Concerns raised 5 Lack of clear staff procedures after a resident is found by police View source Failure to report an unexpectedly absent resident missing View source Lack of MPS guidance to frontline officers on people likely to be missing but not yet reported missing View source Lack of MPS guidance to frontline officers on approaching powers under section 136 of the Mental Health Act View source Lack of clear specific policies and procedures 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
Michael James Crane · 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 James Crane lived in supported accommodation and was absent from the Home from 15 January 2024. He attended hospital and later a police station, but left without being reported missing; his body was retrieved from the River Thames on 18 January 2024. The inquest concluded that he drowned, contributed to by no missing person report being made to the police. The report raised concerns about the absence of MPS guidance for frontline officers dealing with people who may be missing but have not yet been reported as such.
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 Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clear staff procedures after a resident is found by police
Wider context from the report “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following:
• staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours;
• staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London ;
• staff advised the police in London that they intended to report the resident missing but then did not proceed to do so;
• details about any additional training or steps taken to reduce the risks were very vague; and
• details of specific policies and procedures in place at the time were vague.
2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident.
” 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 Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to report an unexpectedly absent resident missing
Wider context from the report “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following:
• staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours ;
• staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London;
• staff advised the police in London that they intended to report the resident missing but then did not proceed to do so ;
• details about any additional training or steps taken to reduce the risks were very vague; and
• details of specific policies and procedures in place at the time were vague.
2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident .
” 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 Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of MPS guidance to frontline officers on people likely to be missing but not yet reported missing
Wider context from the report “1) The MPS constable who gave evidence at the inquest, told me that:
• if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe;
• the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within the next 30 minutes, did not mean that there was more that the officers could have done at the time; and
• there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be missing but have not yet been reported as such .
” 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 Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of MPS guidance to frontline officers on approaching powers under section 136 of the Mental Health Act
Wider context from the report “1) The MPS constable who gave evidence at the inquest, told me that:
• if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe;
• the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within the next 30 minutes, did not mean that there was more that the officers could have done at the time; and
• there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be missing but have not yet been reported as such.
” 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 Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clear specific policies and procedures
Wider context from the report “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following:
• staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours;
• staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London;
• staff advised the police in London that they intended to report the resident missing but then did not proceed to do so;
• details about any additional training or steps taken to reduce the risks were very vague; and
• details of specific policies and procedures in place at the time were vague .
2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident.
” 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 the missing-person policy and wider policies and procedures to clarify when residents should be reported missing.
Verbatim wording from the response “There are a full set of policies and procedures available to all staff, which have since undergone a full review.” Source location Response from Prime Life
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 additional training to Island Place staff and managers on when and how quickly residents should be reported missing.
Verbatim wording from the response “As a provider we are committed to learning lessons from incidents such as the tragic one with Michael, since this incident we have reviewed our missing person policy and have provided additional training to the staff and management at Island Place in order to ensure that they have clear guidance on when and understanding on how quickly a person should be reported missing.” Source location Response from Prime Life
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 staff action was considered necessary after London police contact because the resident had capacity and was entitled to travel and leave the service.
Verbatim wording from the response “There is a clear policy regarding what to do once they become aware of a missing resident, Michael had full capacity to travel wherever he wanted and therefore there was no action for the staff to take when they had contact from the police in London.” Source location Response from Prime Life
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 resident was not considered missing while his whereabouts were known through hospital and police contacts, so reporting was not considered necessary earlier.
Verbatim wording from the response “At this point MC had been off unit 13.5 hours and was not reported missing because he was not missing, we knew he was at St Thomas’s hospital in London and therefore did not need to report him as a missing person.
16th January 11:55- MC was escorted by a member of the hospital staff for a cigarette however he left the hospital and was seen boarding a bus bound for Victoria station.
16th January 12:00- St Thomas hospital called Island Place and said MC had absconded from the hospital.
16th January 16:00- Senior at Island Place called St Thomas hospital to see if he had returned and he had not.
16th January 17:30- PC Cante from town croft police called to say they had approached MC in the street to a welfare check on him and they asked if he was under any section, police said MC expressed he wasn’t ready to return to Island Place and they didn’t have any hold over him.” Source location Response from Prime Life
Open published response
Concerns raised 5 Failure to record incidents in nursing records View source Failure to complete incident forms View source Failure to learn from incidents to safeguard residents View source Failure to investigate accidents and their circumstances View source Failure to establish the origin of incident accounts View source See 2 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
Dorothy Ann SPIBY · 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
Dorothy Ann Spiby, a nursing home resident with dementia, frailty and type 1 diabetes, suffered an unwitnessed fall in her bedroom on 22 October 2021. She sustained an eye-socket fracture and two rib fractures, developed pneumonia in hospital, and died on 28 October 2021. Concerns included unclear and undocumented accounts of the incident, no incident form, no investigation, and no evidence of learning to safeguard residents in future.
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 Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record incidents in nursing records
Wider context from the report “1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records.
2. No incident form was completed.
3. No investigation of the accident or the circumstances giving rise to it was undertaken.
4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete incident forms
Wider context from the report “1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records.
2. No incident form was completed.
3. No investigation of the accident or the circumstances giving rise to it was undertaken.
4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from incidents to safeguard residents
Wider context from the report “1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records.
2. No incident form was completed.
3. No investigation of the accident or the circumstances giving rise to it was undertaken.
4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate accidents and their circumstances
Wider context from the report “1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records.
2. No incident form was completed.
3. No investigation of the accident or the circumstances giving rise to it was undertaken.
4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prime Life Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the origin of incident accounts
Wider context from the report “1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records.
2. No incident form was completed.
3. No investigation of the accident or the circumstances giving rise to it was undertaken.
4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations