6 Apr 2026 Allan STEVENSON · Prevention of Future Deaths report Suffolk
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Concerns raised 8 Failure to provide Network Inspectors with information about deviations from the original temporary traffic scheme plan View source Lack of safety escalation when site operatives identify scheme safety issues View source Lack of a defect-notice mechanism for dangerous special-signage deficiencies View source Lack of enhanced safety review for complex temporary road traffic plans flipped at short notice View source Delayed and indirect replacement pathway for temporary traffic management signage View source Failure to consider required special signage after a temporary traffic plan is flipped View source Failure to answer the temporary traffic management defect line promptly View source Lack of spare signage for correcting identified temporary road traffic scheme errors View source See 5 more concerns
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Allan STEVENSON · 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
Allan Stevenson, a 73-year-old cyclist, died from injuries sustained in a road traffic collision involving an HGV at a roundabout with a temporary traffic management system. The inquest concluded that his death was contributed to by the temporary road layout. Concerns included the flipping of a complex traffic management plan without an enhanced safety review, inadequate or missing signage, limited escalation and inspection processes, delayed responses to reported defects, and the absence of spare signage for immediate changes.
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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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Network Inspectors with information about deviations from the original temporary traffic scheme plan
Wider context from the report “5. I am concerned that there is no apparent system in place to inform Network Inspectors that a traffic scheme has been laid out, contrary to the original plan that was in place (as in this case when a plan has been flipped).
As a result of the Network Inspector having no access to, or sight of the original plan , he was unaware that the original plan had been flipped, unaware of the suspension of the cycle lanes approaching the roundabout and unaware that the special signage deemed necessary in the original plan, was completely absent in the flipped scheme that was put in place.
As such the Network Inspector’s ability to check the safety of the flipped scheme was seriously compromised .
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of safety escalation when site operatives identify scheme safety issues
Wider context from the report “2. I am concerned that there is no apparent safety escalation process , when as in this case a relatively junior Traffic Management Operative identifies a safety issue with a scheme once it has begun operations .
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a defect-notice mechanism for dangerous special-signage deficiencies
Wider context from the report “3. I am concerned that the correct ‘special signage’ that would have undoubtedly made this scheme safer, was not even considered in this case (as a direct result of the flipping of the original plan).
I am further concerned that Network Inspectors have no power to declare a special sign (or the lack of a special sign) as a defect , as these signs fall outside the mandatory signage shown in the Red Book.
As such, even if a Network Inspector identified what they believed to be a dangerous temporary traffic management scheme, any danger being caused by the lack of special signage (or caused by special signage on site that is incorrect), there is no mechanism available for a Network Inspector to issue a defect notice to raise their concern .
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of enhanced safety review for complex temporary road traffic plans flipped at short notice
Wider context from the report “1. I am concerned that what was agreed by witnesses to be a complex temporary road traffic plan, can be ‘flipped’ on the ground on the day it is installed without any identifiable process being in place to ensure the scheme is subsequently safe .
The court heard that some schemes (such as a single carriage way scheme controlled by only two sets of traffic lights) were straight forward to flip if required, but that no additional or enhanced review system was in place when a complex scheme needed to be flipped at short notice .
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Delayed and indirect replacement pathway for temporary traffic management signage
Wider context from the report “4. I am concerned of that the only recourse for a Network Inspector to get temporary traffic management signage replaced, is an apparently protected procedural route involving multiple individuals remote from the site , with the Network Inspector having limited or no contact with the Traffic Management Operatives at the site itself .
I am further concerned that there is no requirement for spare signage to be carried on vehicles used for setting up the schemes, for obvious or frequently occurring errors identified on temporary road traffic schemes (such as in this case the road narrow signs being the wrong way around).
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider required special signage after a temporary traffic plan is flipped
Wider context from the report “3. I am concerned that the correct ‘special signage’ that would have undoubtedly made this scheme safer, was not even considered in this case (as a direct result of the flipping of the original plan ).
I am further concerned that Network Inspectors have no power to declare a special sign (or the lack of a special sign) as a defect, as these signs fall outside the mandatory signage shown in the Red Book.
As such, even if a Network Inspector identified what they believed to be a dangerous temporary traffic management scheme, any danger being caused by the lack of special signage (or caused by special signage on site that is incorrect), there is no mechanism available for a Network Inspector to issue a defect notice to raise their concern.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to answer the temporary traffic management defect line promptly
Wider context from the report “6. I am concerned that the ‘defect line’ operated by Anglian Water was not answered or responded to on the day of this incident , adding unnecessary delay to the changes required to the scheme signage . It is acknowledged that the signage defect identified on the 24th October 2022 would not have affected the tragic outcome of this case, however that may not be the case in future incidents
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of spare signage for correcting identified temporary road traffic scheme errors
Wider context from the report “4. I am concerned of that the only recourse for a Network Inspector to get temporary traffic management signage replaced, is an apparently protected procedural route involving multiple individuals remote from the site, with the Network Inspector having limited or no contact with the Traffic Management Operatives at the site itself.
I am further concerned that there is no requirement for spare signage to be carried on vehicles used for setting up the schemes , for obvious or frequently occurring errors identified on temporary road traffic schemes (such as in this case the road narrow signs being the wrong way around).
” 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 Reinforce Network Inspector inspection and escalation procedures through toolbox talks and refresher learning for Inspectors and Coordinators.
Verbatim wording from the response “Concern 2 principally relates to the internal escalation arrangements of Anglian Water and Core Highways Group Ltd. SCC has reinforced its procedures for identifying relevant issues to those responsible for the temporary traffic management.” Source location Response from Suffolk County Council
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How this respondent position was interpreted
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PFD Monitor interpretation The absence of advance notification about a changed layout did not prevent identification of non-compliance or appropriate enforcement action.
Verbatim wording from the response “The concern raised suggests that the absence of a process to notify the highway authority of changes to a complex scheme (including the “flipping” of the layout) compromised the safety assessment. However:” Source location Response from Suffolk County 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 Network Inspectors cannot raise defects solely for non-prescribed or advisory signage that is not mandatory under the Red Book.
Verbatim wording from the response “3. Concern 3: ‘I am concerned that the correct ‘special signage’ that would have undoubtedly made this scheme safer, was not even considered in this case (as a direct result of the flipping of the original plan).
I am further concerned that Network Inspectors have no power to declare a special sign (or the lack of a special sign) as a defect, as these signs fall outside the mandatory signage shown in the Red Book.
As such, even if a Network Inspector identified what they believed to be a dangerous temporary traffic management scheme, any danger being caused by the lack of special signage (or caused by special signage on site that is incorrect), there is no mechanism available for a Network Inspector to issue a defect notice to raise their concern’.” Source location Response from Suffolk County 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 Anglian Water is responsible for its internal defect-reporting arrangements, which Suffolk County Council cannot comment on.
Verbatim wording from the response “6. Concern 6: ‘I am concerned that the ‘defect line’ operated by Anglian Water was not answered or responded to on the day of this incident, adding unnecessary delay to the changes required to the scheme signage. It is acknowledged that the signage defect identified on the 24 October 2022 would not have affected the tragic outcome of this case, however that may not be the case in future incidents’.” Source location Response from Suffolk County 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 Approving or redesigning undertakers’ temporary traffic management is outside the highway authority’s statutory role.
Verbatim wording from the response “Role of the highway authority” Source location Response from Suffolk County 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 Statutory undertakers and their appointed contractors are responsible for designing, implementing and safely operating temporary traffic management.
Verbatim wording from the response “Under Section 48 of NRSWA, “street works” include not only the placement and maintenance of apparatus but also works required for or incidental to those activities, which includes the provision and management of temporary traffic management necessary to undertake the works safely.” Source location Response from Suffolk County Council
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7 Nov 2025 Anthony Robert CARD · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers View source
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AI-generated summary
Anthony Robert CARD · 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
Anthony Robert CARD, known as Tony, died by suicide by suspension by ligature at 15 Duke Street, Ipswich, between about noon on 21 and 22 November 2023. The report identifies a concern that, outside Care Act safeguarding criteria, there was no mechanism for police to communicate medium-risk mental-health information to relevant medical or mental-health providers, potentially resulting in missed support or affecting later decision-making.
