21 Mar 2024 Sarah Elizabeth ADAMS · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Lack of training for practitioners in the discharge process, including issues arising from out of area admissions View source
Responses linked to these concerns
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AI-generated summary
Sarah Elizabeth ADAMS · 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
Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.
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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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training for practitioners in the discharge process, including issues arising from out of area admissions
Wider context from the report “That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions
” 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 existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.
Verbatim wording from the response “9. We confirm that all Adult Social Care practitioners involved in discharge planning are required to know and act in accordance with the SOP. Precise processes regarding discharge planning may differ from Trust to Trust.” Source location Response from Reading Borough Council
Open published response
12 Dec 2023 Ruth Carla Perry · Prevention of Future Deaths report Berkshire
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Concerns raised 12 Failure to formalise post-inspection confidentiality arrangements in written policy View source Lack of training or policy for recognising and responding to school leader distress during inspections View source Failure of overall inspection labels to distinguish materially different school performance View source Lack of clarity about the form of expanded school leader wellbeing support View source Lack of policy for pausing inspections because of school leader distress View source Failure to conduct or require learning reviews of inspection-related concerns View source Failure to weigh school leader welfare in inspection communications View source Absence of a clear escalation path for unresolved inspection concerns View source Lack of policy on who may attend meetings with inspectors View source Lack of written policy or guidance for communicating available mental health support options View source Failure to conduct or require internal reviews of inspection-related matters View source Lack of written policy or guidance for Reading Borough Council's proactive response to Ofsted concerns View source See 9 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
Ruth Carla Perry · 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
Ruth Carla Perry’s mental health deteriorated significantly during and after an Ofsted inspection of Caversham Primary School in November 2022. She displayed suicidal ideation and planning a few days later, and took her own life on 8 January 2023; the inquest concluded that her suicide was contributed to by the inspection. The principal concerns included the conduct and fairness of the inspection, limited Ofsted training and policy for managing school leader distress, confidentiality requirements, report publication timescales, and aspects of the inspection system affecting school leader welfare.
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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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise post-inspection confidentiality arrangements in written policy
Wider context from the report “4. The confidentiality requirement after an inspection. Some changes have been made already, but this is not yet written into policy. Given how long this policy has been in place, school leaders may fear discussing outcomes with colleagues outside of the school, and mental health professionals, unless this is expressly dealt with in written policy.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training or policy for recognising and responding to school leader distress during inspections
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of overall inspection labels to distinguish materially different school performance
Wider context from the report “1. The first of these relates to my hypothetical schools A and B point, referred to above. I am concerned about the impact on school leader welfare that this system may continue to have. Transparency and ease of message to parents is not currently weighed against teacher welfare. The current system allows a school which is inadequate in all areas to receive the same overall label as a school which is good in all areas, but with some safeguarding issues which can be repaired by the time the report is published.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the form of expanded school leader wellbeing support
Wider context from the report “7. In an Ofsted publication dated 12th June 2023, the Secretary of State for Education was quoted as follows: “We must ensure our school leaders have the support they need, which is why today we are significantly expanding our wellbeing support. This expansion will help make sure headteachers have access to support whenever they need it”. The Ofsted witness was not able to clarify what form this additional support has 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for pausing inspections because of school leader distress
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct or require learning reviews of inspection-related concerns
Wider context from the report “6. No learning review of these matters was conducted by Ofsted. There is no policy requiring this to be done.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to weigh school leader welfare in inspection communications
Wider context from the report “1. The first of these relates to my hypothetical schools A and B point, referred to above. I am concerned about the impact on school leader welfare that this system may continue to have. Transparency and ease of message to parents is not currently weighed against teacher welfare. The current system allows a school which is inadequate in all areas to receive the same overall label as a school which is good in all areas, but with some safeguarding issues which can be repaired by the time the report is published.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear escalation path for unresolved inspection concerns
Wider context from the report “3. Absence of a clear path to raise concerns during an inspection if these cannot be resolved directly with the lead inspector.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of policy on who may attend meetings with inspectors
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of written policy or guidance for communicating available mental health support options
Wider context from the report “3. We heard in evidence that school leaders have received correspondence from Reading Borough Council about what mental health support options are available. I am concerned to know whether there is now written policy or guidance about communicating this, so that this continues to happen in future years .
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct or require internal reviews of inspection-related matters
Wider context from the report “2. Reading Borough Council also did not carry out any form of internal review . I was not made aware of any policy setting out when such an internal review should 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of written policy or guidance for Reading Borough Council's proactive response to Ofsted concerns
Wider context from the report “1. Reading Borough Council indicated an intention to adopt a much more robust and proactive approach to dealing with Ofsted, particularly where there are concerns about an inspection. This is not written policy or guidance – which may go some way towards reassuring school leaders that their employer ‘has their back’ – both now and in future years.
” 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 Establish and formalize a proactive Ofsted inspection challenge and staff-stress mitigation approach, including evidence-based challenge, risk identification and inspection feedback support.
Verbatim wording from the response “Brighter Futures for Children Ltd (on behalf of the Council) has consulted with Head Teachers regarding a more robust and proactive approach by responding to inspections on behalf of school leaders and Governors, through the termly meeting of Reading Headteachers (Friday 12 January 2024) and via the Reading school primary and secondary phase teacher associations (week commencing 15 January).
The principle of the new approach is that Brighter Futures for Children will work with school leaders to understand any concerns regarding an inspection and offer to undertake challenge on a school’s behalf, before, during and after inspection, based on a robust evidence base. This builds on current practice which supports schools to consider” Source location Response from Reading Borough 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 Deliver the endorsed headteacher wellbeing entitlement and support package, including coaching, mentoring or executive support alongside existing wellbeing services.
Verbatim wording from the response “Reading Borough Council is committed to promoting and supporting the welfare and mental health of all its staff including Head Teachers. Brighter Futures for Children undertook a Head Teacher wellbeing and mental health survey in May 2023. Findings from that survey and from Head Teachers’ performance management reviews have informed the development of a wellbeing entitlement offer and support package. The wellbeing entitlement offer, and support package was endorsed by the Education Partnership Board on 8 December 2023.
The Head Teacher wellbeing and mental health survey will be repeated annually, and the survey will inform updates to the entitlement offer and support package.
The wellbeing entitlement offer, and support package is being delivered in 3 strands:” Source location Response from Reading Borough 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 Final approval of HR policies on when independent learning reviews may be appropriate rests with the Council’s Personnel Committee.
Verbatim wording from the response “The intended outcome being that we have a policy or process to consider when an independent learning review might be appropriate. We intend to discuss this matter with Union colleagues and take a proposal through our normal channels of Union engagement. The final sign off for all such policies lies with the Council’s Personnel Committee which meets quarterly and is delegated to agree all such topics on behalf of the Council. This will be presented to Personnel Committee for agreement on 11th July 2024.” Source location Response from Reading Borough Council
Open published response
22 Jun 2023 Lucy Anne Walles · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 10 Failure of safeguarding audit systems to identify and address ongoing issues View source Failure to ensure crisis-team discharges include additional support when needed View source Insufficient training on Section 42 thresholds and options for concerns below the threshold View source Failure to ensure patients in crisis situations are offered appropriate support View source Failure of systems to make involved agencies aware of safeguarding referrals and concerns View source Delays in review and triage of safeguarding referrals View source Inadequate or unsafe resourcing of mental health services View source Inadequate or unsafe resourcing of the safeguarding service View source Inadequate inter-agency interaction and guidance on arranging joint meetings for service users View source Failure to speak to individuals about whom safeguarding concerns have been raised View source See 7 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
Lucy Anne Walles · 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
Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of safeguarding audit systems to identify and address ongoing issues
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure crisis-team discharges include additional support when needed
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient training on Section 42 thresholds and options for concerns below the threshold
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients in crisis situations are offered appropriate support
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of systems to make involved agencies aware of safeguarding referrals and concerns
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in review and triage of safeguarding referrals
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate or unsafe resourcing of mental health services
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate or unsafe resourcing of the safeguarding service
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate inter-agency interaction and guidance on arranging joint meetings for service users
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing 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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to speak to individuals about whom safeguarding concerns have been raised
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Introduce a Quality Assurance Framework with a programme of internal and external audits of safeguarding referrals and related learning feedback.
Verbatim wording from the response “In July 2023 Adult Social Care in Reading introduced a Quality Assurance Framework for the service which includes an audit programme which supports auditing of safeguarding referrals, not just at team level but also incorporating wider auditing by managers and some external commissioned audits undertaken by specialists. The individual learning from these audits is fed back to workers and their managers and any themes for learning which emerge, from the subject of workshops with appropriate staff. This Quality Assurance Framework systematises case audit in a more thorough form from previous auditing activity and allows for more rigorous consideration of any gaps in processes, policies or practice skills.” Source location Response from Reading Borough 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 Hold daily consultations between the Safeguarding Team and Customer Contact Centre to support referral processes and priority flagging.
Verbatim wording from the response “The other improvement in process in the management of safeguarding contacts through the Customer Contact Centre and the Safeguarding Team is that, since the creation of a dedicated senior Safeguarding Lead role for Reading in June this year, there are daily consultations between the Safeguarding Team and the Customer Contact Centre to ensure appropriate referral processes are followed and there is priority flagging of high-risk safeguarding referrals.” Source location Response from Reading Borough 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 Appoint a Senior Safeguarding Lead to strengthen managerial oversight, audit cases and provide expert management of complex Section 42 enquiries.
Verbatim wording from the response “The other improvement in process in the management of safeguarding contacts through the Customer Contact Centre and the Safeguarding Team is that, since the creation of a dedicated senior Safeguarding Lead role for Reading in June this year, there are daily consultations between the Safeguarding Team and the Customer Contact Centre to ensure appropriate referral processes are followed and there is priority flagging of high-risk safeguarding referrals.” Source location Response from Reading Borough 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 priority flags to safeguarding contacts indicating suicidal ideation or significant self-harm risk.
Verbatim wording from the response “Following the death of Ms Lucy Anne Walles and the lack of timeliness of an appropriate safeguarding response to safeguarding contacts in this case, improvements have been made to the safeguarding service in Reading. Those relating to the resourcing of the service, are referred to below. In relation to improvements in processes, where a safeguarding contact contains information which may indicate the individual has suicidal ideation or is at risk of significant self-harm, a priority flag is added at the point of contact on the client recording system for the Safeguarding Team’s attention, or the responsible adult social care team” Source location Response from Reading Borough 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 Provide tailored safeguarding training for managers on consistent handling of safeguarding contacts, referrals and enquiries.
Verbatim wording from the response “In addition to the core training offer outlined above Assistant Directors in Adult Social Care and the Safeguarding Lead are now providing tailored safeguarding training for Managers to ensure that all senior staff have a consistent approach to safeguarding contacts, referrals and enquiries and are appraised of best practice guidance. All Social Care practitioners have access to the training materials and briefing notes produced by the Safeguarding Adults Board following Safeguarding Adult Reviews (SAR) reports and are given opportunities to attend learning events for SAR recommendations. The SAR findings for Ms Lucy Anne Walles (under the title “Bree” SAR) and the recommendations therein will be the subject of learning events.” Source location Response from Reading Borough 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 Require personal contact with individuals about safeguarding referrals before concerns are closed, supported by monitoring and audit.
Verbatim wording from the response “There has been significant tightening up of practice by the safeguarding team to ensure that individuals are personally contacted about safeguarding referrals and these improvements are the subject of greater monitoring and audit in safeguarding cases. The Safeguarding Lead and two senior social workers in the safeguarding team ensure that no safeguarding concern is closed without the individual being contacted.” Source location Response from Reading Borough 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 Strengthen safeguarding case auditing and worker supervision to identify and address practice issues.
Verbatim wording from the response “As noted earlier the West of Berkshire Safeguarding Adults Board provides the framework policies and procedures for all safeguarding in Reading and staff must adhere to those and operate to those, with due regard to the requirements for safeguarding set out in the Care Act (2014) and other legislation and guidance. Any issues identified with the procedures and policies are picked through the SAB as described in 5 (above) and any individual skills deficits with individual workers are addressed through managerial oversight and guidance as work is subject to auditing of cases and worker supervision which has been strengthened in Reading in the last 6 months. Themes from audits and the learning from them are shared with staff in “Learning Together” sessions which are led by the Principal Social Worker and Principal Occupational Therapist.” Source location Response from Reading Borough 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 Increase dedicated safeguarding referral capacity by appointing three additional full-time safeguarding staff.
Verbatim wording from the response “Following the appointment in June 2023 of a Senior Safeguarding lead, 3 additional full time safeguarding staff were appointed, and this has provided a 30% increase in dedicated staff resource for managing safeguarding referrals. The Senior Safeguarding Lead is accountable to, and works with, the Assistant Director for Safeguarding, Quality and Practice. This has strengthened the managerial oversight of the delivery of the safeguarding service and continues to report performance of safeguarding to the Departmental Management Team, led by the Executive Director.” Source location Response from Reading Borough 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 Formal safeguarding policy changes require approval through the West of Berkshire Safeguarding Adults Board, rather than being decided by Reading alone.
Verbatim wording from the response “All policy changes in respect of processes and policies relating to safeguarding in Reading are subject to approval by the West of Berkshire Safeguarding Adults Board, in which Reading is a key statutory agency partner and follow the Pan-Berkshire policies and procedures used by all agencies.” Source location Response from Reading Borough Council
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31 Mar 2017 Malcolm Langford · Prevention of Future Deaths report Berkshire
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Concerns raised 1 Restricted visibility at the Highmoor Road and Albert Road junction View source
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AI-generated summary
Malcolm Langford · 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
Malcolm Langford was walking with his wife when a vehicle, forced off course after a collision at the Highmoor Road junction, mounted the pavement and struck him. He sustained a non-survivable head injury and died the same day. Evidence at the inquest raised concerns about restricted visibility at the junction and the difficulty of safely emerging from Highmoor Road even when Albert Road appeared clear.
Read the report on judiciary.uk
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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 Reading Borough Council; that does not assign responsibility.
PFD Monitor interpretation Restricted visibility at the Highmoor Road and Albert Road junction
Wider context from the report “His evidence was that visibility at the junction is restricted, particularly when looking to the right, due to a house with a large fence and trees. The following four important points were elicited during the inquest:
(1) a vehicle stopped at the stop line on Highmoor Road is first able to see the front offside corner of a vehicle travelling north along Albert Road at a distance of about 35 metres ;
(2) a vehicle stopped at the stop line on Highmoor Road is first able to see the full width of the front of a vehicle travelling north along Albert Road at a distance of about 24 metres ;
(3) if a vehicle is travelling at 30mph along Albert Road, it will take only 2.6 seconds from being completely out of view of drivers on Highmoor Road to reaching the junction. It will take only 1.8 seconds from the time that the front of the vehicle is visible until it reaches the junction ;
(4) given a typical rate of acceleration, it is not possible for a ‘normal’ driver in a ‘normal’ car to pull safely out of Highmoor Road junction even when Albert Road appears to be clear . The only way to negotiate the junction safely is to edge forward, maintaining a constant look-out.
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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 collision evidence indicates driver failure to stop, not the stop-line position; after stopping, drivers must edge forward to gain visibility.
Verbatim wording from the response “Whilst the views expressed by ████████, Forensic Collision Investigator for Thames Valley Police are appreciated they do not reflect the evidence provided by the police to Reading Borough Council and that collected (by us) through CCTV video surveys.” Source location Response from Reading Borough Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations