1 Oct 2024 Scott Bradley Davies · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Poor visibility of a locked steel barrier across a legitimate bicycle and emergency-services route View source
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AI-generated summary
Scott Bradley Davies · 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
Scott Bradley Davies collided with a steel barrier while testing a modified motorcycle in Alexandra Park on 2 February 2024. He sustained serious head injuries, never regained consciousness, and died from a traumatic brain injury at Salford Royal Hospital on 8 March 2024. The report raises concern that a matt black locked steel barrier on a legitimate right of way is difficult to see at dusk and in darkness and could cause serious injury or death to users of the thoroughfare.
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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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Poor visibility of a locked steel barrier across a legitimate bicycle and emergency-services route
Wider context from the report “The section of road bisecting Alexandra Park, known as Cheadle Old Road Edgeley, is a legitimate right of way for bicycles and emergency services vehicles yet there is a matt black locked steel barrier that is hard to see at dusk and in the dark which could result in serious injury or death if struck by an oncoming legitimate user of that thoroughfare .
” 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 Permanently affix reflective panels and reflective tape to comparable barriers at remaining borough locations.
Verbatim wording from the response “However, upon considering the circumstances of Mr Davies accident and subsequent death and your report, Stockport Council has taken action to improve the visibility of barriers within parks by permanently affixing reflective panels and adding reflective tape to the uprights to all barriers of this nature situated in similar positions across the borough. This work has already been completed in Alexandra Park as of 21st November 2024. The remaining work in the other locations will be completed by 31st March 2025.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit surrounding-area lighting for tree obstruction and compliance with BS 5489 standards.
Verbatim wording from the response “To further ensure that we are maximising visibility of the barriers after dusk we are also auditing the lighting in surrounding areas to ensure they are not impeded by tree growth and that the levels are in accordance with BS:5489 lighting standards. Where remedial work is required, this will be completed by 31st March 2025.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upgrade Cheadle Old Road lighting through the LED lighting replacement programme.
Verbatim wording from the response “An audit of the trees in the vicinity of the Alexandra Park barrier was carried out on 21st November 2024 and it was determined that no arboriculture work was needed at that time. The lighting on Cheadle Old Road was upgraded in 2019 as part of the ongoing LED lighting replacement programme, and we can confirm that the luminescence report notes it is compliant with lighting class P5 to BS5489.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Permanently affix reflective panels and reflective tape to barriers in Alexandra Park.
Verbatim wording from the response “However, upon considering the circumstances of Mr Davies accident and subsequent death and your report, Stockport Council has taken action to improve the visibility of barriers within parks by permanently affixing reflective panels and adding reflective tape to the uprights to all barriers of this nature situated in similar positions across the borough. This work has already been completed in Alexandra Park as of 21st November 2024. The remaining work in the other locations will be completed by 31st March 2025.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit trees near the Alexandra Park barrier to determine whether arboricultural work is needed.
Verbatim wording from the response “An audit of the trees in the vicinity of the Alexandra Park barrier was carried out on 21st November 2024 and it was determined that no arboriculture work was needed at that time. The lighting on Cheadle Old Road was upgraded in 2019 as part of the ongoing LED lighting replacement programme, and we can confirm that the luminescence report notes it is compliant with lighting class P5 to BS5489.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing tree management and compliant Cheadle Old Road lighting require no further remedial work at Alexandra Park.
Verbatim wording from the response “To further ensure that we are maximising visibility of the barriers after dusk we are also auditing the lighting in surrounding areas to ensure they are not impeded by tree growth and that the levels are in accordance with BS:5489 lighting standards. Where remedial work is required, this will be completed by 31st March 2025.” Source location Response from Stockport Metropolitan Borough Council
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19 Mar 2024 Ian Dixon · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to review completion and delays in urgent equipment installation and repairs View source Lack of a policy governing interaction following equipment installation requests View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ian Dixon · 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
Ian Dixon, who had confusion, was unsteady on his feet and had a history of falls, was found deceased at the bottom of the stairs in his home on 8 June 2023 after suffering an extensive skull fracture and acute right-sided subdural haematoma. A principal concern was that there was no policy or review process to confirm that urgent equipment requested through the council and Stockport Homes had been installed or to identify delays, and the handrail had not been fitted despite being recorded as complete.
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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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review completion and delays in urgent equipment installation and repairs
Wider context from the report “The Inquest heard that there is no policy in place governing the interaction between Stockport Metropolitan Borough Council and Stockport Homes following a request for the installation of equipment. This means that there is no review undertaken to check whether urgent equipment has been installed, urgent repairs completed or if there are delays/issues with the works requested .
