20 Aug 2025 Masood Hamid · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Ineffective investigation of deaths of detained patients View source Lack of coordinated planning for least-distressing patient transport View source Ineffective learning from deaths of detained patients View source Ineffective communication between police and ambulance services during transport assistance View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Masood Hamid · 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
Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.
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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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Ineffective investigation of deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983 . As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent future deaths.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated planning for least-distressing patient transport
Wider context from the report “1. There was a lack of planning or consideration between all those involved in his care as to the best time and the least distressing way in which Mr Hamid could be transported to the hospital . This in full knowledge that any move would likely cause distress to a patient with dementia and physical health issues.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Ineffective learning from deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983. As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent future deaths .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between police and ambulance services during transport assistance
Wider context from the report “3. There was ineffective communication between GMP and NWAS between 21:28 hours and 23:45 which delayed the deployment of officers to assist NWAS staff with the transportation of the deceased. This delay meant a prolonged period of distress and agitation which contributed to the stress placed on the deceased.
” 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 conveyance was appropriately planned, with patient welfare and distress considered when requesting hospital transport.
Verbatim wording from the response “• Mr Hamid’s conveyance was appropriately planned, and patient welfare was appropriately considered by the AMHP, including giving due consideration that there had been a significant delay of 5 days in admission due to bed availability. It was, therefore not considered appropriate to leave the patient in the setting unnecessarily any longer, due to the level of reported distress, and potential risk to staff and other residents.” Source location Response from Oldham Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Council has no influence or control over the ambulance service’s operational capacity or transport timing.
Verbatim wording from the response “• With regard to the timing of the patient transport, Oldham Council has no influence or control over the operational capacity of Northwest Ambulance Service. Patient transportation must occur at the earliest possible opportunity that suitable patient transport resource is available.” Source location Response from Oldham Council
Open published response
4 Mar 2025 Mark Anthony Fernandez · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to utilise hospital passports View source Failure to provide adequate information about care needs in referrals to specialist services View source Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions 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
Mark Anthony Fernandez · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Anthony Fernandez, who had cerebral palsy, complex medical needs and lived in supported accommodation with full-time carers, was admitted to hospital with suspected meningitis and recurring infections and remained there until his death; he was later placed on end-of-life care. The substantive concerns included inadequate information in a referral, failure to use his hospital passport, and a best-interests decision that did not take account of the knowledge and views of his long-term carers and social services.
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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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to utilise hospital passports
Wider context from the report “1. The hospital passport was not utilised .
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate information about care needs in referrals to specialist services
Wider context from the report “1. The referral to the specialist service did not provide adequate information as to his level of care needs to help assist the service conduct an appropriate examination.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions
Wider context from the report “1. The hospital passport was not utilised.
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual .
” 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 Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.
Verbatim wording from the response “The Council can also confirm that the commissioned IMCA service is able to cover medical best interest decisions. adult social care will work with them to ensure that where they feel interested persons have not been invited to medical best interest decision meetings, they ensure appropriate information is shared with the organisation leading the decision.” Source location Response from Oldham Council
Open published response
26 Jul 2022 Kane Thomas Harley Davidson · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Failure of landlord certificates to clearly disclaim endorsement and safety-standard compliance View source Failure of licence conditions to clearly communicate landlords' personal liability when using intermediary letting agencies View source Lack of clarity about enforcement action for licence-condition non-compliance View source Lack of clarity in licence conditions about landlord obligations View source Granting landlord licences without prior audits of premises View source Failure of residential property audits to address risks to children from internal blinds View source See 3 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
Kane Thomas Harley Davidson · 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
Kane Thomas Harley Davidson was found unresponsive at his family home on 28 January 2022 and died on 1 February 2022 after suffering extensive widespread diffuse hypoxia pattern of ischaemic brain injury. The report identified concerns about the licensing and inspection of privately rented properties, including inadequate assessment and enforcement of risks from non-compliant internal window blinds and unclear information provided to tenants and landlords.
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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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of landlord certificates to clearly disclaim endorsement and safety-standard compliance
Wider context from the report “6. The form of certificate issued to landlords does not make sufficiently clear to actual or prospective tenants :
(1) that the issue of the certificate cannot and should not be taken as an endorsement of the premises to which the certificate relates;
(2) that the premises to which the certificate relates and/or in respect of which the landlord is licensed should not be assumed to be compliant with the relevant safety standards .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of licence conditions to clearly communicate landlords' personal liability when using intermediary letting agencies
Wider context from the report “7. The conditions of licence are insufficiently clear in communicating the obligations upon the licence landlord and/or that the landlord remains personally liable for compliance with the licence conditions notwithstanding the use of any intermediary letting agency .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about enforcement action for licence-condition non-compliance
Wider context from the report “5. There is an absence of clarity as to the enforcement action, if any, to be taken by the Council in the event of a licence holder failing to comply with the conditions of the licence.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in licence conditions about landlord obligations
Wider context from the report “7. The conditions of licence are insufficiently clear in communicating the obligations upon the licence landlord and/or that the landlord remains personally liable for compliance with the licence conditions notwithstanding the use of any intermediary letting agency.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Granting landlord licences without prior audits of premises
Wider context from the report “2. The resultant application process culminates in the grant of a license without any prior audit of the landlord's premises .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of residential property audits to address risks to children from internal blinds
Wider context from the report “3. Where an audit of residential property is undertaken, there is no express obligation upon the person conducting the audit or assessment to refer to other risks to which children might be exposed, including, those posed by internal blinds .
4. This remains the position notwithstanding the fact that the council was on notice of such risk and indeed had issued guidance to those undertaking inspections. The nature and character of the risk posed by such equipment was not accommodated within any documentation to which the Court has been given access.
” 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 Clarify in licensing documentation that awarding a licence does not endorse the property.
Verbatim wording from the response “• It is also explained on the documentation that the award of the licence is not an endorsement of the property” Source location Response from Oldham 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 Clarify on licences holders’ responsibilities, property standards, non-assessment status and regular legal-compliance checks.
Verbatim wording from the response “• The wording on the licence has been amended to make it clear that the licence holder is responsible for adhering to the licence conditions as well as ensuring the property meets the standards of the Housing Act. The licence is issued to the most appropriate person and in some cases this maybe the letting agents or another person who has significant control of the property. It is also made clearer in the documentation that the licence does not indicate that the property has been assessed against any standards and that it is up to the licence holder to carry out regular checks to make sure the property meets legal requirements.” Source location Response from Oldham 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 Clarify on licences that breaches of licensing conditions will result in legal action.
Verbatim wording from the response “• It is now made clearer on the licence that any breaches of the licence conditions will result in legal action.” Source location Response from Oldham 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 Brief residential-property enforcement officers on blind-cord safety and instruct them to check cords at every property visited.
Verbatim wording from the response “• All Enforcement officers within the team who inspect residential properties have been briefed as to the importance of blind cord safety and instructed to check any issues with blind cords at all properties that they visit.” Source location Response from Oldham 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 Add blind-cord safety to licensing conditions and check it during every Environmental Health property visit.
Verbatim wording from the response “• As the Council has discretion regarding the licence conditions that form the basis of the selective licensing scheme, these have been amended to include blind cord safety as a licence condition and this will be checked at every property visited by the Council's Environmental Health team both as part of any audit of a property and also as part of an inspection in response to any other reported issue.” Source location Response from Oldham 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 Licence holders are responsible for regular checks ensuring properties meet legal requirements and comply with licence conditions.
Verbatim wording from the response “• The wording on the licence has been amended to make it clear that the licence holder is responsible for adhering to the licence conditions as well as ensuring the property meets the standards of the Housing Act. The licence is issued to the most appropriate person and in some cases this maybe the letting agents or another person who has significant control of the property. It is also made clearer in the documentation that the licence does not indicate that the property has been assessed against any standards and that it is up to the licence holder to carry out regular checks to make sure the property meets legal requirements.” Source location Response from Oldham 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 National legislative intervention to address blind-cord safety across privately rented properties is a matter for the Government.
Verbatim wording from the response “The selective licensing scheme doesn't require the Council to carry out an audit of every property that is licensed and the scheme only covers a percentage of privately rented properties in Oldham, therefore there will be many more privately rented properties that the Council is unaware of and therefore won't be able to give advice on blind cord safety or check that they comply. There are also a large number of Local Authorities that do not have a licensing scheme in their locality making tackling this issue potentially national issue in the privately rented sector. Can I suggest that as part of your considerations it should be highlighted to the Government's Department of Levelling Up, Housing and Communities (DLUCH) the dangers and inconsistency across the Country without national legislative intervention.” Source location Response from Oldham Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Council cannot advise or check privately rented properties outside its selective licensing scheme or properties it does not visit.
Verbatim wording from the response “The selective licensing scheme doesn't require the Council to carry out an audit of every property that is licensed and the scheme only covers a percentage of privately rented properties in Oldham, therefore there will be many more privately rented properties that the Council is unaware of and therefore won't be able to give advice on blind cord safety or check that they comply. There are also a large number of Local Authorities that do not have a licensing scheme in their locality making tackling this issue potentially national issue in the privately rented sector. Can I suggest that as part of your considerations it should be highlighted to the Government's Department of Levelling Up, Housing and Communities (DLUCH) the dangers and inconsistency across the Country without national legislative intervention.” Source location Response from Oldham Council
Open published response
5 Jun 2017 Jack Edward Braniff · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to fully consider road safety when deciding the size, position and location of illuminated advertising boards on public highways View source Reduction in tree looping resulting in overhanging canopies that compound road visibility issues 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
Jack Edward Braniff · 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
At approximately 01:00 on 5 November 2016, Jack Braniff stepped into the path of an oncoming car on Middleton Road and died at hospital at 02:10 from injuries sustained in the collision. Concerns related to an illuminated advertising board obstructing pedestrians’ and drivers’ views, and overhanging tree canopies compounding visibility problems and potentially contributing to further fatalities.
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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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to fully consider road safety when deciding the size, position and location of illuminated advertising boards on public highways
Wider context from the report “1. The evidence was that the size and position of the illuminated advertising board at the site of the collision obstructed pedestrians’ view of the road and drivers’ view of pedestrians . The concern is to ensure that road safety is fully considered when decisions are made about the size, position and location of illuminated advertising boards on public highways .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Reduction in tree looping resulting in overhanging canopies that compound road visibility issues
Wider context from the report “2. The overhanging tree canopies at the site of the collision compounded the visibility issues which led to this death. The evidence suggested that there is a nexus between a reduction in the tree looping in the Greater Manchester area and an increase in road traffic collisions. The concern is that if this continues, it may lead to further fatalities.
” Open source report
24 Oct 2014 Eliza Bashir · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Unsafe retail display of button batteries accessible to small children View source Lack of lockable battery compartments in non-toy torches View source Lack of knowledge about managing incidents involving ingested button batteries View source Insufficient national awareness of the risks of ingested button batteries 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.
×
AI-generated summary
Eliza Bashir · 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
Eliza Bashir swallowed a button battery from a torch on 22 March 2013. Although the battery was removed and she remained well for almost a week, she collapsed on 30 March 2013 and died after resuscitation failed. Concerns included the lack of a lockable battery compartment because the torch was not classified as a toy, uncertainty among clinicians about managing such incidents, and the accessibility and sale of button batteries to young children.
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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe retail display of button batteries accessible to small children
Wider context from the report “4. Concern remains that such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to gain access to them whilst unobserved .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of lockable battery compartments in non-toy torches
Wider context from the report “1. Evidence from the Trading Standards Officer confirmed that because the torch was not classified as a toy, it did not require a lockable battery compartment , notwithstanding compliance with safety regulations.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge about managing incidents involving ingested button batteries
Wider context from the report “2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient national awareness of the risks of ingested button batteries
Wider context from the report “2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally .
” Open source report
1 Jul 2014 Sindy Louise Woodhall · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Lack of regulation of the sale of large amounts of toxic or potentially fatal gases View source Risk to public health from toxic or potentially fatal gases View source Lack of Trading Standards powers to take action or prosecute 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
Sindy Louise Woodhall · 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
Sindy Louise Woodhall had longstanding addictions to alcohol and butane and propane, which she misused regularly. She was found collapsed in the street on 24 October 2013, was taken to hospital, and subsequently died; the concerns included the sale of large amounts of potentially fatal gases to her by retailers aware of her addiction, along with lack of regulation and limited Trading Standards powers.
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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of the sale of large amounts of toxic or potentially fatal gases
Wider context from the report “1. During the course of the inquest, it transpired that cans of the aforementioned gases were being sold to the deceased by local retailers who were fully aware of her addiction/problems. Whilst morally reprehensible, there was no law to prevent them from selling large amounts of the toxic/potentially fatal gases to the deceased .
2. Lack of regulation.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Risk to public health from toxic or potentially fatal gases
Wider context from the report “4. Risk to public health.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of Trading Standards powers to take action or prosecute
Wider context from the report “3. No powers afforded to Trading Standards to take action/prosecute.
” 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 Legislative action to regulate these products is a matter for the Department for Business, Innovation and Skills to consider.
Verbatim wording from the response “I trust the letter you have written to the Department for Business, Innovation and Skills may prompt them to consider legislating in this area.” Source location 2014-0292-Response-by-Oldham-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 Trading Standards lacks powers to act against retailers selling these products, except where sales to children constitute an offence.
Verbatim wording from the response “The Council was very sorry to note the death of Sindy under such circumstances. As outlined in your notice your concerns were around the lack of regulation or powers afforded to Trading Standards to take any action against a retailer who, in full knowledge of the addition in this matter, still sold products to her. Whilst it is an offence to sell to a child there are no other powers that we have to take any action. There is also no licensing regime in place to register or licence traders of such products, other than alcohol, and therefore we do not know who sells it.” Source location 2014-0292-Response-by-Oldham-Council
Open published response
21 Nov 2013 Lisa Jane CLAYTON · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Failure of the wall rails to prevent climbing onto the car park wall View source Insufficient CCTV monitoring of access to and usage of the 7ᵗʰ floor View source Failure to take direct action in response to identified safety concerns View source Insufficient security control-room staffing for monitoring and coordination duties View source Failure to prevent the low metal barrier from providing a foothold for climbing onto the car park wall View source Risk of acts and attempts to take one's own life at the car park location View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lisa Jane CLAYTON · 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
Lisa Jane Clayton had severe clinical depression and a history of self-harm attempts. On 27 June 2012, she went missing from home and was found at the foot of The Spindles car park after being seen on the wall surrounding its seventh floor. The principal concerns were that the wall and rails provided insufficient prevention of access, CCTV monitoring and security-control-room staffing were inadequate, and previous concerns about suicide attempts at the location had not led to sufficient action.
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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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the wall rails to prevent climbing onto the car park wall
Wider context from the report “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself.
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large . The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall , particularly when combined with the barrier/bumper mentioned at point 1.
3) The wall/rails are an insufficient deterrent/preventative measure.
4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor.
5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room.
6) There have been previous acts and attempts by others to take their own life, at the same location.
Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles.
In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same.
Despite this, little direct action has (or appears to have) been taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient CCTV monitoring of access to and usage of the 7ᵗʰ floor
Wider context from the report “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself.
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1.
3) The wall/rails are an insufficient deterrent/preventative measure.
4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor.
5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room.
6) There have been previous acts and attempts by others to take their own life, at the same location.
Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles.
In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same.
Despite this, little direct action has (or appears to have) been taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take direct action in response to identified safety concerns
Wider context from the report “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself.
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1.
3) The wall/rails are an insufficient deterrent/preventative measure.
4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor.
5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room.
6) There have been previous acts and attempts by others to take their own life, at the same location.
Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles.
In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same.
Despite this, little direct action has (or appears to have) been taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient security control-room staffing for monitoring and coordination duties
Wider context from the report “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself.
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1.
3) The wall/rails are an insufficient deterrent/preventative measure.
4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor.
5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room.
6) There have been previous acts and attempts by others to take their own life, at the same location.
Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles.
In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same.
Despite this, little direct action has (or appears to have) been taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent the low metal barrier from providing a foothold for climbing onto the car park wall
Wider context from the report “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself.
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1.
3) The wall/rails are an insufficient deterrent/preventative measure.
4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor.
5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room.
6) There have been previous acts and attempts by others to take their own life, at the same location.
Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles.
In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same.
Despite this, little direct action has (or appears to have) been taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Risk of acts and attempts to take one's own life at the car park location
Wider context from the report “1) The wall surrounding the 7ᵗʰ floor of the car park has a metal barrier/bumper situated low down on the wall, designed to prevent damage to the wall by parking cars. It equally provides a sturdy foothold allowing adult pedestrians, children etc to climb onto the wall itself.
2) Whilst the wall has two distinct horizontal metal rails fixed to the top of it, the gaps between the two rails are relatively large. The rails themselves potentially provide an effective anchor-point for an individual to climb onto the wall, particularly when combined with the barrier/bumper mentioned at point 1.
3) The wall/rails are an insufficient deterrent/preventative measure.
4) The level and extent of CCTV monitoring – particularly of the 7ᵗʰ floor, which is usually corded off to prevent public usage (save for at the busiest times) – is insufficient. The building has 24 hour security officers in attendance and it is accepted that at night, the building is physically secured. However, day time monitoring is limited (see point 5 below) and in all probability not as effective as it might be in terms of keeping a check on who is accessing a (top) floor that has been corded off to the general public. There has been no allocated/fixed camera covering or monitoring access and usage of the 7ᵗʰ floor.
5) The staffing levels within the security control room are insufficient. There is one guard, watching 6 screens, covering 40 cameras. In addition, the same guard is required to complete paperwork and liaise, assist and co-ordinate security colleagues ‘on the ground’. Even at the busiest times, only one guard is on duty in the control room.
6) There have been previous acts and attempts by others to take their own life, at the same location.
Her Majesty’s Senior Coroner for the Manchester North area has previously put his concerns in writing to the Manager of The Spindles.
In addition, the Senior Investigating Officer (Greater Manchester Police) has also expressed his concerns directly to the same.
Despite this, little direct action has (or appears to have) been taken.
” Open source report
30 Jan 2013 Gareth Mark Slater · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 13 Delays in completing and sending the discharge summary View source Failure to reassess ability to live independently View source Failure to involve family in discharge planning View source Lack of a discharge care plan View source Failure to carry out discharge planning View source Uninhabitable and inadequately maintained accommodation View source Lack of guidance on frequency of community contact View source Lack of a structured and considered care plan View source Failure to hold a Section 17 discharge planning meeting View source Failure to use extended leave to assess tenancy management View source Lack of planning for activities to structure daily living View source Lack of follow-up appointments at discharge View source Insufficient time for considered Community Treatment Order renewal View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Gareth Mark Slater · 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
Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.
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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in completing and sending the discharge summary
Wider context from the report “8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital . There were no follow up appointments in place for Gareth at the time of discharge.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess ability to live independently
Wider context from the report “3. There was no further assessment since 2011 of Gareth’s ability to live independently (as opposed to in supported accommodation which had failed).
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family in discharge planning
Wider context from the report “4. There was no attempt to involve Gareth’s family in the discharge of Gareth .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a discharge care plan
Wider context from the report “1. The discharge planning in relation to Mr Slater was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this. No doubt because of the difficulties to resolve Gareth’s situation there was a failure to actually carry out the important task of discharge planning. No care plan was in place for Gareth, merely a recognition of the conditions of his Community Treatment Order .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out discharge planning
Wider context from the report “1. The discharge planning in relation to Mr Slater was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this. No doubt because of the difficulties to resolve Gareth’s situation there was a failure to actually carry out the important task of discharge planning . No care plan was in place for Gareth, merely a recognition of the conditions of his Community Treatment Order.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Uninhabitable and inadequately maintained accommodation
Wider context from the report “6. On his discharge the flat was unfurnished, without carpets and he was not able to reside there . The condition of the flat at the time of Gareth’s death remained sparsely furnished with a large water leak in the kitchen .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on frequency of community contact
Wider context from the report “10. The lack of a structured and considered Care Plan meant that the only person having any contact with Gareth in the Community was his Care Co-Ordinator who had only been involved with Gareth since the 8th October 2012. There was no guidance to his Care Co-Ordinator as to how often should be seen .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a structured and considered care plan
Wider context from the report “10. The lack of a structured and considered Care Plan meant that the only person having any contact with Gareth in the Community was his Care Co-Ordinator who had only been involved with Gareth since the 8th October 2012. There was no guidance to his Care Co-Ordinator as to how often should be seen.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a Section 17 discharge planning meeting
Wider context from the report “2. There was no Section 17 discharge planning meeting .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to use extended leave to assess tenancy management
Wider context from the report “5. There was no use of extended periods of leave for Gareth to assess his ability to manage his tenancy .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of planning for activities to structure daily living
Wider context from the report “7. There was no planning as to requirements Gareth may need or could be considered to help structure his day i.e. activities, etc.
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of follow-up appointments at discharge
Wider context from the report “8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital. There were no follow up appointments in place for Gareth at the time of discharge .
” 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 Oldham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for considered Community Treatment Order renewal
Wider context from the report “9. The renewal of his Community Treatment Order was rushed , a piece of work which would normally take weeks to carry out was given to an Approved Mental Health Practitioner on the Friday afternoon before Gareth’s appointment at 10am on the Monday morning, meaning that she had just over an hour to consider the suitability of the CTO being renewed .
” 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