23 Jan 2026 Jean GROVES · Prevention of Future Deaths report Norfolk
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Concerns raised 1 Failure to provide emergency responders with access details for vulnerable patients View source
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AI-generated summary
Jean GROVES · 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
Jean Groves, who had a complex health background, became unwell with diarrhoea and vomiting and was later found deceased at home on 24 March 2025 from excessive bleeding related to her underlying health condition. The concern was that emergency responders may not receive access details for vulnerable patients when supporting the ambulance service under the NHS “Access to the Stack” initiative, potentially leading to future deaths.
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× 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide emergency responders with access details for vulnerable patients
Wider context from the report “I have concerns that if emergency responders are not being provided with access details for vulnerable patients when providing support to the ambulance service under the NHS “Access to the Stack” initiative , this may lead to future deaths.
” 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 Referrals without recorded access details are declined and returned to EEAST under the existing process.
Verbatim wording from the response “As no access details were recorded on the system, the referral was subsequently declined and returned to EEAST. If we have no access details recorded on the A2S referral portal or the Service Users Social Care record our process is to decline the referral and return to Stack. In accordance with our usual process, details of declined referrals should be recorded on the Service User’s Social Care record. Unfortunately, in this instance, no such record was created. This was an internal recording error; it had no impact on our decision making.” Source location Response from Norfolk County Council
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17 Jul 2024 Barry John HOWARD · Prevention of Future Deaths report Norfolk
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Concerns raised 8 Failure to assess and address the reasons for not adopting appropriate road-closure measures View source Slippery road surface View source Insufficiency of temporary road-closure signs View source Delays in implementing guideline-compliant permanent road-closure measures View source Failure to position flood warnings sufficiently in advance and visibly before the Ford View source Lack of appropriate warning signs that the Ford is prone to flooding and may be unsafe to cross View source Failure to ensure road-closure teams follow correct procedures for temporary and permanent measures View source Failure to take appropriate action in response to reported incidents involving unawareness of the unbridged Ford risk View source See 5 more concerns
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AI-generated summary
Barry John HOWARD · 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
Barry John Howard entered flood water at an unbridged ford on 13 December 2023, after warning signs were not visible, and his car was swept into the river. He was found deceased in the almost completely submerged car on 14 December 2023. Concerns included inadequate and poorly positioned warning signs, delayed or insufficient road-closure measures, and other risks associated with the ford and road surface.
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× 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and address the reasons for not adopting appropriate road-closure measures
Wider context from the report “vi. The evidence was that more appropriate measures for road closure should have been considered , but there was no evidence as to why they were not, or that this has been considered and action taken to address the reasons . I have not heard of any change to the way the team works, and I was repeatedly told they are a small team with a large area to cover - which means that there are risks of future issues with regards to the suitability of temporary signs and the correct procedures being followed when they need to be more permanent.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Slippery road surface
Wider context from the report “iv. The slippery surface of the road .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficiency of temporary road-closure signs
Wider context from the report “v. The insufficiency of the temporary road closed signs used and the lack of more permanent measures, in accordance with guidelines, once the closure lasted more than 24 hours. It was only a week prior to the inquest, some 7 months after this death, that action was taken. I am concerned that such lengthy delays to implement safety measures will lead to a risk in future incidents at this and possibly other locations.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing guideline-compliant permanent road-closure measures
Wider context from the report “v. The insufficiency of the temporary road closed signs used and the lack of more permanent measures, in accordance with guidelines, once the closure lasted more than 24 hours . It was only a week prior to the inquest, some 7 months after this death, that action was taken. I am concerned that such lengthy delays to implement safety measures will lead to a risk in future incidents at this and possibly other locations.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to position flood warnings sufficiently in advance and visibly before the Ford
Wider context from the report “iii. A lack of signs sufficiently in advance of the Ford so as to warn road users at times of extreme flooding. The current signs were well within the flooded area on the night in question and I am concerned they would not be visible, especially to those unfamiliar with the road and in the dark, until they were already in the flood water .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate warning signs that the Ford is prone to flooding and may be unsafe to cross
Wider context from the report “ii. A lack of any appropriate warning signs that this Ford is prone to flooding which may make it unsafe to cross .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure road-closure teams follow correct procedures for temporary and permanent measures
Wider context from the report “vi. The evidence was that more appropriate measures for road closure should have been considered, but there was no evidence as to why they were not, or that this has been considered and action taken to address the reasons. I have not heard of any change to the way the team works , and I was repeatedly told they are a small team with a large area to cover - which means that there are risks of future issues with regards to the suitability of temporary signs and the correct procedures being followed when they need to be more permanent .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take appropriate action in response to reported incidents involving unawareness of the unbridged Ford risk
Wider context from the report “i. While the evidence I heard was that the Council consider that the current signage is adequate & has been inspected, there was a history of incidents reported to them , and sadly the very tragic death of Barry. That suggests that, while they consider it adequate, it was not sufficiently so to prevent those incidents & Barry’s death. I have heard nothing to reassure me that appropriate action has been taken to prevent others continuing to fail to be aware of the risk of the unbridged Ford, especially after heavy periods of rain .
” 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 Arrange replacement warning signs at locations with missing or damaged signs.
Verbatim wording from the response “As the local highway authority for Norfolk, the Council is responsible for 47 fords across 6,200 miles of highway network. Within days of the incident on 13 December 2023, all these fords had been inspected by the local Highways teams to ensure vehicle users would encounter safe conditions. This initial review identified other locations where roads were closed due to higher than usual water levels, and replacements for any missing and damaged warning signs were also arranged. As a result of these actions, two further fords on the Norfolk network (at West Acre and Caste Acre) were closed and remain closed to ensure public safety.” Source location Response from Norfolk County Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct detailed, site-specific safety reviews of all 47 county fords.
Verbatim wording from the response “Alongside this initial inspection work, more detailed safety reviews of all 47 fords in the Norfolk network were commissioned. The characteristics of each ford across the Norfolk highway network are different and therefore each ford requires a detailed, individual assessment. As part of this review, Engineers are considering the points you have raised in the Regulation 28 Report and are investigating other opportunities to further improve safety at each ford location.” Source location Response from Norfolk County Council
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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 Complete the specific Shotesham Ford safety review and scope alternative safety treatments.
Verbatim wording from the response “A specific safety review has also been undertaken by the Council at Shotesham Ford. This has involved an initial scoping of options for addressing the specific issues identified at Shotesham, which has developed into a full feasibility assessment of alternative treatments at this location.” Source location Response from Norfolk County Council
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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 Install improved warning signage at multiple ford locations following site-specific safety reviews.
Verbatim wording from the response “vi) As outlined earlier in this response, there have been lessons learned from this tragic incident. Safety inspections of all fords in Norfolk were undertaken immediately after the event. Subsequently, more detailed site by site safety reviews have also been undertaken, with measures such as improved signage installed at a number of locations, and even some further road closures where water levels were observed to be high.” Source location Response from Norfolk County Council
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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 Install immovable barriers and associated robust closure measures at Shotesham Ford.
Verbatim wording from the response “i) As stated above, a detailed safety review of Shotesham Ford has been undertaken and a number of actions have already been completed, with further planned. In addition, regular inspections have been undertaken to assess the safety of reopening the ford on a weekly basis and the results of these, combined with the groundwater challenges explained above, have resulted in the ford remaining closed to traffic. Despite regular complaints from local residents and businesses, this remains the case. Given the longer than expected ongoing nature of this closure and evidence to suggest that the road closed warning signs and barriers were being ignored by motorists, the Council therefore recently improved the barriers, by way of installing immovable barriers, to ensure motorists could not continue ignoring the warning signs and barriers.” Source location Response from Norfolk County 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 Inspect all 47 county fords for safe conditions after the incident.
Verbatim wording from the response “As the local highway authority for Norfolk, the Council is responsible for 47 fords across 6,200 miles of highway network. Within days of the incident on 13 December 2023, all these fords had been inspected by the local Highways teams to ensure vehicle users would encounter safe conditions. This initial review identified other locations where roads were closed due to higher than usual water levels, and replacements for any missing and damaged warning signs were also arranged. As a result of these actions, two further fords on the Norfolk network (at West Acre and Caste Acre) were closed and remain closed to ensure public safety.” Source location Response from Norfolk County 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 Make the ford safe with temporary signs and order replacement permanent signs after theft of warning signs.
Verbatim wording from the response “Regrettably, I report that since these more robust measures were installed in July 2024, the warning signs have been stolen on one side of the ford (identified on 1 August 2024) and the local Highway team have made safe with temporary signs and ordered replacement more permanent signs.” Source location Response from Norfolk County Council
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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 Evaluate permanent closure and other longer-term treatment options for Shotesham Ford through a feasibility assessment.
Verbatim wording from the response “A specific safety review has also been undertaken by the Council at Shotesham Ford. This has involved an initial scoping of options for addressing the specific issues identified at Shotesham, which has developed into a full feasibility assessment of alternative treatments at this location.” Source location Response from Norfolk County 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 Maintain Shotesham Ford’s closure until the feasibility work is completed.
Verbatim wording from the response “In summary, given the concerns raised in the Regulation 28 Report, together with the fluctuating and higher than usual water levels at Shotesham, the Council deems it is not safe to reopen Shotesham Ford at the current time and the option of permanent closure to ensure public safety is being evaluated by the Council as part of the feasibility assessment of longer-term options at Shotesham. Until the completion of this feasibility work, which is expected later this year, the ford will remain closed.” Source location Response from Norfolk County Council
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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 Standard temporary road-closure signs and barriers are generally effective for implementing highway closures.
Verbatim wording from the response “v) The temporary road closed signs that have been used are the standard types of signs and barriers used across the country by highway authorities to implement closures such as these. They are usually effective. As explained above, water levels had been expected to return to their normal safe levels in spring. However, due to wider weather conditions, this has not been the case. Highway users have a statutory right to pass and repass on the highway and therefore a longer term closure requires consultation to ensure legitimate access to nearby properties and agricultural land is not impeded. Planning the measures that are currently in place, which included a localised consultation (given the complaints received that the ford was temporarily closed), was undertaken this spring and the measures installed on 9 July 2024.” Source location Response from Norfolk County Council
Open published response
21 Jul 2021 Oscar Anthony SEAMAN · Prevention of Future Deaths report Norfolk
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Concerns raised 3 Reduced junction visibility at night and in inclement weather View source Inadequate stop-sign control at the crossroads View source Failure to prevent repeated speeding on the road 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
Oscar Anthony SEAMAN · 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
Oscar Anthony Seaman, aged 17, was killed after cycling onto the A134 carriageway at a crossroads in Northwold and being struck by a 4x4 vehicle. Concerns included repeated collisions and speeding on the road, reduced visibility at the junction, and the absence of stop signs, with possible measures including speed cameras and a junction mirror discussed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Reduced junction visibility at night and in inclement weather
Wider context from the report “I am informed that the road where Oscar was killed is the scene of at least 126 road traffic collisions. The speed limit was reduced from 60mph to 50mph, but this has not deterred people using the road from ignoring the limits. The crossroads where Oscar, who was just 17 years old, emerged onto the main road has give way signs but not stop signs painted on it. The view from one direction appears to be reasonable in daylight but at night, and if the weather is inclement, visibility is reduced. The person who lives on the corner of that junction has had to buttress his garden fence against collisions.
The parish council has reported many concerns about people speeding on the road specially HGV lorries as well as cars.
It is apparent that people regularly break the law on this stretch of road and that a speed camera or average speed cameras would address the problem and slow motorists down. A mirror would be able to be placed at the junction, an inexpensive but important item which is likely to reduce death and accident when people venture onto the main highway.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate stop-sign control at the crossroads
Wider context from the report “I am informed that the road where Oscar was killed is the scene of at least 126 road traffic collisions. The speed limit was reduced from 60mph to 50mph, but this has not deterred people using the road from ignoring the limits. The crossroads where Oscar, who was just 17 years old, emerged onto the main road has give way signs but not stop signs painted on it. The view from one direction appears to be reasonable in daylight but at night, and if the weather is inclement, visibility is reduced. The person who lives on the corner of that junction has had to buttress his garden fence against collisions.
The parish council has reported many concerns about people speeding on the road specially HGV lorries as well as cars.
It is apparent that people regularly break the law on this stretch of road and that a speed camera or average speed cameras would address the problem and slow motorists down. A mirror would be able to be placed at the junction, an inexpensive but important item which is likely to reduce death and accident when people venture onto the main highway.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent repeated speeding on the road
Wider context from the report “I am informed that the road where Oscar was killed is the scene of at least 126 road traffic collisions. The speed limit was reduced from 60mph to 50mph, but this has not deterred people using the road from ignoring the limits. The crossroads where Oscar, who was just 17 years old, emerged onto the main road has give way signs but not stop signs painted on it. The view from one direction appears to be reasonable in daylight but at night, and if the weather is inclement, visibility is reduced. The person who lives on the corner of that junction has had to buttress his garden fence against collisions.
The parish council has reported many concerns about people speeding on the road specially HGV lorries as well as cars.
It is apparent that people regularly break the law on this stretch of road and that a speed camera or average speed cameras would address the problem and slow motorists down. A mirror would be able to be placed at the junction, an inexpensive but important item which is likely to reduce death and accident when people venture onto the main highway.
” 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 Undertake speed surveys to measure driver compliance.
Verbatim wording from the response “There have been a number of highway safety interventions introduced to include: red centre hatch treatment, provision of bend warning chevron boards which better reflect the alignment of the bend to the southeast, sign relocations, provision of hedges to control visibility, provision of ‘Slow’ markings on the carriageway, cutting back of other vegetation, and addition of side road triggers to the existing junction warning vehicle activated signs. In addition to the above interventions, the speed limit was reduced to 50mph in response to this incident. In light of your comments concerning vehicle speed, it is agreed that NCC will undertake speed surveys to measure driver compliance.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
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 visibility approaching the A134 from the northeast arm of the junction.
Verbatim wording from the response “With regard to the provision of “STOP” road markings and signs, such measures are restricted to those locations where visibility of a junction is severely impaired whereby highways users are reminded to stop and giveway to traffic before proceeding ensuring it is safe to do so. This has been investigated previously in accordance with national guidance contained within the Traffic Signs Manual (Chapter 3), and neither junction met the requirements for the introduction of “STOP” markings and signs. This is particularly so for the southeast arm, where existing visibility is well above the minimum requirements even for a 60mph speed limit. However, a further review will be undertaken to reassess the visibility approaching the A134 from the northeast arm of the junction.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
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 Reduce the speed limit to 50 mph.
Verbatim wording from the response “There have been a number of highway safety interventions introduced to include: red centre hatch treatment, provision of bend warning chevron boards which better reflect the alignment of the bend to the southeast, sign relocations, provision of hedges to control visibility, provision of ‘Slow’ markings on the carriageway, cutting back of other vegetation, and addition of side road triggers to the existing junction warning vehicle activated signs. In addition to the above interventions, the speed limit was reduced to 50mph in response to this incident. In light of your comments concerning vehicle speed, it is agreed that NCC will undertake speed surveys to measure driver compliance.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
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 Investigate whether STOP markings and signs were warranted at the junctions under national guidance.
Verbatim wording from the response “With regard to the provision of “STOP” road markings and signs, such measures are restricted to those locations where visibility of a junction is severely impaired whereby highways users are reminded to stop and giveway to traffic before proceeding ensuring it is safe to do so. This has been investigated previously in accordance with national guidance contained within the Traffic Signs Manual (Chapter 3), and neither junction met the requirements for the introduction of “STOP” markings and signs. This is particularly so for the southeast arm, where existing visibility is well above the minimum requirements even for a 60mph speed limit. However, a further review will be undertaken to reassess the visibility approaching the A134 from the northeast arm of the junction.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
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 Implement highway safety measures including centre hatching, bend chevrons, sign relocations, visibility controls, slow markings, vegetation cutting and junction warning triggers.
Verbatim wording from the response “There have been a number of highway safety interventions introduced to include: red centre hatch treatment, provision of bend warning chevron boards which better reflect the alignment of the bend to the southeast, sign relocations, provision of hedges to control visibility, provision of ‘Slow’ markings on the carriageway, cutting back of other vegetation, and addition of side road triggers to the existing junction warning vehicle activated signs. In addition to the above interventions, the speed limit was reduced to 50mph in response to this incident. In light of your comments concerning vehicle speed, it is agreed that NCC will undertake speed surveys to measure driver compliance.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
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 STOP markings and signs are not warranted because junction visibility meets applicable national guidance requirements.
Verbatim wording from the response “With regard to the provision of “STOP” road markings and signs, such measures are restricted to those locations where visibility of a junction is severely impaired whereby highways users are reminded to stop and giveway to traffic before proceeding ensuring it is safe to do so. This has been investigated previously in accordance with national guidance contained within the Traffic Signs Manual (Chapter 3), and neither junction met the requirements for the introduction of “STOP” markings and signs. This is particularly so for the southeast arm, where existing visibility is well above the minimum requirements even for a 60mph speed limit. However, a further review will be undertaken to reassess the visibility approaching the A134 from the northeast arm of the junction.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
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 Speed-camera provision cannot be pursued because the site does not meet Department for Transport injury-accident criteria.
Verbatim wording from the response “Your report mentions that the provision of a speed camera or an average speed camera system would help with speed limit compliance. Highway Authorities are required to follow Department for Transport (DfT) guidance when considering whether speed camera provisions are required to improve road safety. DfT circular 01/2007 recommends that only those sites with three recorded injury accidents within 36month period could be considered where excessive speed was a factor. This is not the case at A134 Northwold.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
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 Junction mirrors cannot be installed because they are not authorised or recommended due to potential glare and distance-judgement risks.
Verbatim wording from the response “I acknowledge your observation concerning the provision of a mirror at the junction. I regret that the installation of mirrors is not authorised or recommended by the County Council. This is because mirrors can dazzle highway users and can affect driver’s ability to judge the distance of on-coming traffic.” Source location 2021-0252-Response-from-Norfolk-County-Council_Published
Open published response
2 Feb 2021 Michael Yemm · Prevention of Future Deaths report Norfolk
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Concerns raised 5 Failure to coordinate hospital discharge with the receiving care home View source Placement of people in unsuitable and unsafe residential settings View source Failure to provide appropriate falls prevention for patients in cohorted hospital bays View source Failure to respond to requests for help finding suitable placements View source Discharge of patients with medicines that the receiving care home cannot administer View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Yemm · 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
Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in hospital.
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× 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate hospital discharge with the receiving care home
Wider context from the report “The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back . He was also discharged on insulin which the home could not administer as they do not have trained nursing staff.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Placement of people in unsuitable and unsafe residential settings
Wider context from the report “That Mr Yemm was placed into a totally unsuitable and unsafe residential setting . Shortly after his arrival, the next day, the manager contacted Mr Yemm's social worker and told them they couldn't look after him properly . Despite this he was left in this care home . ████████ wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply. She was also told that after his falls that he had hairline fractures of his left hip before the fall in hospital.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate falls prevention for patients in cohorted hospital bays
Wider context from the report “That he was able, in a cohorted patient bay, to climb past raised bedrails , he did not have a lowered bed , whilst staff were present. A cohorted bay has extra staff to deal with challenging patients and fell fracturing his hip , necessitating surgery. For the whole of his stay Mr Yemm was agitated, confused anxious and distressed, he had to move wards because of the need for surgery which further exacerbated his condition.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to requests for help finding suitable placements
Wider context from the report “That Mr Yemm was placed into a totally unsuitable and unsafe residential setting. Shortly after his arrival, the next day, the manager contacted Mr Yemm's social worker and told them they couldn't look after him properly. Despite this he was left in this care home. ████████ wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply . She was also told that after his falls that he had hairline fractures of his left hip before the fall in hospital.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Discharge of patients with medicines that the receiving care home cannot administer
Wider context from the report “The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back. He was also discharged on insulin which the home could not administer as they do not have trained nursing staff .
” 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 Adult Social Care cannot source higher-level specialist placement until the CCG agrees to fund it.
Verbatim wording from the response “because the nursing homes were unable to meet Mr Yemm’s level of need. Until the CCG agrees to fund a specialist neurological placement, adult social care is not able to source a placement with a higher level of care. It was not until Mrs Yemm complained that her husband’s needs were assessed for specialist provision by healthcare services.” Source location 2021-0024-Response-from-Adult-Social-Services-Norfolk-County-Council-Redacted
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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 Adult Social Services cannot place someone in nursing care without a health professional’s nursing needs assessment.
Verbatim wording from the response “On 24 May 2020, Adult Social Services was contacted by a member of the ward staff at Langley Ward, NNUH, advising that Mr Yemm required ‘Support following hospital discharge. Unplanned admission to NNUH. Short term 24 hour residential support required while delirium resolving.’ Mr Yemm had been placed on D2A pathway 2. Norfolk County Council is not able to place people in nursing home care without a nursing needs assessment carried out by a health professional. We were advised by health professionals that nursing care was not needed at this time and residential placement was sourced at Melton House, in line with the hospital’s assessment.” Source location 2021-0024-Response-from-Adult-Social-Services-Norfolk-County-Council-Redacted
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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 letter was escalated through the community response team and senior management, so no escalation to the Director was considered necessary.
Verbatim wording from the response “A letter has been identified which Mrs Yemm shared with the community response team social worker. The community response team social worker shared this with her senior manager and at that point the meeting was called with the CCG on 2 September 2020.” Source location 2021-0024-Response-from-Adult-Social-Services-Norfolk-County-Council-Redacted
Open published response
17 Sep 2019 Tyla Katherine Joan COOK · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to organise a multi-disciplinary learning event on emergency non-technical skills View source Failure to maintain up-to-date written care and crisis plans View source Delays in Eating Disorder Service assessment due to caseload capacity 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
Tyla Katherine Joan COOK · 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
Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.
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× 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to organise a multi-disciplinary learning event on emergency non-technical skills
Wider context from the report “3. The Review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust, Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non-technical skills (teamwork, leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event . The Care providers indicated it was the West Norfolk Clinical Commissioning Group. The West Norfolk Clinical Commissioning Group do not appear to accept responsibility for organisation of the event. Tyla died on 15 November 2017. The West Norfolk Clinical Commissioning Group Review was published 8 May 2019. No steps have been taken with regard to this learning event , save East of England Ambulance Service Trust has been in contact with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary learning event will not be organised and will not take place .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date written care and crisis plans
Wider context from the report “2. There was no written up-to-date care and crisis plans in place . The most recent written care plan related to Tyla being an inpatient at the Dragonfly Unit, from where he was discharged on 9 August 2017. The written plans were therefore several months out of date . This is against Trust Policy. Evidence was heard that at a CETR meeting on 6 November 2017 a period of a further 3 months was requested to prepare an up to date written care plan. In the event, and despite the family’s repeated requests for plans in writing, it was decided the care plan could be commenced by 30 November 2017, on the basis Tyla’s input into the Care Plan was important and it would take time to gain his meaningful input. The evidence was that there were oral plans in place which were relayed to the parents (including at times of distress), who continued to request plans in writing. The high level of distress and anxiety within Tyla’s home was recognised. An interim written plan was not considered nor that a written plan may have helped the family in providing support to Tyla. Steps have been taken by the Trust to recognise when up to date written plans are not in place and it is understood staff have undergone some work in improving the quality of care plans. However in this case an active decision was made not to update the written plan for some time . Further the evidence did not reveal any insight into the support a written plan could have given the family to support Tyla.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in Eating Disorder Service assessment due to caseload capacity
Wider context from the report “1. It was agreed at the CETR meeting on 9 August 2017 that Tyla was to be seen by the Eating Disorder Service. He was not seen until 25 October 2017 . The evidence was the 11 week delay in seeing Tyla was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with Tyla ;
” 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 The review’s learning themes are already being addressed through existing work and approaches for working with children and families.
Verbatim wording from the response “Although these are recommendations from this particular review, they are all areas of work that are currently underway and being adopted in our approach to working with children and families.” Source location 2019-0299-Response-by-Norfolk-County-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 Most specific recommendations concern health partners, which will provide the Coroner with a joint response on matters pertinent to them.
Verbatim wording from the response “The majority of the specific points made in your report relate to actions to be taken by our health partners. We have been in liaison with health colleagues on these matters and the various health partnerships will be providing you with their joint response to the recommendations pertinent to them.” Source location 2019-0299-Response-by-Norfolk-County-Council_Redacted
Open published response
1 Feb 2016 LORRAINE SHEILA YOUNGS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Lack of a system for following up implementation of agreed care packages 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
LORRAINE SHEILA YOUNGS · 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
Lorraine Sheila Youngs was a detained patient at Hellesdon Hospital who was found unresponsive after wrapping a telephone cord around her neck and died two days later in hospital. The report raised concern that an agreed community care package had not been implemented or followed up, and that there appeared to be no system for monitoring implementation.
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× 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for following up implementation of agreed care packages
Wider context from the report “The inquest heard evidence regarding Lorraine Young's care in the community. Evidence was given from Lorraine's social worker that a care package had been agreed in principle at a visit on 12 February 2015. At the time of her death, this had not been implemented. The evidence given was that this had not been followed up. Whilst it could not be said in the context of Lorraine's death whether the delay affected the outcome, I was concerned that a delay in following up implementation of an agreed care package could, in different circumstances, affect the outcome for a vulnerable Service User . The evidence before the inquest was that there appeared to be no system for following up implementation of an agreed care package .
” 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 communication and an unmet-need log when required care and support cannot be sourced.
Verbatim wording from the response “Having this dedicated team ensures that the care requests are followed up and actioned. CAS keep the social worker informed of their actions and the care they have arranged. If CAS are unable to source the care and support required they inform the social worker and keep an unmet need log.” Source location Lorraine-Youngs-Response
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 discharged people’s care packages at four weeks and at regular intervals to ensure continuing suitability.
Verbatim wording from the response “Once the person is discharged from hospital, the locality social work team becomes responsible for ensuring that the care package continues to meet the needs of the person by carrying out an initial review at four weeks and then at regular intervals.” Source location Lorraine-Youngs-Response
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 Instruct the Care Arranging Service to source longer-term care, share assessment information with providers, identify start dates and record actions on CareFirst.
Verbatim wording from the response “This service can be arranged at short notice and can support hospital discharge. If the assessment by the hospital discharge social worker indicates longer term needs, the worker instructs the NCC Care Arranging Service to source care services. The Care Arranging Service (CAS) shares the relevant assessment information with the potential care provider to ensure that they are able to meet the person’s assessed care and support needs and identifies the date the care package is needed to start. The actions of the Care Arranging Service are recorded on CareFirst, the NCC electronic client based information system.” Source location Lorraine-Youngs-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide staff cover and daily duty-system backup so agreed actions and urgent requests are followed up during absences and outside planned arrangements.
Verbatim wording from the response “The Hospital Discharge Social Care staff cover for one another during any period of absence to ensure that agreed actions are followed up. There is also the back-up of the North locality mental health team duty system, whereby there is a member of staff available every day during office hours to respond to urgent and unplanned requests.” Source location Lorraine-Youngs-Response
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 dedicated Hospital Discharge Social Care team and Care Arranging Service ensure agreed care requests are followed up and actioned.
Verbatim wording from the response “Three experienced mental health social worker/approved Mental Health Professionals based in this team link with the acute wards to ensure early signposting, timely and proportionate needs assessments, multi-disciplinary decision making and discharge planning. This facilitates much closer working arrangements which ensure that patients who are admitted to the ward can be assessed as soon as they are well enough, and arrangements made for their discharge. This means that delays and last minute arrangements are avoided.” Source location Lorraine-Youngs-Response
Open published response
1 Apr 2015 CHRISTOPHER WATSON · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to make direct contact with vulnerable people to ensure they understand available help View source Failure to assess capacity where required View source Failure to verify receipt, accessibility and understanding of letters before closing the file 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
CHRISTOPHER WATSON · 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
Christopher Watson, who had become isolated after losing his job, was found dead in his home on 7 January 2015 after having been dead for some weeks. The concerns focused on Norfolk County Council Adult Social Care closing his file after sending a letter that Mr Watson might not receive, open or understand, and on the lack of direct contact to ensure he understood that help was available and to assess whether his capacity needed assessment. The inquest recorded that he died from exsanguination after cutting his own arm, with his intention not known.
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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make direct contact with vulnerable people to ensure they understand available help
Wider context from the report “(2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. “painfully thin, unwashed and dishevelled”. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess capacity where required
Wider context from the report “(2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. “painfully thin, unwashed and dishevelled”. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to verify receipt, accessibility and understanding of letters before closing the file
Wider context from the report “(1) There is no concern over the actions of ASC prior to the letter being sent to Mr Watson. The concern is over the contents of the letter to the effect that if the person does not require action then they are to ignore the letter and the file is then closed . No steps are taken to ensure that the person actually receives, opens and understands the letter or whether they can read for instance.
” 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 Implement contact-monitoring and risk-escalation requirements, including recording contact attempts, assessing risk, arranging visits, and escalating delayed contact to senior staff.
Verbatim wording from the response “I can confirm that staff have been reminded to record all the steps they have taken to make contact with the person about whom concerns have been raised. At each attempt, the level of risk must be assessed and recorded. If the risk to the person is thought to be significant, staff have been instructed that an immediate home visit will be arranged. Even where the risk to the person is thought to be low, if the time taken to make contact extends to two days, the case must be escalated to a senior member of staff; either a Practice Consultant or Team Manager. The manager will” Source location 2015-0133-Response-by-Norfolk-County-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 Stop sending letters that close concerns without confirmed contact and require face-to-face contact when telephone contact fails.
Verbatim wording from the response “I can confirm that action has been taken to ensure that practice across all Adult Social Services teams has been changed. An instruction has been issued to staff to ensure that the practice of sending a letter to individuals about whom concerns have been raised is ceased with immediate effect. In cases where the Department is unable to contact an individual by telephone, staff have been instructed to ensure that face-to-face contact is made with the person.” Source location 2015-0133-Response-by-Norfolk-County-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 Formalise the contact-monitoring and risk-escalation requirements as a new Operational Instruction.
Verbatim wording from the response “be required to make a timely and appropriate decision regarding the next course of action. For example, this may mean a welfare check or emergency visit. This advice has been re-issued to staff in the form of a best practice factsheet. It is also being formalised as a new Operational Instruction which will be completed shortly.” Source location 2015-0133-Response-by-Norfolk-County-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 No concern is identified regarding Adult Social Services’ actions before the letter was sent.
Verbatim wording from the response “(1) There is no concern over the actions of ASC prior to the letter being sent to Mr Watson. The concern is over the contents of the letter to the effect that if the person does not require action then they are to ignore the letter and the file is then closed. No steps are taken to ensure that the person actually receives, opens and understands the letter or whatever they can read for instance.” Source location 2015-0133-Response-by-Norfolk-County-Council
Open published response
2 Feb 2015 MARTHA ANNE SEAWARD · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to implement safety measures for the Lodge Hill bus stop and adjacent A148 View source Dangerous bus stop and stretch of road at Lodge Hill View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MARTHA ANNE SEAWARD · 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
Martha Seaward, aged 18, was struck and fatally injured by a lorry while crossing the A148 after alighting from a bus at Lodge Hill. Concerns included the dangers of the bus stop and road crossing, with possible safety measures such as a pedestrian refuge, improved visibility, bus stop changes and a speed limit having been considered but not acted upon.
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× 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement safety measures for the Lodge Hill bus stop and adjacent A148
Wider context from the report “(1) The bus stop at Lodge Hill is regarded as busy by Norfolk County Council (NCC) with 778 passengers in 2014. There used to be an hourly service from this stop into West Beckham until 2006 when it was stopped due to it being too dangerous for the bus to travel across the A148. There is now a service 1 per day - 3 days per week. The bus stop services a local tourist attraction as well as the nearby village of West Beckham.
(2) Concerns have been raised with the NCC on two occasions in the past 2 years (unrelated to this incident) with regard to the dangers of this bus stop/stretch of road.
(3) There has been communication between NCC and Norman Lamb MP regarding a feasibility study carried out for safety measures to be introduced in respect of this area. No action has been taken since May 2014. The outcome of the Inquest has been awaited before taking any further action.
(4) Matters which have been considered but in respect of which no action has been taken include:
1. Affordable options to improve safety for pedestrians crossing the A148, such as a pedestrian refuge;
2. Improvements to visibility;
3. Bus stop arrangements such as a lay-by
4. Speed limit.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Dangerous bus stop and stretch of road at Lodge Hill
Wider context from the report “(1) The bus stop at Lodge Hill is regarded as busy by Norfolk County Council (NCC) with 778 passengers in 2014. There used to be an hourly service from this stop into West Beckham until 2006 when it was stopped due to it being too dangerous for the bus to travel across the A148 . There is now a service 1 per day - 3 days per week. The bus stop services a local tourist attraction as well as the nearby village of West Beckham.
(2) Concerns have been raised with the NCC on two occasions in the past 2 years (unrelated to this incident) with regard to the dangers of this bus stop/stretch of road .
(3) There has been communication between NCC and Norman Lamb MP regarding a feasibility study carried out for safety measures to be introduced in respect of this area. No action has been taken since May 2014. The outcome of the Inquest has been awaited before taking any further action.
(4) Matters which have been considered but in respect of which no action has been taken include:
1. Affordable options to improve safety for pedestrians crossing the A148, such as a pedestrian refuge;
2. Improvements to visibility;
3. Bus stop arrangements such as a lay-by
4. Speed limit.
” 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 Implement the proposed Lodge Hill pedestrian-safety package, including guided footpaths, verge lowering, and warning signs.
Verbatim wording from the response “It is proposed to implement an improvement as soon as possible within the financial year 2015/16 comprising:” Source location 2015-0033-Response-by-Norfolk-County-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 Refresh the A148 carriageway’s “SLOW” markings.
Verbatim wording from the response “Since May 2014, the “SLOW” markings on the carriageway have been refreshed. It is regrettable that the timespan has lengthened linked to the delay in holding the inquest.” Source location 2015-0033-Response-by-Norfolk-County-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 Implement Local Safety Scheme improvements, including vegetation clearance, relocated advance signs, and refreshed road markings and give-way lines.
Verbatim wording from the response “Local Safety Scheme improvements were implemented in October 2009:” Source location 2015-0033-Response-by-Norfolk-County-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 Implement a localised road-safety campaign promoting safe crossing practices for bus users.
Verbatim wording from the response “□ We will implement a localised road safety campaign to raise awareness of safety issues for bus users, in particular regarding crossing the road. We provide specialist education from road safety experts in both primary and secondary schools to promote awareness of the risks in crossing roads, and measures to stay safe. We continually monitor and evaluate this programme to reflect best practice and latest research to provide the best possible opportunity for Road Safety education.” Source location 2015-0033-Response-by-Norfolk-County-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 Recommend relocating the Lodge Hill bus stop to reduce pedestrian crossings of the A148.
Verbatim wording from the response “Currently buses stop at Lodge Hill to allow passengers to alight before turning right onto the A148. If the bus stop were to be moved from Lodge Hill onto the A148 this would prevent passengers having to cross the A148 road should they wish to continue their journey into West Beckham.” Source location 2015-0033-Response-by-Norfolk-County-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 Reduced highway-improvement funding requires prioritisation by risk, making a roundabout unlikely in the medium term and not currently justifiable.
Verbatim wording from the response “The extent to which we can deliver improvements is governed by available funding. Following government funding reductions in 2010/11, we do not receive enough funding to maintain the highway network to current standards. Although we prioritise funding toward maintenance work, we still have a £72.5m backlog of such work.” Source location 2015-0033-Response-by-Norfolk-County-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 A Vehicle Activated Sign was not progressed because the relevant parish councils would need to submit a bid and provide funding.
Verbatim wording from the response “The possibility of a Vehicle Activated Sign (VAS) to highlight the crossroads to drivers was discussed and the possibility of providing a VAS through our “Parish Partnership” initiative (which delivers low cost highway improvements across Norfolk, jointly funded with parish / town councils) was discussed. This would have required a bid and funding from the relevant parish councils, and was not progressed.” Source location 2015-0033-Response-by-Norfolk-County-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 accident evidence does not indicate a significant safety problem at Lodge Hill or across Norfolk's rural bus stops.
Verbatim wording from the response “□ A review has been conducted of accident patterns near bus stops on the A road network. The A road network within the county spans 480 miles. Our review has shown that in the last 10 years, 83 pedestrians were killed or seriously injured in collisions which occurred on the rural 50mph+ network in Norfolk. This accounts for 2.3% of the killed and serious injury accidents in the county. Of these, 20 occurred within 100m of a bus stop; however, this does not indicate whether the bus stop was implicated in the cause of the accident or not. With over 2,000 rural bus stops in Norfolk, only 4 have more than 1 pedestrian collision within 100m over the past 10 years. This does not suggest a significant safety problem at any particular site or across Norfolk as a whole.” Source location 2015-0033-Response-by-Norfolk-County-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 existing evidence-based casualty-reduction process does not normally warrant a crossing scheme or Local Safety Scheme at this junction.
Verbatim wording from the response “Our Road Safety Team monitors injury accidents to identify accident ‘cluster sites’. For rural locations like Lodge Hill, this means five injury accidents within 50m over the past three years. This would trigger investigations which may result in a ‘Local Safety Scheme’. Our evidence-based approach to casualty reduction helps target investment at the most hazardous locations first. The accident record at this junction would not normally trigger the implementation of either a road crossing scheme or Local Safety Scheme, even taking account of this tragic fatality.” Source location 2015-0033-Response-by-Norfolk-County-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 A pedestrian refuge and lay-by were discounted because their required locations would be impracticable and could create unacceptable safety risks.
Verbatim wording from the response “1. A “D-shaped” pedestrian refuge (with limited main road widening to accommodate it) was considered and discounted because a) the need to accommodate vehicular turning movements mean it would be placed too far from the junction to be practicable and b) the risk of vehicles colliding with the refuge on a high-speed road would create an unacceptable risk for pedestrians and drivers, and is not recommended by the applicable design standards. The recommended proposal to improve safety for pedestrians is summarised in the final section of this response.” Source location 2015-0033-Response-by-Norfolk-County-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 A lower speed limit is not considered justified under the Speed Management Strategy because the road lacks frontage development and driver compliance is good.
Verbatim wording from the response “4. In line with our agreed Speed Management Strategy, the lack of frontage development on the A148 makes it difficult to justify a lower speed limit, given that limits should appear self-evident based on the characteristics of the road. Speed readings at this site demonstrate a good level of driver compliance.” Source location 2015-0033-Response-by-Norfolk-County-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 independent bus operator is responsible for bus routes, service frequency and stop locations, and the council cannot require changes.
Verbatim wording from the response “The bus service in this area is operated by Sanders Limited, a bus operating company, who are independent from the County Council. Sanders have operated the routes in this area for over 10 years. Bus routes, frequency of routes and locations of bus stops are the responsibility of the bus operating company. Bus operating companies are free to decide where and when to stop their buses along the route.” Source location 2015-0033-Response-by-Norfolk-County-Council
Open published response
17 Dec 2014 DARREN HAYES · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to escalate unanswered telephone contact attempts to a senior worker View source Failure to contact relevant health and support professionals after no response View source Failure to document telephone contact attempts View source Failure to fully consider identified risks in assessment View source Delays in contacting people referred for assessment despite identified risks View source See 2 more concerns
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
DARREN HAYES · 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
Darren Hayes had significant physical health problems, opiate dependence and alcohol abuse, and was losing weight, struggling with nutrition and personal care, living alone without a cooker. He died on 11 March 2014 before a planned community care assessment could take place; the inquest recorded poisoning by morphine and benzodiazepines, with empyema of the gallbladder. Concerns included delayed and inadequately documented attempts to contact him, insufficient consideration of the risks he presented, and failure to contact other relevant services when he did not respond.
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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate unanswered telephone contact attempts to a senior worker
Wider context from the report “(1) Attempts to contact Mr Hayes by telephone were not documented nor escalated to a senior worker – it is understood NCC have taken steps to ensure that staff are aware that all calls (even those where there is no response are documented) and a senior member of staff is made aware ;
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to contact relevant health and support professionals after no response
Wider context from the report “(3) Despite eating no response to telephone calls or letter, SW did not contact GP, District Nurse or Red Cross (who had discharged him)
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document telephone contact attempts
Wider context from the report “(1) Attempts to contact Mr Hayes by telephone were not documented nor escalated to a senior worker – it is understood NCC have taken steps to ensure that staff are aware that all calls (even those where there is no response are documented) and a senior member of staff is made aware;
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to fully consider identified risks in assessment
Wider context from the report “(3) The risks with which Mr Hayes were not fully considered ie his diabetes being “out of control”, weighing less than 7 stone, lacking motivation, struggling to manage at home, living alone and having no cooker . He was no longer receiving 3 daily visits from NFRS . The evidence was that Mr Hayes had a microwave and could swallow small pieces “a hot drink”.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in contacting people referred for assessment despite identified risks
Wider context from the report “(2) The time taken to contact Mr Hayes in the light of the information provided and the risks with which Mr Hayes was presenting . The initial referral to the ECCT was on 10.3.2014, he was allocated for initial assessment which was due to take place on 28.3.14; 3 weeks later. The first attempt to telephone Mr Hayes was on 1.4.2014. A letter was sent to Mr Hayes and on receiving no response, there was no further attempt to contact Mr Hayes until 16.4.2014, almost 5 weeks after both the initial referral and his death .
” 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 Review guidance for prioritising referrals, including how individual risks are identified and assessed.
Verbatim wording from the response “I confirm a review of the Duty Operational Instructions is already in progress, and the Coroner’s concerns will be built into this work. It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised.” Source location 2014-0538-Response-by-Norfolk-County-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 Duty Operational Instructions to incorporate risk information into decisions about when referred people receive initial contact.
Verbatim wording from the response “I confirm a review of the Duty Operational Instructions is already in progress, and the Coroner’s concerns will be built into this work. It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised.” Source location 2014-0538-Response-by-Norfolk-County-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 Develop a best-practice factsheet formalising contact attempts, escalation, identification of relevant contacts, and communication when referred people cannot be reached.
Verbatim wording from the response “(1) Attempts to contact Mr Hayes by telephone were not documented nor escalated to a senior worker – it is understood NCC have taken steps to ensure that staff are aware that all calls (even where there is no response are documented) and a senior member of staff is made aware;” Source location 2014-0538-Response-by-Norfolk-County-Council
Open published response
11 Sep 2014 ANN MARY WELLS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Unsafe positioning of light switches beside beds View source Lack of risk assessment for room placement 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
ANN MARY WELLS · 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
Ann Mary Wells, a resident of Julian Hospital, fell in her room on 21 November 2013 while attempting to access the wall beside her bed, sustaining a fractured pelvis and later dying on 28 December 2013. The concerns identified were the positioning of the light switch beside her bed and the absence of a risk assessment for placing her in that room.
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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe positioning of light switches beside beds
Wider context from the report “(1) A light switch was positioned on the wall beside Mrs Wells’ bed (see attached a photograph). Mrs Wells was 77 years of age, frail with scoliosis, osteoarthritis and a history of falls. In light of the fact that she had been diagnosed with dementia and had a sitting position in bed, it could have been reasonably foreseen that she might attempt to reach for the light switch . Her fall resulted in a fractured pelvis and subsequent complications.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for room placement
Wider context from the report “(2) No risk assessment had been carried out with regard to Mrs Wells being placed in this particular room .
” Open source report
5 Aug 2014 JOHN HENRY WILSHER · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure to communicate concerns about care home adequacy View source Delays in NCC Community Services assessments View source Unavailability of nursing assessment outcomes during community services assessments View source Inaccurate information in NNUH discharge letters View source See 1 more concern
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 HENRY WILSHER · 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
Mr Wilsher, a resident of Springdale Care Home, deteriorated after falls and was found to have extradural and subdural haemorrhages. He died on 21 December 2013 after discharge from hospital to the care home, which quickly became unable to cope with his mobility. Concerns included inaccurate discharge information, inadequate communication about his care needs and prior referral, and delays or gaps in care assessments.
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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerns about care home adequacy
Wider context from the report “(2) Concerns were raised by the GP and a referral made to NCC Community Services on 25 November 2013 as to the suitability of the Care Home in providing care to Mr Wilsher due to his deteriorating condition. He was admitted to NNUH on 27 November 2013 for assessment and plans were made for discharge to the Care Home. Neither NNUH nor the Care Home were aware concerns had already been raised (prior to a further deterioration in his condition) as to the adequacy of the Care Home to cope with his needs . On Mr Wilsher’s discharge to the Care Home it quickly became apparent they could not cope with 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in NCC Community Services assessments
Wider context from the report “(3) An assessment was carried out by NCC Community Services on 13 December 2013 by which time Mr Wilsher had been admitted to NNUH and discharged and plans were already in place for his transfer to a nursing home .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of nursing assessment outcomes during community services assessments
Wider context from the report “(4) The outcome of the Nursing Assessment carried out on 10 December 2013 was not available at the time of the Community Services Assessment .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate information in NNUH discharge letters
Wider context from the report “(1) The information contained in the NNUH Discharge Letter is inaccurate ;
” Open source report
22 May 2014 SIMON TONY HAINES · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Lack of a clear protocol or guidelines for signposting people to other agencies and services for help and support View source Failure to consider re-signposting to other agencies and services 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.
×
AI-generated summary
SIMON TONY HAINES · 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
Simon Haines was found unresponsive in his parked vehicle on 21 November 2013 and was declared deceased at the scene. The inquest concluded that he killed himself, with the medical cause of death recorded as diphenhydramine toxicity. The report raised concern that there was unclear guidance and insufficient consideration of re-signposting people experiencing difficulty after a significant decision or outcome, creating a continuing risk that others might not receive appropriate support.
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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear protocol or guidelines for signposting people to other agencies and services for help and support
Wider context from the report “On the evidence I received, as outlined above, it was unclear whether there was any protocol or guidelines for signposting someone in Simon Haines’ position who might be having difficulty accepting a decision or outcome , and little or no consideration was given to re-signposting. I am concerned therefore that, without a review of the current system, whilst it cannot be said whether the outcome for Simon would have been different, there is a continuing risk that others might not be signposted to other agencies and services for help and support in similar circumstances , and that if they were this would or might prevent future incidents similar to Simon Haines’.
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider re-signposting to other agencies and services
Wider context from the report “On the evidence I received, as outlined above, it was unclear whether there was any protocol or guidelines for signposting someone in Simon Haines’ position who might be having difficulty accepting a decision or outcome, and little or no consideration was given to re-signposting . I am concerned therefore that, without a review of the current system, whilst it cannot be said whether the outcome for Simon would have been different, there is a continuing risk that others might not be signposted to other agencies and services for help and support in similar circumstances , and that if they were this would or might prevent future incidents similar to Simon Haines’.
” Open source report
4 Mar 2014 RYAN JAMES PETTENGELL · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to maintain existing safety signage View source Lack of signage prohibiting swimming around the lake View source Failure to prevent public access to the officially closed site 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.
×
AI-generated summary
RYAN JAMES PETTENGELL · 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
On 16 July 2013, Ryan James Pettengell entered a lake at a disused quarry and drowned while attempting to swim to a nearby island. Concerns included continued public access, absent or damaged swimming-prohibition signage, and no action having been taken six months after safety recommendations.
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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain existing safety signage
Wider context from the report “(6) Some of the existing signage is damaged and/or has been removed .
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage prohibiting swimming around the lake
Wider context from the report “(5)There is no signage around the lake prohibiting swimming in the area where Mr Pettengell entered the water ;
” 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 Norfolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent public access to the officially closed site
Wider context from the report “(1) The site has been officially closed since this incident (and another drowning on the same day) whilst meetings are ongoing with the community as to the best way to provide recreational facilities to the public whilst having regard to the public’s safety;
(2) Recommendations were put forward by the King’s Lynn and West Norfolk Council on 20 August 2013 with regard to increasing safety at the site;
(3) Six months later, no action has been taken with regard to increasing safety at the site;
(4) Evidence was given at the inquest that the public are still gaining access to the site ;
” 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