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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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
Wider context from the report “Outside of situations where section 42 of the Care Act 2014 applies, there appears to be no mechanism available to enable front-line police officers who wish, of their own volition and with the subject's consent, to communicate risk information, arising out of an interaction with an adult at Medium risk to self from mental ill-health, to medical or mental health care providers , whom may be the right person or agencies to provide support in the medium term.
The information that an individual has, for example, been reported as presenting in such a way that police have had to consider detaining them under section 136 of the Mental Health Act 1983 could be important risk information that would assist medical or mental health care providers.
Not having this risk information available in future assessments may adversely affect decision-making - e.g. not having this information available could contribute to a decision not to admit compulsorily the patient for mental health care if they were to present again in, say, one week from the police interaction.
If such risk information is not received by treating medical or mental health care providers, there may be omission to offer vital further mental health support.
” Open source report
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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 Continue cooperating with partner agencies and sharing relevant information under applicable arrangements to support timely clinically led crisis assessment when suicide risk is identified.
Verbatim wording from the response “SCC will continue to co-operate with other partner agencies and share relevant information in accordance with applicable information-sharing arrangements, to support timely access to clinically led crisis assessment where suicide risk is identified” Source location Response from Suffolk County 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 Adult mental health provision and clinical pathways are the responsibility of NHS commissioners and mental health providers.
Verbatim wording from the response “The responsibility for adult mental health provision and clinical pathways as identified by the report rests predominantly with NHS commissioners and NHS mental health providers (this is without prejudice to SCC’s distinct statutory responsibilities in respect of mental health social care, including Care Act functions and, where applicable, joint aftercare duties under the Mental Health Act).” Source location Response from Suffolk County 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 SCC will not create a new MASH pathway for adult mental health-only referrals outside safeguarding or adult social care functions.
Verbatim wording from the response “Where information relates solely to adult mental health concerns and does not meet statutory adult safeguarding criteria and/or does not otherwise engage adult social care functions, SCC is not the appropriate recipient for clinical triage or onward clinical referral into adult mental health pathways. Where a contact nonetheless indicates an appearance of care and support needs, SCC will consider whether Care Act assessment duties are engaged.” Source location Response from Suffolk County Council
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9 Oct 2024 Nigel Hutton HAMMOND · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team View source
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Nigel Hutton HAMMOND · Prevention of Future Deaths report
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Report summary
Nigel Hammond died at Addenbrooke’s Hospital on 14 March 2024, three days after falling from a window at home and sustaining serious injuries. The inquest concluded that the death was suicide while the balance of his mind was disturbed. The principal concern was that the AMHP could not directly refer Nigel to the Crisis Resolution and Home Treatment Team, and that this may have delayed support before his fatal fall.
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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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team
Wider context from the report “7. That said, although Nigel did not meet the criteria for immediate admission, the AMHP believed Nigel was mentally very unwell, and in need of immediate support. The court heard that such support would be available within a 4-hour target time, from the emergency Crisis Resolution and Home Treatment Team.
8. However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team .
9. The court heard that the normal route for such referrals was via the GP Surgery, or primary care Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on Monday 11th March 2024 . Nigel’s fall which led to his death, occurred at 06:25 that morning.
10. I am concerned, as had the AMHP in Nigel’s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would have attended , and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death.
” 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 Develop and disseminate concise guidance to Suffolk AMHPs on CRHTT referral criteria and processes.
Verbatim wording from the response “Following receipt of the Regulation 28, NSFT and SCC have worked jointly together to develop a short and concise information guide for AMHPs on the referral criteria and process in respect of all CRHHTs in Suffolk. This guidance has been shared with all AMHPs across Suffolk and will be followed up for robust discussion via SCC’s AMHP Service Forum and with all CRHTTs within NSFT.” Source location Response from Suffolk County 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 AMHPs were able to refer directly to the CRHTT, and the NSFT 111 Service could also make such referrals.
Verbatim wording from the response “Since the inquest into Nigel’s death, it has been established through joint meetings between senior managers from both NSFT and SCC that AMHPs are able to refer to the CRHTT but that not all AMHPs were aware of this and that the process for referral was not clear across the AMHP service. The NSFT policy/pathway information had not been shared with SCC and the AMHP service hence resulting in confusion and lack of clarity.” Source location Response from Suffolk County Council
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30 May 2024 Katie MADDEN · Prevention of Future Deaths report Suffolk
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Concerns raised 7 Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children View source Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations View source Failure of the funding pathway to provide access to specialist psychological treatment View source Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS View source Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification View source Lack of independent Social Services support for vulnerable parents View source Lack of independent professional holistic case review for vulnerable parents View source See 4 more concerns
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AI-generated summary
Katie MADDEN · 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
Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
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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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children
Wider context from the report “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation , with no system in place to assess any additional risks posed to Kate herself . There were no additional steps, or risk assessments undertaken in relation to Kate , even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations
Wider context from the report “1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered . It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the funding pathway to provide access to specialist psychological treatment
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved .
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding ’. In addition, funding was very rarely made available , and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS .
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification
Wider context from the report “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration . As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent . The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of independent Social Services support for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services , and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of independent professional holistic case review for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities . It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report
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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 Implement prompts across children’s and adults’ multi-agency referral forms to identify and route related concerns about adults or children.
Verbatim wording from the response “Action is already underway following a Serious Case Review in respect of MANDY for a process of prompts in both children’s and adult Multi Agency Referral Forms. This is for the practitioner to consider, when putting in a referral related to a child, whether there is an adult involved for whom there are also concerns. The practitioner will be prompted at the end of the referral form to direct the practitioner to submit the additional concerns in relation to the adult to the relevant portal for triaging. This process will also be implemented when referrals are received in respect of adults where the practitioner will be prompted to refer any concerns identified in relation to a child to the relevant portal.” Source location Response from SCC
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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 Add guidance to the MASH practice note and Standard Operating Procedure to identify vulnerable adults in safeguarding referrals concerning children.
Verbatim wording from the response “Any referrals related to safeguarding concerns for a parent would be passed to the MASH who will consider any safeguarding actions required in accordance with Section 42 of the Care Act. A practice note and addition to the Standard Operating Procedure for the MASH will be made to remind MASH practitioners of the need to identify the vulnerabilities of any adults involved in safeguarding referrals in respect of children.” Source location Response from SCC
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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 Refer parents needing additional support during PLO proceedings to Adult Social Care for eligibility assessment and services.
Verbatim wording from the response “CYP staff were aware of the “Claire’s Law” disclosure recorded having had access to all safeguarding referrals relating to the family. However, SCC accept that if a parent demonstrates that they are in need of additional support as a result of the onset of PLO proceedings then CYP staff should make a referral to ASC by way of a referral to its Customer First Team in addition to any support they may already be receiving from other agencies. This is particularly pertinent, in cases such as Katie’s, where a parent has an established history of rumination and behaving unpredictably during stressful life events. The purpose of the referral would be to determine eligibility for assessment and services in accordance with the Care Act 2014. This activity may result in further signposting, including to primary or secondary mental health services.” Source location Response from SCC
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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 Ensure advocate support is accessible and appropriate to the assessed needs of parent carers.
Verbatim wording from the response “ownership and responsibility across the wider system. We will ensure that advocate support is accessible and appropriate to the needs of parent/carers where risk assessed. CYP staff will also be reminded that the PLO process should be utilised, wherever possible, as a restorative tool which is approached with compassion and from a trauma-informed place.” Source location Response from SCC
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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 referral practice and recognition of significant mental-health issues a dedicated focus of annual PLO training, informed by parent and carer experience.
Verbatim wording from the response “Whilst a referral of this type is wholly dependent on the person’s consent and may not always result in the aforementioned assessment(s) staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, recognising that SW are not able to undertake specific MH assessments. The voice of parent/carers as “experts by experience” will inform our PLO training programme. We shall work alongside our judiciary partners such as CAFCASS to raise awareness and promote” Source location Response from SCC
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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 Require Legal Services staff accepting new CYP cases to discuss parental vulnerabilities and whether referral or further signposting is needed.
Verbatim wording from the response “In addition, staff at Legal Services, when accepting a new case from CYP, shall be required to discuss with social workers any relevant vulnerabilities relating to the parent(s) and whether a referral or any further signposting is needed.” Source location Response from SCC
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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 Children’s social workers cannot undertake specific mental health assessments, requiring referral or signposting to appropriate services.
Verbatim wording from the response “Whilst a referral of this type is wholly dependent on the person’s consent and may not always result in the aforementioned assessment(s) staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, recognising that SW are not able to undertake specific MH assessments. The voice of parent/carers as “experts by experience” will inform our PLO training programme. We shall work alongside our judiciary partners such as CAFCASS to raise awareness and promote” Source location Response from SCC
Open published response
17 Dec 2019 Jamie Finlay · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Failure of the filter lane and junction design to prevent wrong-side entry into Thetford Road View source
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AI-generated summary
Jamie Finlay · 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
Jamie Finlay was a passenger in a car involved in a collision on the A1088 near Thetford Road after another vehicle turned right before a filter lane bollard and both drivers swerved. He was taken to Addenbrooke’s Hospital, where his life support was switched off on 11 May 2017; the concern identified was that the junction design did not prevent drivers turning right ahead of the bollards onto the wrong side of them.
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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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the filter lane and junction design to prevent wrong-side entry into Thetford Road
Wider context from the report “The design of the filter lane and junction from the A1088 to Thetford Road does not prevent drivers turning right ahead of the bollards, and onto the wrong side of those bollards into Thetford Road.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the junction design, layout and potential engineering solutions to reduce opportunities for drivers to turn right before the centre island.
Verbatim wording from the response “In reviewing the concerns you raise in your report, to take action to prevent drivers from turning right from the A1088 into Thetford Road in advance of the centre island and bollard, Suffolk County Council proposes the following action:” Source location 2019-0510-Response-from-Suffolk-County-Council-Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The junction is not a high collision cluster, and proposed physical alterations are expected to provide low accident reduction and poor value for money.
Verbatim wording from the response “• As such this is not a high collision cluster site based on 3 or more injury collisions in last 5 years.” Source location 2019-0510-Response-from-Suffolk-County-Council-Redacted.pdf
Open published response
6 Apr 2019 Darren Edward KING · Prevention of Future Deaths report Suffolk
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Concerns raised 3 Lack of effective follow-up action when high-risk patients with learning disabilities disengage View source Lack of a clear escalation process for increased risks that cannot be easily addressed View source Lack of a structured medication review within the overall Care Plan Approach 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
Darren Edward KING · 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
Darren King died at home after an epileptic seizure while in the bath, with drowning recorded as the medical cause of death. The report identified concerns about inadequate follow-up when a high-risk patient with learning disabilities disengages, the lack of a clear escalation process, and the absence of a structured medication review within the care plan.
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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of effective follow-up action when high-risk patients with learning disabilities disengage
Wider context from the report “1. The lack of effective follow up action when a patient with learning disabilities disengages , especially when they are a high-risk patient (such as Darren).
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear escalation process for increased risks that cannot be easily addressed
Wider context from the report “2. The lack of a clear escalation process when an increased risk is identified and this risk cannot be easily addressed (as it was in Darren’s 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a structured medication review within the overall Care Plan Approach
Wider context from the report “3. The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral/escalation routes should they have a concern.
” Open source report
27 Mar 2019 Justin John BROWN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to confirm addiction support at hospital discharge View source Failure to monitor addiction-service referrals and service-user outcomes 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
Justin John BROWN · 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
Justin John Brown was found deceased at his address on 19 February 2016 after police attended following a welfare call. The inquest concluded that he died from ketoacidosis due to diabetes and chronic alcohol abuse, with underlying chronic pancreatitis and bronchopneumonia. A principal concern was that he had been discharged from hospital without confirmed addiction support, and that referral monitoring and communication with the drug service were inadequate.
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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm addiction support at hospital discharge
Wider context from the report “Justin Brown had been discharged from hospital without confirmed support for his addiction between 4 January and his death on 19 February 2016. In light of his history of cooperation with the service the hospital would have been assisted by an agreed protocol and closer working with the commissioned drug service to enable monitoring of referrals sent and outcomes for the service users.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor addiction-service referrals and service-user outcomes
Wider context from the report “Justin Brown had been discharged from hospital without confirmed support for his addiction between 4 January and his death on 19 February 2016. In light of his history of cooperation with the service the hospital would have been assisted by an agreed protocol and closer working with the commissioned drug service to enable monitoring of referrals sent and outcomes for the service users .
” Open source report
12 May 2016 James Hall · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to provide handholds or footholds for recovery from the bridge wall View source Failure to provide a barrier that prevents or deters climbing onto the bridge wall 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.
×
AI-generated summary
James Hall · 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 Hall, a Lincoln University student, returned to Ipswich and later left in the family car before being found beneath Orwell Bridge; efforts to resuscitate him were unsuccessful, and he was pronounced dead on 24 November 2015. The report raised concerns about the bridge’s easy access, low concrete walls, lack of deterrents to climbing, and absence of handholds or footholds to prevent or recover from a fall.
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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide handholds or footholds for recovery from the bridge wall
Wider context from the report “The Orwell Bridge is a well known very high structure in Suffolk that can be easily accessed on foot. There are a number of locations that provide parking within close walking distance.
Once on the bridge there is a pedestrian walkway on both sides which allows full access to its entire length. A concrete wall runs the length of the bridge on the river side of each walk way. A vehicle crash barrier separates each walkway from the carriageway.
The bridge wall is between waist and low chest height for an adult and is approximately 30-40 cm in width. As such it is easy to straddle for the majority of reasonable fit adults or young persons.
This relatively low concrete wall is the only barrier preventing a fall from the bridge. There is nothing in place that would make it either physically difficult or provide a deterrent against climbing onto the bridge wall.
Further, the river side of the bridge walls are bare vertical concrete. As such should someone who had straddled the wall subsequently slip, there is nothing on the structure that would provide a hand or foothold allowing them the opportunity to climb back onto the bridge.
This is by no means an isolated incident and I am aware that further inquests are to be held shortly in relation to other deaths resulting from falls from Orwell Bridge.
” 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 Suffolk County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a barrier that prevents or deters climbing onto the bridge wall
Wider context from the report “The Orwell Bridge is a well known very high structure in Suffolk that can be easily accessed on foot. There are a number of locations that provide parking within close walking distance.
Once on the bridge there is a pedestrian walkway on both sides which allows full access to its entire length. A concrete wall runs the length of the bridge on the river side of each walk way. A vehicle crash barrier separates each walkway from the carriageway.
The bridge wall is between waist and low chest height for an adult and is approximately 30-40 cm in width. As such it is easy to straddle for the majority of reasonable fit adults or young persons.
This relatively low concrete wall is the only barrier preventing a fall from the bridge. There is nothing in place that would make it either physically difficult or provide a deterrent against climbing onto the bridge wall.
Further, the river side of the bridge walls are bare vertical concrete. As such should someone who had straddled the wall subsequently slip, there is nothing on the structure that would provide a hand or foothold allowing them the opportunity to climb back onto the bridge.
This is by no means an isolated incident and I am aware that further inquests are to be held shortly in relation to other deaths resulting from falls from Orwell Bridge.
” 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