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy governing interaction following equipment installation requests
Wider context from the report “The Inquest heard that there is no policy in place governing the interaction between Stockport Metropolitan Borough Council and Stockport Homes following a request for the installation of equipment . This means that there is no review undertaken to check whether urgent equipment has been installed, urgent repairs completed or if there are delays/issues with the works requested.
” 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 Monitor major adaptation progress through the monthly Adaptations Panel.
Verbatim wording from the response “2. The progress of major adaptations (e.g. stairlifts, level access showers etc) will be monitored via the monthly Adaptations Panel attended by both SMBC and SHG Officers. This meeting is already established.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a shared SharePoint site for monitoring minor adaptation installation and provision.
Verbatim wording from the response “3. A Sharepoint site will be developed providing access to both SMBC and SHG staff to monitor the progress of the installation and provision of minor adaptations (e.g. handrails, grab rails etc) - this will be in place by the end of May 2024.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, agree and publish target timescales for adaptation installations.
Verbatim wording from the response “To address these issues SMBC have liaised with Stockport Homes and have seen evidence of changes they will implement and will ensure we are active participants including:” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen the service-level agreement with formal governance, agreed targets and monitoring arrangements.
Verbatim wording from the response “4. In relation to all actions identified above, strengthening of the current SLA is required to ensure that both consistency of approach between both organisations and necessary targets are set and monitored. This will be completed by the end of June ensuring formal governance and sign off is agreed and understood.” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make the ordering worker responsible for confirming adaptation requests are actioned before case closure.
Verbatim wording from the response “In addition to the changes that will be made in collaboration with Stockport Homes SMBC will take the following actions:” Source location Response from Stockport Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign the Team Manager oversight of the process and use the Adaptations Panel to monitor the changes.
Verbatim wording from the response “3. The Team Manager will have responsibility for oversight of this process and will retain the role of chair of the Major Adaptations Panel and has close links with Stockport Homes colleagues and will use this forum to monitor the changes described above.” Source location Response from Stockport Metropolitan Borough Council
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8 Jun 2021 Darrell Spear · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Lack of a clear strategy to address identified risks View source Poor inter-agency information sharing View source Delays in addressing identified self-neglect and hoarding risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Darrell Spear · 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
Darrell Leonard Spear died in a fire at his home on 22 September 2020. The fire was probably accidental and accelerated by extensive hoarding and an open conservatory door. Concerns included poor communication and information sharing between agencies, and the absence of a clear strategy to address the fire risk associated with self-neglect and hoarding.
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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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear strategy to address identified risks
Wider context from the report “2. The evidence before the inquest suggested that communication between agencies was poor in relation to information sharing and that there was no clear strategy to address the risk presented to both Mr Spear and his wife .
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Poor inter-agency information sharing
Wider context from the report “2. The evidence before the inquest suggested that communication between agencies was poor in relation to information sharing and that there was no clear strategy to address the risk presented to both Mr Spear and his wife.
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in addressing identified self-neglect and hoarding risks
Wider context from the report “1. The inquest heard that Mr Spear and his wife were known to agencies and that it was recognised that self-neglect and hoarding were significant issues. Their lifestyle meant that there was a significant risk to them both including from fire. Although these issues had been identified in the months preceding Mr Spear’s death it was only on 22nd September that steps were taken to arrange to clear the property later that week.
” Open source report
3 Jan 2020 James Thomas Wheeler · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure to provide annual Care Act Reviews to eligible service users View source Lack of authoritative guidance on monitoring people with refractory epilepsy View source Insufficient resources for councils to undertake annual Care Act reviews View source Lack of guidance on the availability and use of assistive technology for monitoring people at high risk from seizures View source See 1 more concern
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
James Thomas Wheeler · 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
James Thomas Wheeler, who had refractory epilepsy alongside cerebral palsy and severe learning disability, was found unresponsive at Cheddle Lodge on 22 January 2018 and died shortly afterwards. The inquest concluded that he died following a nocturnal epileptic seizure while unobserved and not actively monitored. Concerns included the lack of authoritative UK guidance on monitoring people with refractory epilepsy and assistive technology, failures to provide required annual Care Act Reviews, and insufficient resources for local authorities to fulfil those duties.
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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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide annual Care Act Reviews to eligible service users
Wider context from the report “2. To Ms Pam Smith, Chief Executive, Stockport Metropolitan Borough Council
The court heard evidence that, notwithstanding the Local Authority’s statutory obligations under the Care Act 2014 in this regard, Mr Wheeler (and indeed many other eligible service users) did not receive annual Care Act Reviews as required by law .
Whilst the court heard evidence about the process of transformation of adult social care underway within the Local Authority, it is a matter of concern that the default position still appears to be that an obligatory Care Act Review will not take place , unless some exceptional circumstance is identified about the case.
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of authoritative guidance on monitoring people with refractory epilepsy
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings .
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures.
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for councils to undertake annual Care Act reviews
Wider context from the report “3. To Rt. Hon. Matt Hancock, Secretary of State for Health and Social Care
The court heard evidence that, whilst parliament had conferred on Local Authorities a statutory duty to undertake annual reviews pursuant to the Care Act 2014, insufficient resources had been made available to enable councils to discharge this duty alongside existing statutory obligations .
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the availability and use of assistive technology for monitoring people at high risk from seizures
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings.
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures .
” 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 Create a dedicated team of six social workers and a manager to address the Learning Disabilities Service review backlog during 2020/21.
Verbatim wording from the response “However, at present Stockport Council is in the process of addressing these matters. A business case has been presented and agreed, in order to fund and create a dedicated review team comprising initially of six social workers plus a team manager - including an option to increase staff numbers as required - with a view to addressing the entire backlog of reviews throughout the financial year 2020/21. Furthermore, additional work will be undertaken with the intention of evaluating Stockport Council’s staffing resource and implementing a sustainable model for managing reviews from April 2021 onwards.” Source location 2020-0001-Response-from-Stockport-Metropolitan-Borough-Council-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate staffing resources and develop a sustainable model for managing Learning Disabilities Service reviews from April 2021.
Verbatim wording from the response “However, at present Stockport Council is in the process of addressing these matters. A business case has been presented and agreed, in order to fund and create a dedicated review team comprising initially of six social workers plus a team manager - including an option to increase staff numbers as required - with a view to addressing the entire backlog of reviews throughout the financial year 2020/21. Furthermore, additional work will be undertaken with the intention of evaluating Stockport Council’s staffing resource and implementing a sustainable model for managing reviews from April 2021 onwards.” Source location 2020-0001-Response-from-Stockport-Metropolitan-Borough-Council-Redacted
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17 Dec 2019 Lewis Victor Mendelson · Prevention of Future Deaths report Manchester South
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Concerns raised 10 Failure to provide an IMCA during hospital treatment View source Failure to hold a formal best interests meeting during hospital treatment View source Failure of treating physicians to understand the complexity of learning disability and communication issues View source Failure to put required DoLS authorisations in place View source Repeated distressing nasogastric tube insertion attempts with limited evidence of benefit View source Failure to discuss End of Life Care with an IMCA View source Failure to assess the appropriate care if the patient rallied during End of Life Care View source Delays in required annual care reviews View source Failure to hold a best interests meeting for End of Life Care View source Absence of a designated social worker overseeing care View source See 7 more concerns
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AI-generated summary
Lewis Victor Mendelson · 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
Lewis Victor Mendelson, who had profound learning and physical disabilities, became unwell after vomiting on 8 May 2019, was taken to hospital, later received end-of-life care, and died at home on 16 May 2019. The concerns included the absence of a DoLS authorisation, statutory care review and allocated social worker, as well as hospital treatment and end-of-life decisions without a formal best interests meeting or IMCA involvement.
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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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an IMCA during hospital treatment
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence that it would be beneficial;
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a formal best interests meeting during hospital treatment
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence that it would be beneficial;
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of treating physicians to understand the complexity of learning disability and communication issues
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability . The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence that it would be beneficial;
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to put required DoLS authorisations in place
Wider context from the report “1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death . He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages. There was no designated Social worker overseeing his care due to staffing shortages;
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Repeated distressing nasogastric tube insertion attempts with limited evidence of benefit
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence that it would be beneficial ;
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss End of Life Care with an IMCA
Wider context from the report “3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the appropriate care if the patient rallied during End of Life Care
Wider context from the report “3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in required annual care reviews
Wider context from the report “1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death. He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages . There was no designated Social worker overseeing his care due to staffing shortages;
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a best interests meeting for End of Life Care
Wider context from the report “3. He was placed on End of Life Care with no best interests meeting taking place or discussion with an IMCA or assessment of what should happen if he rallied – as he did.
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a designated social worker overseeing care
Wider context from the report “1. The inquest was told that he met the criteria for a DoLS but due to backlogs within the Local Authority one was not in place at the time of his death. He also met the criteria for an annual review of his care - this had not taken place for over 2 years due to staff shortages. There was no designated Social worker overseeing his care due to staffing shortages;
” 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 Evaluate staffing resources to inform a sustainable model for managing annual reviews from April 2021.
Verbatim wording from the response “However, at present Stockport Council is in the process of addressing these matters. A business case has been presented and agreed, in order to fund and create a dedicated review team comprising initially of six social workers plus a team manager - including an option to increase staff numbers as required - with a view to addressing the entire backlog of reviews throughout the financial year 2020/21. Furthermore, additional work will be undertaken with the intention of evaluating Stockport Council’s staffing resource and implementing a sustainable model for managing reviews from April 2021 onwards.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
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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 Approve funding for a dedicated Learning Disabilities Service annual-review team.
Verbatim wording from the response “However, at present Stockport Council is in the process of addressing these matters. A business case has been presented and agreed, in order to fund and create a dedicated review team comprising initially of six social workers plus a team manager - including an option to increase staff numbers as required - with a view to addressing the entire backlog of reviews throughout the financial year 2020/21. Furthermore, additional work will be undertaken with the intention of evaluating Stockport Council’s staffing resource and implementing a sustainable model for managing reviews from April 2021 onwards.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
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 Create a dedicated annual-review team of six social workers and a team manager to address the review backlog.
Verbatim wording from the response “However, at present Stockport Council is in the process of addressing these matters. A business case has been presented and agreed, in order to fund and create a dedicated review team comprising initially of six social workers plus a team manager - including an option to increase staff numbers as required - with a view to addressing the entire backlog of reviews throughout the financial year 2020/21. Furthermore, additional work will be undertaken with the intention of evaluating Stockport Council’s staffing resource and implementing a sustainable model for managing reviews from April 2021 onwards.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medical treatment decisions fall outside the Council’s responsibility, so it cannot comment on the individual’s hospital treatment.
Verbatim wording from the response “This response solely addresses the concerns under paragraph 1, “The MATTER OF CONCERN”. Stockport Metropolitan Borough Council are unable to comment in respect of paragraph 2 which refers to the individual’s hospital treatment as, in accordance with the Mental Capacity Act 2005, the decision maker for best interest decisions in relation to medical treatment had been the NHS Trust. The arrangement of an IMCA and formal best interests meeting had been the responsibility of the Trust as this had concerned medical decisions. In this instance the NHS Trust would have been under a duty to consult with Stockport Council as stated in the Mental Capacity Act “...anyone engaged in caring for the person or interested in his welfare...”. Ultimately, if the matter had gone to the Court of Protection, the NHS Trust would have been the applicant.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NHS Trust was responsible for arranging an IMCA and formal best-interests meeting concerning medical treatment.
Verbatim wording from the response “This response solely addresses the concerns under paragraph 1, “The MATTER OF CONCERN”. Stockport Metropolitan Borough Council are unable to comment in respect of paragraph 2 which refers to the individual’s hospital treatment as, in accordance with the Mental Capacity Act 2005, the decision maker for best interest decisions in relation to medical treatment had been the NHS Trust. The arrangement of an IMCA and formal best interests meeting had been the responsibility of the Trust as this had concerned medical decisions. In this instance the NHS Trust would have been under a duty to consult with Stockport Council as stated in the Mental Capacity Act “...anyone engaged in caring for the person or interested in his welfare...”. Ultimately, if the matter had gone to the Court of Protection, the NHS Trust would have been the applicant.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
Open published response
3 Mar 2016 Aleeza Ahmed · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Use of chamfered kerb stones on the carriageway View source Absence of a protective barrier on the central reservation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Aleeza Ahmed · 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
Aleeza Ahmed was being carried unrestrained in a car driven by her father when the vehicle left the carriageway, overturned and threw her from the vehicle, causing severe head injuries. Concerns included the possible contribution of chamfered kerbs and the absence of a protective barrier on the central reservation to the vehicle’s overturning and trajectory.
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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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Use of chamfered kerb stones on the carriageway
Wider context from the report “1. This incident occurred at Crookilley Way, Stockport on the 26th July 2015. The vehicle had exited the M60 (clockwise section) at junction 25. As it left the roundabout on to Crookilley Way, the driver lost control and the vehicle mounted the offside kerb, crossed the central reservation and overturned throwing the child from the car as this happened. The kerb stones to the offside of the carriageway are of a chamfered design and it would appear that this may have contributed to the vehicle overturning . Questions were raised as to whether these kerbs should be replaced with a more traditional 90 degree type .
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a protective barrier on the central reservation
Wider context from the report “2. There would appear to be no protective Armco type barrier on the central reservation at this point . The evidence suggested that had such been present the trajectory of the vehicle might have been different and less danger caused to all road users .
” 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 Submit a proposed Crookilley Way central barrier scheme for consideration among possible improvements to the key route network.
Verbatim wording from the response “Following the establishment of Transport for Greater Manchester (“TfGM”) from the former Greater Manchester Passenger Transport Executive (“GMPTE”) in April 2011 the remit of the new organisation was expanded to include, among other things, joint highway responsibility with the local authorities over a network of strategic roads known as the key route network (“KRN”). Parts of the A560 within Stockport are identified as being part of the KRN, including Crookilley Way.” Source location 2016-0089-Response-by-Stockport-Borough-Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make a funding bid for installing a central barrier on Crookilley Way during 2016/2017.
Verbatim wording from the response “Among the schemes proposed for consideration was inclusion of a possible central barrier on Crookilley Way. No details of the form of the barrier were known or detailed on the list. This was proposed on the basis that at the time of the review there was no such barrier in place on Crookilley Way and installing such a barrier would potentially avoid cross over type collisions and bring the road up to modern standards.” Source location 2016-0089-Response-by-Stockport-Borough-Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Installation of a central barrier cannot proceed without external funding because road-safety improvement funds are limited and already committed.
Verbatim wording from the response “As Crookilley Way is part of the KRN any installation or amendments to the carriageway would need the support of TfGM. No response has been received from TfGM to the submitted list of potential improvements to the KRN and no funding has been received from TfGM for this installation. It is estimated that the cost of such a barrier would be in excess of £50,000. SMBC has extremely limited funding for road safety improvements and the budget for 2016/2017 is already committed so funding will have to come from some other source for this installation to be made. There is potential for a bid to be made to the Greater Manchester Casualty Reduction Partnership (“GMCRP”) and we anticipate making such a bid during the course of 2016/2017.” Source location 2016-0089-Response-by-Stockport-Borough-Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing splayed kerb is appropriate for a dual carriageway because it allows vehicles to leave the carriageway during emergencies.
Verbatim wording from the response “A splayed kerb is used on Crookilley Way, which is the type of kerb used on dual carriageways and motorways and where there are no adjacent footpaths. Whilst one of the purposes of a kerb is to provide a physical check to prevent vehicles leading the carriageway, the design of the splayed kerb used on such a carriageway has an angled face which presents an inclination. This is designed to allow a vehicle to mount the verge in an emergency and keep the carriageway clear, which is of critical importance on a dual carriageway or motorway.” Source location 2016-0089-Response-by-Stockport-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 TfGM must support any central-barrier installation because Crookilley Way forms part of the key route network.
Verbatim wording from the response “Following the establishment of Transport for Greater Manchester (“TfGM”) from the former Greater Manchester Passenger Transport Executive (“GMPTE”) in April 2011 the remit of the new organisation was expanded to include, among other things, joint highway responsibility with the local authorities over a network of strategic roads known as the key route network (“KRN”). Parts of the A560 within Stockport are identified as being part of the KRN, including Crookilley Way.” Source location 2016-0089-Response-by-Stockport-Borough-Council
Open published response
12 Jun 2015 Sidney Barnett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Inadequate and unstructured safeguarding investigation processes View source Failure to test care home employees’ accounts during investigations View source Inadequate observation of clients View source Lack of clear rules governing when windows may be open View source Insufficient care for clients’ general welfare View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sidney Barnett · 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
Sidney Barnett, a care home resident whose health was gradually declining, was found inadequately clothed and cared for, struggling to eat alone and unattended, and later died in hospital from pneumonia on 3 January 2015. The principal concerns were inadequate observation and general welfare, unclear rules about open windows, and inadequate and insufficiently structured safeguarding investigations.
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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unstructured safeguarding investigation processes
Wider context from the report “4. As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council. Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the ‘complaint’ was unsubstantiated.
5. The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation . Too much reliance is placed on what the “Care home” employees say, without testing that and further querying what actually happened.
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to test care home employees’ accounts during investigations
Wider context from the report “4. As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council. Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the ‘complaint’ was unsubstantiated.
5. The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation. Too much reliance is placed on what the “Care home” employees say, without testing that and further querying what actually happened .
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate observation of clients
Wider context from the report “1. Whilst at Berrycroft, the level and quality of observation of the client appears to have been inadequate .
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear rules governing when windows may be open
Wider context from the report “3. The 'cleaner' at the care Home “opens the windows, whatever..” There seemed to be no clear rule in place as regards the appropriateness of the windows being open .
” 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 Stockport Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient care for clients’ general welfare
Wider context from the report “2. There was an insufficiency of care shown to the deceased in terms of his general welfare (whether he was warm enough, whether he was washed and shaved, whether he was able to take his meals safely, whether his clothing was adequate and clean etc.).
” 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