynes Hospital
Open published response
23 May 2014 Ross Robson · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure to place people in settings appropriate for their needs View source Lack of adequate assessment of individual needs 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
Ross Robson · 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
Ross Robson Boyd died following a number of falls from his wheelchair while resident at the Willows Care Home in Milton Keynes. The principal concern was that he was admitted without an adequate assessment of his needs and placed in a setting that was inappropriate for those 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to place people in settings appropriate for their needs
Wider context from the report “Ross Boyd was admitted to the Willows without an adequate assessment as to his needs being carried out with the result that he was placed at the Willows that was totally inappropriate for his needs .
” 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 Milton Keynes City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate assessment of individual needs
Wider context from the report “Ross Boyd was admitted to the Willows without an adequate assessment as to his needs being carried out with the result that he was placed at the Willows that was totally inappropriate for his needs.
” Open source report
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Addressed to “Milton Keynes Council”, a former name of Milton Keynes City Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations