Concerns raised 2 Failure to co-ordinate care through multi-disciplinary and multi-agency meetings View source Failure to make safeguarding referrals for formal safeguarding supervision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Establish and operate a monthly High Intensity User Group to oversee people with repeat or frequent agency interactions.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Establish and operate a monthly South Tyneside Interface Meeting for cross-agency communication, issue resolution, decision-making and planning.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Launch the Safeguarding Adults Threshold Guidance Tool across adult social care teams, provide training and require recorded rationale for safeguarding decisions.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Develop and use the Complex Adult Risk Management approach to coordinate assessment, responsibilities, action plans, monitoring and review for adults at serious risk outside safeguarding criteria.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Establish and convene a Suicide Prevention Group when individuals are identified as being at high risk of suicide.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Establish the Multi-Agency Safeguarding Hub to screen all safeguarding contacts and referrals through integrated multi-agency information gathering and decision-making.
Stated plannedThe respondent said that this action was planned when they made their response on 14 May 2024. View source
Action
Establish a daily multi-agency Police Triage Process to review Police Concern Notifications, share information and determine safeguarding actions.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Establish weekly multidisciplinary team meetings to discuss high-risk individuals, allocate responsibilities and agree coordinated risk-reduction support.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Establish a weekly Risk Management Forum with service and senior management oversight for people whose risks remain or increase despite interventions.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source See 6 more actions
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AI-generated summary
Christopher Paul Vickers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Paul Vickers had worsening mental health and ADHD symptoms, with escalating risks of self-harm and harm to others. He was found with a ligature around his neck on 18 July 2021 and death was certified that day. The report identified repeated missed opportunities to coordinate his care through multi-disciplinary or multi-agency meetings and to make safeguarding referrals despite the escalating risks.
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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to co-ordinate care through multi-disciplinary and multi-agency meetings
Wider context from the report “1. There were multiple repeated missed opportunities to co-ordinate the Deceased’s care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.
2. There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others.
There remains a risk that future deaths could occur as the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed. Current action that has been undertaken does not address my concerns.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals for formal safeguarding supervision
Wider context from the report “1. There were multiple repeated missed opportunities to co-ordinate the Deceased’s care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.
2. There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others .
There remains a risk that future deaths could occur as the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed. Current action that has been undertaken does not address my concerns.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a monthly High Intensity User Group to oversee people with repeat or frequent agency interactions.
Verbatim wording from the response “To ensure effective collaborative, multi-agency working, a number of new multi-agency meetings and groups have been established. These include:” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a monthly South Tyneside Interface Meeting for cross-agency communication, issue resolution, decision-making and planning.
Verbatim wording from the response “To ensure effective collaborative, multi-agency working, a number of new multi-agency meetings and groups have been established. These include:” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the Safeguarding Adults Threshold Guidance Tool across adult social care teams, provide training and require recorded rationale for safeguarding decisions.
Verbatim wording from the response “1.6. Tools and Guidance” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and use the Complex Adult Risk Management approach to coordinate assessment, responsibilities, action plans, monitoring and review for adults at serious risk outside safeguarding criteria.
Verbatim wording from the response “2.2. Complex Adult Risk Management (CARM)” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and convene a Suicide Prevention Group when individuals are identified as being at high risk of suicide.
Verbatim wording from the response “• Suicide Prevention Group – a meeting that is attended by the Service Manager for South Tyneside Adult Mental Health Service and operational” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the Multi-Agency Safeguarding Hub to screen all safeguarding contacts and referrals through integrated multi-agency information gathering and decision-making.
Verbatim wording from the response “2.1. Multi-Agency Safeguarding Hub (MASH)” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a daily multi-agency Police Triage Process to review Police Concern Notifications, share information and determine safeguarding actions.
Verbatim wording from the response “The Police have a duty to recognise the signs and symptoms of abuse and to act on any concerns. This includes notifying the Local Authority of safeguarding concerns relating to vulnerable adults. The process for the Police to refer safeguarding concerns to South Tyneside Council is via a Police Concern Notification (ACN) form. Adult Social Care receives ACNs from Northumbria Police daily and the number of ACNs has significantly increased year-on-year.” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish weekly multidisciplinary team meetings to discuss high-risk individuals, allocate responsibilities and agree coordinated risk-reduction support.
Verbatim wording from the response “• Weekly MDTs – these are weekly multi-disciplinary team meetings that are attended by practitioners from mental health and social care services to discuss high risk individuals. The purpose of the meeting is to discuss risks and concerns, agree roles and responsibilities, agree actions to reduce risk, and agree co-ordinated support to achieve the best possible outcome for the individual.” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a weekly Risk Management Forum with service and senior management oversight for people whose risks remain or increase despite interventions.
Verbatim wording from the response “1.4. Risk Management Forum” Source location Response from South Tyneside Council
Open published response
22 Jun 2023 Mason French · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 1 Continuing risk to cyclists in the collision area View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mason French · 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
Mason French died aged 11 on 25 October 2022 when his bicycle collided with a passenger bus at a concealed junction on Lizard Lane, Whitburn. The report raises concern that, despite safety improvements, cyclists remain at risk in the area without further measures.
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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Continuing risk to cyclists in the collision area
Wider context from the report “Despite the safety improvements at the location of the road traffic collision, I continue to be concerned that without further measures cyclists in particular remain at risk in that area .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the Traffic Regulation Order process and consultation for proposed parking restrictions around the collision area and nearby junctions.
Verbatim wording from the response “The proposals shown in Appendix A will keep the area clear of parked vehicles in the area around the collision. This will ensure that vehicles can remain on the correct side of the carriageway when passing the junction. The proposed parking restrictions will also look to protect the junctions of Highcroft Park, Westcroft and Maple Grove and further improve visibility.” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the Traffic Regulation Order process and consultation for the proposed 20mph speed limit on Lizard Lane.
Verbatim wording from the response “To improve road safety along the entire length of Lizard Lane in Whitburn, it is proposed to make Lizard Lane 20mph. As traffic speeds are currently above the compliance level for 20mph, it is proposed to implement additional traffic calming to further reduce speeds. Appendix B shows the extent of the proposed 20mph Zone and details of the proposed traffic calming.” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the formal legal notification process for proposed additional traffic calming on Lizard Lane.
Verbatim wording from the response “To improve road safety along the entire length of Lizard Lane in Whitburn, it is proposed to make Lizard Lane 20mph. As traffic speeds are currently above the compliance level for 20mph, it is proposed to implement additional traffic calming to further reduce speeds. Appendix B shows the extent of the proposed 20mph Zone and details of the proposed traffic calming.” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake programmed works to reduce the stone wall height and improve visibility at the lane access.
Verbatim wording from the response “To improve visibility, it is proposed to reduce the height of the stone wall on both sides of the access to the lane by approximately 1m. This will greatly improve the visibility splay and will improve the intervisibility between road users.” Source location Response from South Tyneside Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementation of measures requiring legal consultation or notification cannot be guaranteed because proceeding would pre-judge the consultation outcome.
Verbatim wording from the response “For the measures that must follow the TRO process or legal notification, we cannot guarantee that the measures can be implemented as this would be seen to pre-judge the outcome of the consultation process. However, given the recent fatality, there should be sufficient grounds to overturn any objection on road safety grounds.” Source location Response from South Tyneside Council
Open published response
31 Mar 2015 Olive Nugent · Prevention of Future Deaths report Newcastle Upon Tyne
View report summary
Concerns raised 4 Escalation process dependent on unguaranteed availability of other agencies View source Subjective prioritisation of response to falls detection device activation View source Insufficient staffing capacity to meet demand for assistance View source Failure to prioritise fall-device activations from persons unable to respond verbally 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
Olive Nugent · 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
Olive Nugent fell down the stairs at home on 16 December 2014 and her falls detector activated, but no warden attended for 2 hours and 27 minutes. She sustained an unsurvivable brain injury and died. The principal concerns were delayed and subjective prioritisation of responses, insufficient staffing, and the risk to people who were unable to respond verbally through the device.
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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Escalation process dependent on unguaranteed availability of other agencies
Wider context from the report “(1) Mrs Nugent lay critically injured in her home for 2 hours and 27 minutes without assistance or access to medical treatment.
(2) Her falls activator device had activated automatically indicating that she had fallen.
(3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case.
(4) Priority was given to clients whose devices had activated in some cases at a time later than Mrs Nugent's but who had been able to verbally respond to call handlers via their devices.
(5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels and (b) the personal practices of individual team leaders.
(6) On 16th December 2014 there were insufficient staff to meet the demand for assistance. This contributed to the delayed response to Mrs Nugent's needs.
(7) A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death.
(8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process", however, reaffirms that prioritisation of response remains a subjective process. A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memorandum of Understanding.
(9) The provision of Falls Detection Devices is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall.
(10)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers.
(11)Review of the Guidance and Policy Document and staffing levels is necessary to reduce this risk.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Subjective prioritisation of response to falls detection device activation
Wider context from the report “(1) Mrs Nugent lay critically injured in her home for 2 hours and 27 minutes without assistance or access to medical treatment.
(2) Her falls activator device had activated automatically indicating that she had fallen.
(3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case.
(4) Priority was given to clients whose devices had activated in some cases at a time later than Mrs Nugent's but who had been able to verbally respond to call handlers via their devices.
(5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels and (b) the personal practices of individual team leaders.
(6) On 16th December 2014 there were insufficient staff to meet the demand for assistance. This contributed to the delayed response to Mrs Nugent's needs.
(7) A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death.
(8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process", however, reaffirms that prioritisation of response remains a subjective process. A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memorandum of Understanding.
(9) The provision of Falls Detection Devices is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall.
(10)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers.
(11)Review of the Guidance and Policy Document and staffing levels is necessary to reduce this risk.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity to meet demand for assistance
Wider context from the report “(1) Mrs Nugent lay critically injured in her home for 2 hours and 27 minutes without assistance or access to medical treatment.
(2) Her falls activator device had activated automatically indicating that she had fallen.
(3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case.
(4) Priority was given to clients whose devices had activated in some cases at a time later than Mrs Nugent's but who had been able to verbally respond to call handlers via their devices.
(5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels and (b) the personal practices of individual team leaders.
(6) On 16th December 2014 there were insufficient staff to meet the demand for assistance. This contributed to the delayed response to Mrs Nugent's needs.
(7) A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death.
(8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process", however, reaffirms that prioritisation of response remains a subjective process. A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memorandum of Understanding.
(9) The provision of Falls Detection Devices is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall.
(10)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers.
(11)Review of the Guidance and Policy Document and staffing levels is necessary to reduce this risk.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise fall-device activations from persons unable to respond verbally
Wider context from the report “(1) Mrs Nugent lay critically injured in her home for 2 hours and 27 minutes without assistance or access to medical treatment.
(2) Her falls activator device had activated automatically indicating that she had fallen.
(3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case.
(4) Priority was given to clients whose devices had activated in some cases at a time later than Mrs Nugent's but who had been able to verbally respond to call handlers via their devices.
(5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels and (b) the personal practices of individual team leaders.
(6) On 16th December 2014 there were insufficient staff to meet the demand for assistance. This contributed to the delayed response to Mrs Nugent's needs.
(7) A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death.
(8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process", however, reaffirms that prioritisation of response remains a subjective process. A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memorandum of Understanding.
(9) The provision of Falls Detection Devices is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall.
(10)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers.
(11)Review of the Guidance and Policy Document and staffing levels is necessary to reduce this risk.
” Open source report
Concerns raised 9 Failure to periodically review and revise staff training View source Failure to provide formalised, regular and personalised training on establishment practices and protocols View source Failure to accurately record incidents affecting residents’ care and management View source Failure to reinforce effective record keeping through regular management file checks View source Failure to prioritise assistance with improving care-note recording View source Failure to regularly evaluate care-note quality and communicate shortcomings to staff View source Unauthorised medication or prescription of ineffective remedies by non-medically qualified care staff View source Unauthorised speculation by non-medically qualified care staff about possible causes of symptoms View source Lack of a clear directive for care staff to seek medical advice without delay for residents presenting with pain View source See 6 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
EDWIN THOMPSON · 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
Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and record keeping.
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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to periodically review and revise staff training
Wider context from the report “Training in the practices and protocols within the establishment should be formalised, regularised and directed as a personalised package to all staff. It should be the subject of planned periodic review and revision throughout the year and an integral part of the established annual appraisal of staff members and their performance.
The quality and effectiveness of in house training provision should be an integral and essential element in and of the periodic appraisal of management performance.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formalised, regular and personalised training on establishment practices and protocols
Wider context from the report “Training in the practices and protocols within the establishment should be formalised, regularised and directed as a personalised package to all staff. It should be the subject of planned periodic review and revision throughout the year and an integral part of the established annual appraisal of staff members and their performance.
The quality and effectiveness of in house training provision should be an integral and essential element in and of the periodic appraisal of management performance.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record incidents affecting residents’ care and management
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reinforce effective record keeping through regular management file checks
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise assistance with improving care-note recording
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly evaluate care-note quality and communicate shortcomings to staff
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unauthorised medication or prescription of ineffective remedies by non-medically qualified care staff
Wider context from the report “There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay.
Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unauthorised speculation by non-medically qualified care staff about possible causes of symptoms
Wider context from the report “There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay.
Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear directive for care staff to seek medical advice without delay for residents presenting with pain
Wider context from the report “There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay.
Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care.
” Open source report
Concerns raised 7 Failure to maintain follow-up contact and home visits after service withdrawal or missed review View source Failure to robustly and objectively investigate vulnerable adults' circumstances View source Failure to coordinate and share information across community care agencies View source Failure to respond to medication non-collection with a home assessment View source Failure to examine the full home environment during care visits View source Failure to identify and diagnose apparent dementia View source Failure to provide an urgent home assessment after a reported deterioration in health View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joan Farran · 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
Joan Farran, who had multiple co-morbidities and was cared for by her adult son, died at home from bronchopneumonia due to chronic obstructive pulmonary disease and Alzheimer’s disease. The report states that her death from a potentially treatable pneumonia was contributed to by neglect in obtaining medical support and treatment. Concerns included inadequate coordination and information-sharing between agencies, limited assessment of the home environment, withdrawal of community visits without replacement services, and the cancellation of a GP home visit without further follow-up.
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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain follow-up contact and home visits after service withdrawal or missed review
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly and objectively investigate vulnerable adults' circumstances
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate and share information across community care agencies
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to medication non-collection with a home assessment
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to examine the full home environment during care visits
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and diagnose apparent dementia
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” 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 South Tyneside Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an urgent home assessment after a reported deterioration in health
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” 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