25 Oct 2024 Natasha Johnston · Prevention of Future Deaths report Surrey
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Concerns raised 1 Lack of regulation restricting the number and weight of dogs an individual may walk in a public place View source
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Natasha Johnston · 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
Natasha Johnston died on 12 January 2023 after being viciously attacked by an unknown number of dogs from a group of eight that she had been walking. The principal concern was the lack of local and national regulation restricting the number and weight of dogs that one person may walk in a public place.
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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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation restricting the number and weight of dogs an individual may walk in a public place
Wider context from the report “1. The lack of regulation, both locally and nationally, that restricts the number and weight of dogs that an individual person can walk on their own in a public place.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Licensing was not pursued because enforcing it across Surrey’s 10,000-acre countryside estate required resources that its income could not fund.
Verbatim wording from the response “During Spring/Summer 2023, Council officers discussed this issue with a number of stakeholders before developing an options appraisal, with options that ranged from taking no action through to a formal licensing scheme for users of its Countryside Estate (in this case a licence would only apply to Surrey County Council land, because wider licensing is a District and Borough function).” Source location Response from Surrey 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 A Surrey-wide countryside licensing scheme was not pursued because it could displace problems and create confusing inconsistent rules across landowners.
Verbatim wording from the response “During Spring/Summer 2023, Council officers discussed this issue with a number of stakeholders before developing an options appraisal, with options that ranged from taking no action through to a formal licensing scheme for users of its Countryside Estate (in this case a licence would only apply to Surrey County Council land, because wider licensing is a District and Borough function).” Source location Response from Surrey 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 A lower dog-walking maximum was not adopted because it could reduce business viability and undermine the engagement and education approach.
Verbatim wording from the response “The Dog Walking Code of Conduct highlights that walkers should only walk the maximum number of dogs that can be safely controlled, with advice for no more than six. This figure was carefully considered; six dogs is the number referred to in guidance from DEFRA on Public Space Protection Orders (please find extract below) and is the usual maximum used by insurers for professional dog walking cover.” Source location Response from Surrey 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 Dog services and animal welfare licensing are assigned to borough, district or unitary councils.
Verbatim wording from the response “Currently there is no standardised approach to the regulation of professional dog walkers across England, with a variety of different schemes in place in different areas, or often none at all. The responsibility for providing overall regulation on issues such as the number and weight of dogs being walked sits with the Department for Environment, Food and Rural Affairs (DEFRA), while ‘dog services’ and animal welfare licensing are a Borough and District (or Unitary) Council function, usually as part of its Environmental Health responsibilities.” Source location Response from Surrey 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 National regulation of professional dog walking, including dog numbers and weights, is assigned to DEFRA.
Verbatim wording from the response “Currently there is no standardised approach to the regulation of professional dog walkers across England, with a variety of different schemes in place in different areas, or often none at all. The responsibility for providing overall regulation on issues such as the number and weight of dogs being walked sits with the Department for Environment, Food and Rural Affairs (DEFRA), while ‘dog services’ and animal welfare licensing are a Borough and District (or Unitary) Council function, usually as part of its Environmental Health responsibilities.” Source location Response from Surrey County Council
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14 Oct 2024 Jennifer Sharren Chalkley · Prevention of Future Deaths report Surrey
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Concerns raised 3 Lack of a national system for guaranteed transfer of safeguarding information View source Delayed transfer of safeguarding information at the start of a new term View source Misunderstanding that £6,000 must be spent before applying for a statutory assessment View source
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Jennifer Sharren Chalkley · 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
Jennifer Sharren Chalkley, aged 17, died by suicide on 12 October 2021 after being found hanging in her bedroom. The report identifies concerns about delays and misconceptions affecting Education, Health and Care Plan assessments, failures to transfer safeguarding information promptly when she changed college, and shortcomings in multi-agency assessment, information sharing and support for her mental health needs and suicide risk.
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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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system for guaranteed transfer of safeguarding information
Wider context from the report “I also heard that there is no centralised system that stores and transfers learning support and safeguarding information between schools and colleges, or other agencies who are supporting young people . Rather, the transfer of documents is undertaken by the individual schools and colleges concerned, with, I heard, variable levels of efficiency and reliability .
In the circumstances, I am concerned that there is not a national system in place to require and facilitate the guaranteed transfer of safeguarding information in advance of a child or young person starting a new school or college at the start of a new term or academic year, and that this exposes a suicidal child or young person to additional and avoidable risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Delayed transfer of safeguarding information at the start of a new term
Wider context from the report “At the inquest hearing the evidence showed that in September 2021, shortly before her death, Jennifer commenced a course at a new college. I heard that the new college did not receive her safeguarding file from her previous educational establishment prior to her death on the 12th October 2021; as a result the new college’s ability to recognise and manage Jennifer’s needs and risks, including her risk of suicide, was undermined.
I heard that the Keeping Children Safe in Education 2024 statutory guidance for schools and colleges, and its previous iterations, state that where a child leaves a school or college, the designated safeguarding lead should ensure that their child protection file is transferred to the new school or college as soon as possible, and within 5 days for an in-year transfer, or otherwise within the first 5 days of the start of a new term, to allow the new school or college to have support in place for when the child arrives.
I am concerned that the requirement to transfer safeguarding information “within the first 5 days of the start of a new term” means that a child who is at risk of self-harm or suicide may start at a new school or college without that establishment having all or any of the information in the safeguarding file . As that information is likely to be relevant to their management of the risk, I am concerned that permitting transfers up to five days after the start of term undermines the stated intention that the new school or college should “have support in place for when the child arrives” .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding that £6,000 must be spent before applying for a statutory assessment
Wider context from the report “At the prevention of future deaths hearing, it was confirmed that there is no statutory or other requirement for a school to have to spend an additional £6,000 per annum in meeting a child’s SEN needs before applying for a statutory assessment. I am concerned that the misunderstanding by schools and colleges is delaying or preventing applications for statutory assessments being made in some cases and thereby acting as a barrier to ensuring all children and young people with additional needs are receiving effective support as soon as possible . I am concerned that this creates or increases the risk of avoidable suicidality developing.
I heard that, in response to this misconception, Surrey County Council has, since Jennifer’s death, updated its guidance on the criteria that will be considered to determine when a statutory assessment will be conducted and that the new guidance seeks to make it clear that there is no requirement for £6,000 to be spent before an application for assessment can be made. However, the evidence I received from a local college showed that the misunderstanding persists, despite the updated guidance. It seems therefore that further action is needed to ensure that all Surrey schools and colleges understand, clearly, that spending an additional £6,000 on a child is not a pre-requisite to applying for a statutory assessment.
I heard too that this misunderstanding probably originates from the School and Early Years Finance (England) Regulations 2023 (and their previous iterations), which set the high needs costs threshold at £6,000; it seems that the confusion may also stem from information issued by the Education and Skills Funding Agency.
I am concerned that the misconception persists nationally and that, for the reasons set out above, action is needed to ensure that all schools and colleges understand, clearly, that spending an additional £6,000 on a child is not a pre-requisite to applying for a statutory assessment.
” 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 Prepare a clarification communication for all Surrey education providers explaining that no £6,000 spending threshold applies before requesting an EHC needs assessment.
Verbatim wording from the response “In response, we have prepared a communication to be sent to all Surrey education providers, including schools, non-maintained independent sector providers, and further education institutions, to address and clarify this misunderstanding.” Source location Response from Surrey County 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 Disseminate the clarification communication through established channels to all relevant Surrey education providers.
Verbatim wording from the response “The full wording of this communication is attached for your information, and we will be disseminating it via our established channels to ensure that it reaches all relevant Surrey education providers.” Source location Response from Surrey 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 The £6,000 funding threshold is not a legal prerequisite or barrier to requesting an EHC needs assessment.
Verbatim wording from the response “Under the Children and Families Act 2014, local authorities are required to consider an EHC needs assessment if the child has or may have SEN, and if the provision may need to be made through an EHCP. There is no mention in the law or in the SEND Code of Practice of a requirement for the school to spend a specific amount before initiating an assessment.” Source location Response from Surrey County Council
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18 Sep 2024 Helen Jane Kerr · Prevention of Future Deaths report Surrey
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Concerns raised 6 Failure to access relevant police records during assessment View source Failure to inform refuge workers of a relevant police presentation View source Lack of evidenced efficacy of implemented changes View source Failure to appropriately assess declining mental health information and provide timely mental health referrals View source Lack of timely out-of-hours information sharing between police, mental health agencies and adult safeguarding View source Failure to assess and act on risk to the public View source See 3 more concerns
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AI-generated summary
Helen Jane Kerr · 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
Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.
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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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to access relevant police records during assessment
Wider context from the report “(2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform refuge workers of a relevant police presentation
Wider context from the report “(4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of evidenced efficacy of implemented changes
Wider context from the report “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment.
Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately assess declining mental health information and provide timely mental health referrals
Wider context from the report “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment.
Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of timely out-of-hours information sharing between police, mental health agencies and adult safeguarding
Wider context from the report “(3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and act on risk to the public
Wider context from the report “(2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Emergency Duty Team and police contact processes adequately support urgent out-of-hours referrals; SCARF need not be shared outside office hours.
Verbatim wording from the response “The Scarf Process is not designed to be used as an emergency referral out of hours. There is a clear, well known and well used process for officers, in that they must contact the Emergency Duty Team outside hours, if they need urgent social care intervention. The EDT has a single number that is published on the SCC website https://www.surreycc.gov.uk/adults/care-and-support/contact . This has not changed for many years. In terms of the Police the relevant numbers are included within all of the Mental Health briefing products (briefing slides, routine orders) and the force Mental Health guide which is available via officer’s mobile devices and their intranet hub. The number is also included within all of their training products relating to s136.” Source location Response-from-Surrey-Council
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8 May 2024 John William BASS · Prevention of Future Deaths report Surrey
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Concerns raised 2 Lack of clear guidance for inspectors identifying vegetation encroachment on footpaths View source Insufficient frequency of pavement inspections View source
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AI-generated summary
John William BASS · 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
John William Bass, aged 80, died from head and chest injuries after falling from his bicycle into an approaching vehicle on A217 Brighton Road, Tadworth, on 6 December 2022. Concerns were raised that vegetation narrowing the pavement was not identified as a safety concern and that yearly inspections may be insufficient for a route frequently used by cyclists beside a busy road.
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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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for inspectors identifying vegetation encroachment on footpaths
Wider context from the report “When the footpath was inspected in November 2022, just weeks before the accident, the highway inspector did not consider the narrowing of pathway as a safety concern and or met an intervention level which required action . It is noted in the policy that there is reference to trees and vegetation, but no clear guidance in terms of vegetation which encroaches on pavements . I am concerned that there is a risk to future pavement users if clear guidance is not provided to inspectors to identify safety concerns regarding vegetation on growth footpaths . The Highways current inspection of the pavement is only yearly albeit in evidence given at inquest by the family, this road is used frequently by cyclists next to a busy road. I am therefore concerned that the frequency of the inspections need to be reviewed.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient frequency of pavement inspections
Wider context from the report “When the footpath was inspected in November 2022, just weeks before the accident, the highway inspector did not consider the narrowing of pathway as a safety concern and or met an intervention level which required action. It is noted in the policy that there is reference to trees and vegetation, but no clear guidance in terms of vegetation which encroaches on pavements. I am concerned that there is a risk to future pavement users if clear guidance is not provided to inspectors to identify safety concerns regarding vegetation on growth footpaths. The Highways current inspection of the pavement is only yearly albeit in evidence given at inquest by the family, this road is used frequently by cyclists next to a busy road. I am therefore concerned that the frequency of the inspections need to be reviewed .
” 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 Remind inspectors to assess pavement narrowing or obstruction risks to vulnerable users and request maintenance or urgent responses where necessary.
Verbatim wording from the response “SCC believes that our current inspection processes are in line with the legal requirements and with the risk-based approach encouraged by national guidance. Following the receipt of the Prevention of Future Deaths report however, we have reminded our inspectors to consider the risk that narrowing/obstruction situations may pose, particularly to vulnerable users of pavements, such as wheelchair users or those with push chairs etc and to request maintenance work where needed, or to raise as an immediate risk for a quicker response where they consider such a risk to be very serious or life threatening.” Source location Response from Surrey 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 Current inspection processes and public-reporting mechanisms sufficiently address pavement debris and vegetation risks without changing the inspection guidance.
Verbatim wording from the response “Instances such as the situation on the pavements of the A217 in November/December 2022 where there has been a narrowing of the footway due to seasonal vegetation growth/detritus, are considered as street cleansing or general maintenance issues rather than as “safety defects” which require an immediate response. These situations are generally identified through reports from the public.” Source location Response from Surrey 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 The footway's annual Category 4 inspection is considered appropriate because its hierarchy is correctly assessed and public reports are handled throughout the year.
Verbatim wording from the response “Footways have four levels of hierarchy. The highest is a primary walking route (Category 1) which is inspected monthly, then a secondary walking route (Category 2) which is inspected every three months, link footways (Category 3) which are inspected every 6 months and finally local access footways (Category 4) which are inspected annually.” Source location Response from Surrey County Council
Open published response
8 Feb 2024 Jake Brian BAKER · Prevention of Future Deaths report Surrey
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Concerns raised 8 Failure to ensure mandatory and adequately assured training for personal advisers View source Opaque process for obtaining learning disability diagnoses View source Failure to ensure adequately informed and recorded internal and formal review meetings View source Lack of audit of the effectiveness and practical use of Mental Capacity Act training in adult services View source Confusing and delayed access to adult social care assessments for care leavers View source Inadequacy of pathway plans for care leavers View source Lack of practice standards for risk assessments of care leavers View source Non-mandatory Mental Capacity Act training in children’s services View source See 5 more concerns
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AI-generated summary
Jake Brian BAKER · 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
Jake Baker, who had learning disability and type 1 diabetes, developed diabetic ketoacidosis while staying with his family and died at home on 31 December 2019. The report identified concerns about inadequate pathway planning, risk assessment, information-sharing, diabetes support and advice to his family, as well as failures to assess his capacity and ensure appropriate care-leaver support.
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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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mandatory and adequately assured training for personal advisers
Wider context from the report “a.) The issues surrounding the inadequacy of Jake’s pathway plan have not been addressed comprehensively in the last 4 years. Training for personal advisers is not mandatory and is only now being rolled out . The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Opaque process for obtaining learning disability diagnoses
Wider context from the report “b.) The process by which diagnoses of learning disabilities can be obtained remains opaque . There is no protocol in relation to this . The current situation leaves those making decisions in relation to young people struggling to obtain this vital information .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequately informed and recorded internal and formal review meetings
Wider context from the report “d.) How internal meetings and formal review meetings with other interested parties are informed and recorded is not subject to a protocol and the risk remains that decisions will be taken without adequate information and inquiry as to the risks inherent in those decisions .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of the effectiveness and practical use of Mental Capacity Act training in adult services
Wider context from the report “f.) Mental Capacity Act training is not mandatory in children’s services and the adult services have no audit of the effectiveness of the mandatory training provided and how it is being used in practice . There is therefore a risk that erroneous assumptions as to capacity will continue to be made .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Confusing and delayed access to adult social care assessments for care leavers
Wider context from the report “c.) The issue of how the numerous adult social care teams are accessed to obtain adult social care assessments for care leavers leads to confusion and delays . Vulnerable care leavers are at risk of being denied necessary support .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of pathway plans for care leavers
Wider context from the report “a.) The issues surrounding the inadequacy of Jake’s pathway plan have not been addressed comprehensively in the last 4 years . Training for personal advisers is not mandatory and is only now being rolled out. The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of practice standards for risk assessments of care leavers
Wider context from the report “e.) Practice standards have not been put in place in relation to risk assessments of care leavers to inform their needs .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Non-mandatory Mental Capacity Act training in children’s services
Wider context from the report “f.) Mental Capacity Act training is not mandatory in children’s services and the adult services have no audit of the effectiveness of the mandatory training provided and how it is being used in practice. There is therefore a risk that erroneous assumptions as to capacity will continue to be made.
” 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 Audit pathway plans and disseminate resulting learning across the service to improve practice.
Verbatim wording from the response “SCC has a well-developed audit process and pathway plans are audited as part of that activity within the Looked After Children and Care Leavers service with any learning arising disseminated across the service to further improve practice.” Source location Response from Surrey County 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 Mandate Mental Capacity Act e-learning in Children’s Service induction and refresher training.
Verbatim wording from the response “The position with MCA training within SCC's Children’s Service is currently under review. The intention is to mandate e-learning around the MCA as part of induction and refresher training to all staff to heighten awareness of the MCA.” Source location Response from Surrey County 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 Provide pathway plan surgeries across relevant teams to support timely completion and practice guidance.
Verbatim wording from the response “The current training content for personal advisers was updated in 2024 with a rolling programme of training throughout the year. In addition, the pathway plan surgeries are in place across the Looked After Teams which also extend to social workers in the Safeguarding Adolescents Teams to ensure timely completion of pathway plans whilst providing advice and guidance on the content of the pathway plan.” Source location Response from Surrey County 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 Liaise with GPs and, where necessary, specialist health services to confirm young people’s diagnoses.
Verbatim wording from the response “SCC staff have, and will continue to, liaise with the young person's GP in the first instance to confirm diagnosis. Where necessary, SCC staff will also liaise with specialist health services if they are known to be working with the young person.” Source location Response from Surrey County 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 Review the risk assessment tool to strengthen consideration of learning disability, mental capacity and health issues.
Verbatim wording from the response “Surrey has a generic risk assessment tool used to understand the risks presented to children and care leavers. The assessment tool does enable consideration of care leaver’s needs however on review could be strengthened to consider more specifically issues related to learning disability, mental capacity and health. A review of the current assessment tool is underway and will be completed by April 2024.” Source location Response from Surrey County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and launch a Multi-Agency Transition Protocol directing staff how to respond when diagnoses are unclear.
Verbatim wording from the response “SCC are in the process of developing a Multi-Agency Transition Protocol which is due to be launched in the coming weeks having now been signed off by all key parties. This Protocol will include direction to frontline staff on steps to take where a person's diagnosis is unclear. SCC also have integrated meetings with health colleagues such as the Preparation for Adulthood Board, Post 16 SEND panel and the Joint Commissioning panel to name but a few. These forums provide additional opportunities for people’s health needs to be explored and joint solutions to be found around how best to meet needs.” Source location Response from Surrey County 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 Reinforce expectations that decision-making meetings are properly minuted and records remain accessible.
Verbatim wording from the response “SCC has an expectation that any meetings that involve other professionals, and which have the remit to make decisions that may affect the care arrangements for children and young people, should be properly minuted and that those records be accessible. In light of the Coroner’s findings these expectations are being reinforced across key service areas in supervision meetings and team meetings.” Source location Response from Surrey County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver updated pathway plan training through a rolling programme for personal advisers.
Verbatim wording from the response “The current training content for personal advisers was updated in 2024 with a rolling programme of training throughout the year. In addition, the pathway plan surgeries are in place across the Looked After Teams which also extend to social workers in the Safeguarding Adolescents Teams to ensure timely completion of pathway plans whilst providing advice and guidance on the content of the pathway plan.” Source location Response from Surrey County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update Practice Standards to confirm pathway plan training is mandatory.
Verbatim wording from the response “Pathway Plan training has always formed part of personal advisers' induction when they join SCC. A formal training programme has been in place since at least September 2021. Whilst there is no written document confirming this is mandatory, since the training commenced in 2021 managers have been clear in supervision and performance conversations with staff about the mandatory nature of this training. In addition, SCC’s Practice Standards are being reviewed and updated this year as part of our review cycle and will confirm the mandatory nature of pathway plan training for clarity.” Source location Response from Surrey County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Performance Dashboard to monitor meeting-minute compliance and address identified gaps.
Verbatim wording from the response “Completion of minutes of meetings is checked as part of the Performance Dashboard, a system through which managers are able to review compliance. Managers will continue to use this system to ensure that meetings are being minuted and to address any gaps with staff.” Source location Response from Surrey County 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 Role-specific mental capacity training, supervision and practice forums are considered sufficient for staff awareness across adult and children’s services.
Verbatim wording from the response “We adopt a stratified approach to training staff across both adults and children’s directorates due to the diverse range of qualification and expertise involved across our teams, taking into account the requirements for individual roles. Staff in roles that require mental capacity act awareness and knowledge will continue to receive the necessary training specific to their role, however, staff across both directorates will be supported to understand circumstances where the MCA framework may need to be implemented.” Source location Response from Surrey County 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 Diagnosis of learning disabilities is a health-led process, with healthcare professionals responsible for assessment and diagnosis.
Verbatim wording from the response “Diagnosis is a health led process and it starts with a healthcare professional identifying a learning disability, through assessment, based on the person’s needs. Diagnosis can be undertaken at different times such as birth, in childhood or in adulthood. The Local Authority accepts that timely diagnosis can in some cases lead to improved outcomes for children and young people.” Source location Response from Surrey County 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 Existing locality, specialist and contact-centre arrangements provide clear pathways for eligible care leavers seeking adult social care support.
Verbatim wording from the response “Our Adults, Wellbeing and Health Partnerships Directorate (AWHP) is made up of both locality and specialist teams. There is a locality team covering each specific geographic area across Surrey. The specialist teams are the Transition Team, Learning Disability and Autism Team and the Mental Health Teams. Both the locality teams and specialist teams offer a clear pathway into adult social care for those individuals meeting the eligibility criteria under the Care Act 2014.” Source location Response from Surrey County Council
Open published response
22 Dec 2023 Barbara Ann WOODMAN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 8 Inaccessibility of primary care records to secondary mental health services View source Delays in considering SCARF information View source Failure to communicate relevant SCARF information to family View source Failure of the out-of-hours SCARF process to provide timely effective information transfer View source Failure to produce a clear holistic care and crisis contingency plan View source Lack of a unified record-keeping system for sharing patient information View source Breakdowns in communication between inpatient staff and the CMHT View source Failure to gather relevant collateral history while respecting patient confidentiality View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Barbara Ann WOODMAN · 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
Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of primary care records to secondary mental health services
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████.
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services . This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in considering SCARF information
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant SCARF information to family
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur . The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the out-of-hours SCARF process to provide timely effective information transfer
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to produce a clear holistic care and crisis contingency plan
Wider context from the report “c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community . Although not causative of the death and I noted ████████’s very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a unified record-keeping system for sharing patient information
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS , including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians .
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Breakdowns in communication between inpatient staff and the CMHT
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP .
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to gather relevant collateral history while respecting patient confidentiality
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████ .
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” Open source report
23 Nov 2023 Kevin Stephen O’Hara · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 High-risk reviews being undertaken by the officer who conducted the initial Safe and Well Visit View source Lack of oversight to ensure that appropriate risk assessments follow visits View source Lack of review or audit of completed Safe and Well Visits 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
Kevin Stephen O’Hara · 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
Kevin Stephen O’Hara, who was bedbound and lived alone with carers visiting four times a day, died in a fire at his home on 7 February 2023 after a lit cigarette ignited debris on a mattress used as a crash mat. The fire produced significant smoke and was detected only after smoke seeped through a closed living-room door to a hallway alarm. Concerns included inadequate review and oversight of Safe and Well Visits by Surrey Fire and Rescue Service, and insufficient oversight by Surrey Adult Social Care to ensure that required risk assessments followed visits.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation High-risk reviews being undertaken by the officer who conducted the initial Safe and Well Visit
Wider context from the report “That SFRS reviews of individuals deemed high risk, are usually undertaken by the officer who conducted the initial Safe and Well Visit with the risk that opportunities for oversight and reassessment are missed .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight to ensure that appropriate risk assessments follow visits
Wider context from the report “Evidence was given that the visit to Mr O’Hara by ASC on 23 January 2023 should have resulted in a risk assessment. Although ASC has policy (some of which predated Mr O’Hara’s death) about when to conduct a risk assessment it does not appear to have in place a system of oversight to ensure that where appropriate, risk assessments follow a visit .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of review or audit of completed Safe and Well Visits
Wider context from the report “Evidence was given that the Safe and Well Visit in November 2022 was conducted by an inexperienced officer. The results of that visit did not seem to be subject to any scrutiny. SFRS do not appear to have in place a system of review or audit by line managers or more experienced staff of completed Safe and Well Visits , with the risk, as in this case, that errors or issues requiring action are not identified.
” Open source report
10 Oct 2022 Charles Michael Stringer · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Failure to ensure defect inspectors receive recent road-condition complaints View source Delays in completing road-defect repairs after serious injuries or deaths View source Lack of reflection and learning following road-related deaths View source Failure to ensure timely communication of road complaints between the contact centre and highways department View source Failure to conduct detailed holistic risk assessments for road defects View source Failure of inspector guidance and training to prevent overly mechanistic road-defect assessments View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charles Michael Stringer · 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
Charles Michael Stringer, a cyclist, died after hitting a pothole on Church Lane, causing a punctured front tyre and loss of control that resulted in a fatal chest injury. The report raises concerns about Surrey County Council’s lack of documented reflection, changes to pothole-management systems, communication, risk assessment, defect categorisation and timely repairs following his death.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure defect inspectors receive recent road-condition complaints
Wider context from the report “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death
SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular:
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to?
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in completing road-defect repairs after serious injuries or deaths
Wider context from the report “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death
SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular:
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to?
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of reflection and learning following road-related deaths
Wider context from the report “1. A lack of reflection by SCC following Mr Stringer’s death
SCC indicated in their written submissions that a senior manager was available to give evidence as to reflection and learning following Mr Stringer’s death, in the absence of any such evidence in writing or a request to do so during the hearing .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely communication of road complaints between the contact centre and highways department
Wider context from the report “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death
SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular:
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to?
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct detailed holistic risk assessments for road defects
Wider context from the report “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death
SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular:
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to?
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of inspector guidance and training to prevent overly mechanistic road-defect assessments
Wider context from the report “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death
SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular:
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to?
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?
” 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 Build a new data system and assess whether historical complaint data should be made available to highway inspectors.
Verbatim wording from the response “There are risks and benefits to providing historical data and not providing it. These have been carefully considered, and SCC is still giving specific consideration to whether providing historical complaint data to Inspectors would be beneficial.” Source location Response from Surrey County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement LTP4 measures to collect and use cycle-route data in network management and future maintenance decisions.
Verbatim wording from the response “3. The Local Transport Plan 4 (LTP4) is currently being implemented. This has prompted broad consideration of ways to improve the services we deliver. In particular, the LTP4 places greater emphasis on cyclist-use of roads within the network and steps are being taken to collect data on cycle-routes in order to inform future decisions about how best to incorporate this knowledge into the policy and systems and, if appropriate, to facilitate access to this data for highways-inspectors.” Source location Response from Surrey County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce immediate notification requirements with Surrey Police and the Surrey Contact Centre after serious road incidents.
Verbatim wording from the response “5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?” Source location Response from Surrey County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the pictorial defect guide and matrix to reflect new contract arrangements and reinforce their use within dynamic risk assessments.
Verbatim wording from the response “The pictorial guide is periodically reviewed and following this inquest SCC has reviewed it in detail and a new draft has been produced with a number of pictures updated along with updates to reflect the changes introduced as part of the new contact arrangements. SCC maintains that the pictures provide suitable supplementary assistance for classification of defects in accordance with the policy. The most recent review aligns the guide with the changes made as part of the new contract arrangements in terms of repairing the area” Source location Response from Surrey County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase capacity for larger-scale pothole repairs where conditions warrant.
Verbatim wording from the response “The Inquest did not therefore determine that the current system was inadequate. However, given the tragic circumstances of Mr Stringer’s death, SCC has undertaken reviews of each of the issues raised by the Family (set out at paragraphs 1-5 in Section 5 of the PFD Report) and several changes have been made since the Inquest (albeit not all directly as a result of this Inquest). Most pertinently the main changes since Mr Stringer’s passing are:” Source location Response from Surrey County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct customer-care operatives to contact Highways directly and immediately when they are unsure about reported issues.
Verbatim wording from the response “The primary method for contacting the Highways service is by using the on-line web-portal which is where the vast majority of highway concerns are reported and which go directly to the Highways Service. Customers are also able to phone the SCC contact centre to raise issues and the contact centre will log issues with the Highways Service on their behalf. The corporate standard response time is 5 days.” Source location Response from Surrey County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate dedicated internal audits and continuous performance monitoring of defect assessment and repair quality.
Verbatim wording from the response “SCC also has a team dedicated to carrying out internal audits of the quality of repairs and of the assessment of defects to ensure that an ‘overly mechanistic’ approach is not adopted. All stages of the safety defect process from identification and categorisation through to the repair are monitored and scrutinised continuously. Issues are reviewed and, where necessary, discussed with relevant officers. Trends and performance are reported through a monthly performance board and as a result processes are continuously evolving across the teams involved.” Source location Response from Surrey County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide regular refresher training emphasising situational and wider characteristics in dynamic defect risk assessments.
Verbatim wording from the response “In addition to the pictorial guide and matrix, the training that Inspectors receive continues to emphasise that the situational and wider characteristics of a defect are important – as described in point 2 above. Refresher training happens regularly for SCC Inspectors which covers the risk assessment process and how a dynamic risk assessment is to be conducted without placing over-reliance on the dimensions of a defect in an overly mechanistic way.” Source location Response from Surrey County 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 Significant reflection and learning occurred following the death, and service improvements were implemented afterward.
Verbatim wording from the response “concern in this regard, evidence was provided (in written form) by Ms Amanda Richards, addressing each of the points of concern raised by the Family).” Source location Response from Surrey County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited resources and inconsistent public reporting mean inspections cannot be redirected or biased solely by the number of complaints received.
Verbatim wording from the response “Inspections are based on what the Inspector sees at the point in time that the inspection takes place. SCC often gets multiple reports of what might be the same defect and there can be a variety of reasons why certain defects may be the subject of multiple reports (it is not always the case that a higher number of reports means that a defect poses a greater risk than a defect which has received only one report). For this reason, while we assess all reports from the public regarding potential safety defects, we need to ensure that limited resources are not diverted or biased based on what can be inconsistent reporting by the public. It is important that inspections that are prompted by a customer complaint are carried out to review what is reported at that point in time as an independent one-off inspection carried out by a trained Inspector.” Source location Response from Surrey County 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 The pictorial guide and matrix remain suitable supplementary tools within inspectors’ broader dynamic risk assessments, training and audit arrangements.
Verbatim wording from the response “All highway authorities have their own guidance and processes to provide guidance to staff in carrying out their role. The pictures are helpful to give an indication of the types of defect that may fall into each category and as an aide-mémoire. The document clearly states that it is there to “assist” with identification and classification and that it should be used in conjunction with other information. Comparing the visual characteristics of a defect against the pictures in the guide provides a good starting point for Inspectors when assessing the risk posed by a defect.” Source location Response from Surrey County 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 The existing pothole-management system was not determined to be inadequate; defects were correctly classified and assigned appropriate repair periods.
Verbatim wording from the response “The Coroner has indicated that the written submissions provided (it is assumed by ████████ refer to ‘a number of discussions…but there has been no documented changes in systems of practice’. SCC notes that the conclusion of the Inquest was Accident and that the Coroner determined that at every relevant inspection where the index defect was identified, it was classified correctly, and an appropriate repair completion date was imposed. Tragically, Mr Stringer’s accident occurred whilst the pothole was scheduled for repair (and was within the appropriate repair time window).” Source location Response from Surrey County Council
Open published response
31 Jan 2022 OSKAR MILES NASH · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 15 Inadequate information and record sharing before EHCP school placements View source Lack of mandatory Autism training for Education and SEN staff View source Lack of training and monitoring programme for EHCP medical advisers View source Failure to establish changed child mental health triage practices in written guidance View source Failure of the threshold of needs document to reflect risks for autistic children View source Lack of specific safeguarding guidance for children with disabilities View source Lack of clarity about schools’ information-sharing powers and duties View source Lack of clinician understanding of EHCP medical advice responsibilities View source Inappropriate closure or referral of child mental health referrals View source Lack of monitoring of access to clinical teams and referral outcomes View source Lack of comprehensive, relevant and mandatory Autism training across state agencies View source Insufficient process, guidance and oversight for effective post-death investigations View source Automatic categorisation of routine referrals as low risk View source Lack of mandatory Autism training for Children’s Services staff View source Lack of mandatory Autism training for child mental health referral triage staff View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
OSKAR MILES NASH · 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
Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate information and record sharing before EHCP school placements
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing . On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP . I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents, and any data protection ramifications this may have.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Education and SEN staff
Wider context from the report “The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training and monitoring programme for EHCP medical advisers
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process. I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish changed child mental health triage practices in written guidance
Wider context from the report “I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the threshold of needs document to reflect risks for autistic children
Wider context from the report “Despite these changes, I remain concerned that the “threshold of needs” document does not adequately and clearly reflect the known risks of mental health difficulties, self-harm, and suicidal ideation for autistic children (given their prevalence in this group of children) and that, consequentially, there is an ongoing risk that an autistic child in these circumstances will be allocated an insufficient level of support , as was the case for Oskar.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specific safeguarding guidance for children with disabilities
Wider context from the report “I am concerned that “Working Together” does not provide clearer guidance specifically for the safeguarding of children with disabilities, including Autism , and the approach to be taken by agencies to parents and families.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about schools’ information-sharing powers and duties
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing. On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP. I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents , and any data protection ramifications this may have.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician understanding of EHCP medical advice responsibilities
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process . I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Inappropriate closure or referral of child mental health referrals
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies . In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of access to clinical teams and referral outcomes
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies. In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive, relevant and mandatory Autism training across state agencies
Wider context from the report “At the prevention of future deaths hearing, I heard evidence of more training being available, but also of an ongoing absence of comprehensive, relevant and mandatory training .
I was told that the National Autism Strategy does not currently include a timetabled commitment for relevant mandatory Autism training to be provided to all state agencies working directly with autistic adults and children .
I am concerned that this poses an ongoing risk to autistic children and their ability to access the services they require for their support, welfare, and safeguarding.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient process, guidance and oversight for effective post-death investigations
Wider context from the report “Ineffective review by the child death review processes results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation , which should not be dependent on the inquest process, is achieved in all cases.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Automatic categorisation of routine referrals as low risk
Wider context from the report “The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk” . I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Children’s Services staff
Wider context from the report “The evidence at the inquest revealed that the staff in SCC’s Children’s Services Department, including Social Workers and other Team members, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for child mental health referral triage staff
Wider context from the report “The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I have been told that the triaging process is now undertaken by an “Access and Advice Team” but I am concerned that there continues to be no requirement for the staff in that Team to undertake relevant Autism training on a mandatory basis .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out further autism, self-harm and suicidal-ideation training to relevant Education and Children’s Services staff.
Verbatim wording from the response “The training does not currently capture fully the link between autism and self harm or suicidal ideation, and the associated risks. The SCC Children’s Academy is currently in the process of reviewing the training required in order to equip all frontline workers to recognise this risk and is in the process of identifying the most appropriate further training package for relevant staff to broaden understanding around this. SCC is committed to rolling out this further training package at the very earliest opportunity.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make autism awareness training mandatory for staff working directly with children and young people, including new starters, and monitor individual uptake.
Verbatim wording from the response “Response:
On 30 November 2021 the Executive Director for Children Families, Lifelong Learning and Culture wrote to all staff in the Directorate setting out the Autism Awareness Training offer available for all staff in the Directorate.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Effective Family Resilience document to highlight how autism, mental health, suicidal ideation and self-harm may affect assessment and risk grading, subject to partnership approval.
Verbatim wording from the response “Response:
In light of the concern raised, there has been a further review of the current ‘Effective Family Resilience’ document undertaken and careful consideration of the need to make changes to that document. At the current time, we do not believe there is a need to update the document in the level of need descriptions with additional definitions or criteria. However, we have reflected that adding some wording within the section on page 8 (as outlined below) draws attention to the need to consider aggravating factors of mental health, suicidal ideation and autism which should weigh more on the assessment and need / risk grading rather than simply the initial referral trigger.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train SEND officers to draw EHCPs using advice from the relevant professional network.
Verbatim wording from the response “Steps have been taken to better train SEND officers with a view to ensuring EHCPs are drawn properly with advice from the wide range of professionals named. Significant improvements in the quality of EHCPs have resulted. These EHCPs can then be relied upon to share all necessary information.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review SEND guidance and incorporate clearer information on information-sharing parameters and requesting additional records between educational providers.
Verbatim wording from the response “SCC is in the process of reviewing its guidance to educational providers and has committed to incorporating in that guidance clearer information around the parameters within which information can be shared between educational providers and to highlight” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to the Effective Family Resilience document require agreement from the Surrey Safeguarding Children Partnership and approval by its Board.
Verbatim wording from the response “We intend to update the 'Effective Family Resilience' document to expand this paragraph and include the wording above in red. This change cannot be unilaterally made but will be subject to the agreement of the Surrey Safeguarding Children Partnership and will need the approval of the Surrey Safeguarding Children's Board. We anticipate that agreement will be forthcoming and the document will then be amended accordingly.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local safeguarding partnership determines whether a post-death review is appropriate and how learning should be generated.
Verbatim wording from the response “safeguarding partnership to decide how learning may be best generated and disseminated. Even if the criteria are met, it is not an automatic requirement to hold a Local Children’s Safeguarding Practice Review “It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice” (HM Government 2028:87). It is ultimately most important that local safeguarding partners respond to any death in a proportionate and appropriate way.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Post-death reviews follow national guidance, which permits proportionate local arrangements; the thematic review was accepted by the National Panel.
Verbatim wording from the response “safeguarding partnership to decide how learning may be best generated and disseminated. Even if the criteria are met, it is not an automatic requirement to hold a Local Children’s Safeguarding Practice Review “It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice” (HM Government 2028:87). It is ultimately most important that local safeguarding partners respond to any death in a proportionate and appropriate way.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Blanket sharing of safeguarding files for children with EHCPs is unnecessary; schools can request additional information by exception.
Verbatim wording from the response “To this end, any school wishing to seek further information from the current/prior school can request such information and the school receiving that request can make a decision about whether it is suitable to share such information in line with the guidance. This is a matter of professional judgment on a case by case basis.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Effective Family Resilience document does not need additional level-of-need definitions or criteria.
Verbatim wording from the response “Response:
In light of the concern raised, there has been a further review of the current ‘Effective Family Resilience’ document undertaken and careful consideration of the need to make changes to that document. At the current time, we do not believe there is a need to update the document in the level of need descriptions with additional definitions or criteria. However, we have reflected that adding some wording within the section on page 8 (as outlined below) draws attention to the need to consider aggravating factors of mental health, suicidal ideation and autism which should weigh more on the assessment and need / risk grading rather than simply the initial referral trigger.” Source location 2022-0031-Response-from-Surrey-County-Council_Published
Open published response
9 Nov 2020 Name not published · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to inform the general practitioner of children’s removal and care proceedings View source Failure to involve general practitioners in MARAC meetings View source Failure to inform the treating general practitioner of domestic abuse and coercion allegations View source Failure to communicate MARAC-identified risks and planned safeguarding measures to general practitioners View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Name not published · 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
The deceased died at home on 29 November 2017 after consuming considerable amounts of alcohol and cocaine and hanging herself with a ligature. Concerns included limited communication between the MARAC process and her general practitioner about domestic abuse risks and safeguarding measures, and the GP not being informed about her children being removed from her care and subsequent care proceedings, or the associated mental health stressors.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the general practitioner of children’s removal and care proceedings
Wider context from the report “6. ████████ children were removed from her care in ████████ and she was then involved in care proceedings. Her general practitioner was not made aware of this although it would have been a further significant stressor so far as her mental health was concerned .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to involve general practitioners in MARAC meetings
Wider context from the report “3. ████████ general practitioner was not invited to contribute to the MARAC meetings held in July and August 2017 . General Practitioners are not routinely invited to MARAC meetings .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the treating general practitioner of domestic abuse and coercion allegations
Wider context from the report “5. The general practitioner responsible for treating ████████ mental health was not made aware of the allegations of domestic abuse and coercion that ████████ had made.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate MARAC-identified risks and planned safeguarding measures to general practitioners
Wider context from the report “4. The risks and the planned safeguarding measures identified by the MARAC were not communicated to the general practitioner .
” 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 Share Domestic Homicide Review learning across Children’s Services.
Verbatim wording from the response “This was a point of learning identified early within the Domestic Homicide Review and action was taken immediately to share this learning across our service and to strengthen practice. We now ensure that when we are making plans to remove children into our care we consider how to manage any increased risk to the parents. If the agencies working with them are part of the children’s core group we would always contact them. If they are not we would ask the consent of the parents to contact them, or support them to make contact with them themselves. This would include GPs as well as domestic abuse services or adult services.” Source location Response to Surrey coroner area - Prevention of future deaths report
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 Implement the Children’s Services Improvement Plan to strengthen information sharing with partner agencies.
Verbatim wording from the response “In relation to Point 6, Surrey County Council recognises the importance of informing agencies involved with a family about the removal of a child. Our practice has strengthened considerably since 2017 and Children's Services has implemented an Improvement Plan in order to secure continuing improvement over time. This includes improving the way in which information is shared with partner agencies. When a child moves into our care we routinely notify our health colleagues and this would ensure that the GP would now be informed. However, this would be the GP for the children, rather than the GP for the parents and we recognise the focus in this situation was on the needs of the mother and her increased vulnerability in the light of the removal of her children.” Source location Response to Surrey coroner area - Prevention of future deaths report
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 Assess increased parental risk during child-removal planning and contact or support contact with relevant agencies, including GPs and specialist services.
Verbatim wording from the response “This was a point of learning identified early within the Domestic Homicide Review and action was taken immediately to share this learning across our service and to strengthen practice. We now ensure that when we are making plans to remove children into our care we consider how to manage any increased risk to the parents. If the agencies working with them are part of the children’s core group we would always contact them. If they are not we would ask the consent of the parents to contact them, or support them to make contact with them themselves. This would include GPs as well as domestic abuse services or adult services.” Source location Response to Surrey coroner area - Prevention of future deaths report
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 Assist Surrey Police with its detailed review of MARAC workings.
Verbatim wording from the response “Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.” Source location Response to Surrey coroner area - Prevention of future deaths report
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 Surrey Police, as MARAC lead agency and chair, is responsible for reviewing and improving MARAC workings; Surrey County Council will assist.
Verbatim wording from the response “Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.” Source location Response to Surrey coroner area - Prevention of future deaths report
Open published response
9 Jun 2020 Mitica Mihaita Ladunca · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Absence of signage warning drivers on the A322 of the pedestrian crossing point linking to Swift Lane across both carriageways View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mitica Mihaita Ladunca · 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
Mitica Mihaita Ladunca died at St. George’s Hospital on 8 November 2019 after unintentionally stepping into the path of a large vehicle while attempting to cross the A322 in Surrey. The report raised concern that the absence of signage warning drivers about the uncontrolled pedestrian crossing could give rise to a risk of future deaths.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of signage warning drivers on the A322 of the pedestrian crossing point linking to Swift Lane across both carriageways
Wider context from the report “- There is an absence of signage warning drivers on the A322 that there is a crossing point for pedestrians which links to Swift Lane across both carriageways.
- Consideration should be given to introducing such signage.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install advance signage at the uncontrolled crossing to warn drivers that pedestrians may cross.
Verbatim wording from the response “In light of your report the Area Highway Manager has reviewed the location and while it is clear that your findings are that lack of signage did not contribute to this fatality he will install advance signage at this location. He is pleased to confirm that this work will go ahead on 29/30 September. This will be coordinated with the County’s high speed Traffic Management programme.” Source location Response from Surrey County Council
Open published response
8 May 2018 Stephen Ian William Tidey · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to record the basis for reduced risk-of-self-harm assessments View source Lack of safeguards to ensure MASH referrals are followed up by the appropriate Community Mental Health Team 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
Stephen Ian William Tidey · 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
Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record the basis for reduced risk-of-self-harm assessments
Wider context from the report “He was assessed by a member of the Criminal Liaison and Diversion Service (CLDS) on the same day and was initially assessed by them as being at risk of self-harm. The member of the CLDS subsequently telephoned the Home Treatment Team to discuss referring him to the service. Mr Tidey was then re-assessed by the same member of the CLDS who stated he appeared calmer and was no immediate risk to himself. No notes were recorded on the Police or Mental Health Service computer system to record how this assessment of reduced risk of self-harm had been reached.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards to ensure MASH referrals are followed up by the appropriate Community Mental Health Team
Wider context from the report “On Friday 16th December 2016, Police were made aware that Mr Tidey had lost his job as a consequence of being charged with the offences and therefore that one of the contingent events highlighted in the MASH referral of 3.2.2016 as placing Mr Tidey at higher risk of self-harm had materialised. They therefore completed a further MASH referral form and this was emailed to the MASH hub at 15.40 and forwarded on to Waverley CMHRS at 16.41.
On Monday 19th December 2016 at 11.30am, Waverley CMHRS forwarded the MASH report to Guildford CMHRS, but then emailed again at 11.36am to state they noted Waverley CMHRS should actually follow up Mr Tidey. However, for reasons, which cannot be ascertained, no further action was taken. It is not possible to ascertain who the duty worker was who received the referral by email.
████████, Community Services Manager for South West Community Mental Health Recovery Service, stated in evidence that had he received Mr Tidey’s MASH referral on 16th December 2016, he would have taken action the same day, initially via a telephone triage assessment and then via the options available of HTT referral; EDT Mental Health Act Assessment, crisis planning with safe havens or CMHRS non-crisis support, as appropriate.
Evidence was given that there were no safeguards in place to check referrals were being acted upon, and that this remains the case.
” Open source report
22 Dec 2017 Ronald Arthur Farrington · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Failure to conduct an adequate safeguarding enquiry View source Failure to inform family about CQC enquiries View source Failure to obtain independent evidence about care View source Failure to refer infected pressure sores to a general practitioner View source Failure to keep accurate care records View source Inadequate tissue viability nurse service capacity View source Failure to incorporate tissue viability advice into care plans View source Failure to involve family in safeguarding review View source Failure to produce an adequate s42 report View source Failure to provide accurate information about tissue viability nurse involvement View source Failure to follow tissue viability advice on turning and dressing sores View source Failure to inform family about developed pressure sores View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ronald Arthur Farrington · 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
Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an adequate safeguarding enquiry
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family about CQC enquiries
Wider context from the report “4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores, nor that the CQC were conducting any enquiries.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain independent evidence about care
Wider context from the report “3. The CQC did not obtain independent evidence about Mr Farrington’s care having received 2 notifications that he had developed pressure sores.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to refer infected pressure sores to a general practitioner
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate care records
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate tissue viability nurse service capacity
Wider context from the report “2. Only one tissue viability nurse was employed by First Community Care from March 2016 onwards. They were on annual leave for 6 weeks between the 18th March and the 15th June 2016. This was not an adequate level of service.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate tissue viability advice into care plans
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family in safeguarding review
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to produce an adequate s42 report
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about tissue viability nurse involvement
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to follow tissue viability advice on turning and dressing sores
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family about developed pressure sores
Wider context from the report “4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores , nor that the CQC were conducting any enquiries.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review systems to support expected adult safeguarding practice and produce better management information for oversight.
Verbatim wording from the response “We expect these policies and procedures to be in place by April 2018, when they will be followed by a learning and development programme to support our staff to understand and be able to meet the expectations on them. We will also review our systems to ensure they are able to support the practice we expect and produce better management information to help oversee the work. We expect this work to be completed by October 2018.” Source location 2017-0494-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a learning and development programme to help staff meet revised adult safeguarding expectations.
Verbatim wording from the response “We expect these policies and procedures to be in place by April 2018, when they will be followed by a learning and development programme to support our staff to understand and be able to meet the expectations on them. We will also review our systems to ensure they are able to support the practice we expect and produce better management information to help oversee the work. We expect this work to be completed by October 2018.” Source location 2017-0494-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a revised quality assurance auditing programme for adult safeguarding work.
Verbatim wording from the response “We have also put in place a revised quality assurance auditing programme of our adult safeguarding work so that we can more readily identify when our adult safeguarding work is falling short of expectations and take action to address this.” Source location 2017-0494-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve systems to identify long-running adult safeguarding enquiries and bring them to satisfactory conclusions.
Verbatim wording from the response “We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period. We are confident we can sustain this improved performance.” Source location 2017-0494-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise adult safeguarding policies and procedures with clearer expectations for planning, family involvement, organisational contributions, responsibility and timeliness.
Verbatim wording from the response “We are in the process of revising our adult safeguarding policies and procedures, and working with our colleagues on Surrey Safeguarding Adults Board to guide the Board’s policies and procedures, so that” Source location 2017-0494-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The employing provider had first responsibility to complete the safeguarding enquiry, subject to the Council assuring its sufficiency and following up if necessary.
Verbatim wording from the response ““It is important that all partners are clear where responsibility lies where abuse or neglect is carried out by employees or in a regulated setting, such as a care home, hospital, or college. The first responsibility to act must be with the employing organisation as provider of the service … However, a local authority would have to satisfy itself that an employer’s response has been sufficient to deal with the safeguarding issue and, if not, to undertake any enquiry of its own and any appropriate follow up action”” Source location 2017-0494-Response
Open published response
23 Mar 2017 Ralph Ian Brazier · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to specifically consider cyclist numbers and risks in highway repair assessments View source Failure to account for highway use by cyclists in highway-defect priority categorisations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ralph Ian Brazier · 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
Ralph Ian Brazier, a 52-year-old man, died after his bicycle struck a pothole next to a drainage gully cover on the A317 on 1 March 2016, throwing him onto the road. The concern was that Surrey County Council’s defect categorisation and repair priorities did not sufficiently account for cyclists using highways, particularly the nearside section of the road.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to specifically consider cyclist numbers and risks in highway repair assessments
Wider context from the report “Having heard evidence from a number of members of Surrey County Council, I am concerned that insufficient consideration is taken by the Council of the increasing number of cyclists on their highways, particular in relation to the categorisation of defects on the highway. I am particularly concerned that designated cycle lanes are given higher priority relating to a defect than a highway, despite the high number of cyclists using the highway rather than cycle lanes with closer proximity to traffic including heavy goods vehicles.
- Surrey County Council has failed to take into sufficient account the fact that cyclists use the highways as well as the cycle lanes in their priority categorisations.
- That the great number of cyclists, and the risks to them using the highways, particularly the nearside section, are not specifically considered when Surrey County Council are assessing the highways for repair.
Re-consideration should be given to whether any steps, including changes to the categorisation of highway defects in light of the greater use of public highways by cyclists, can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to account for highway use by cyclists in highway-defect priority categorisations
Wider context from the report “Having heard evidence from a number of members of Surrey County Council, I am concerned that insufficient consideration is taken by the Council of the increasing number of cyclists on their highways, particular in relation to the categorisation of defects on the highway. I am particularly concerned that designated cycle lanes are given higher priority relating to a defect than a highway, despite the high number of cyclists using the highway rather than cycle lanes with closer proximity to traffic including heavy goods vehicles.
- Surrey County Council has failed to take into sufficient account the fact that cyclists use the highways as well as the cycle lanes in their priority categorisations.
- That the great number of cyclists, and the risks to them using the highways, particularly the nearside section, are not specifically considered when Surrey County Council are assessing the highways for repair.
Re-consideration should be given to whether any steps, including changes to the categorisation of highway defects in light of the greater use of public highways by cyclists, can be taken to address the above concerns.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the highway policy, analyse cyclists’ use of the network, and consider whether inspection, defect assessment, or categorisation should be amended.
Verbatim wording from the response “The latest revision of the Code of Practice was published in October 2016 and in accordance with the revision of this national document SCC has begun a review of its highway policy. As part of this review SCC will also consider the Coroner’s concerns and if and to what extent the inspection regime, including defect assessment and categorisation, should be amended. This will include further analysis of the number of cyclists and differing use of the highway network by cyclists in Surrey. To allow for sufficient consideration of the revised national Code of Practice the authority has two years to make any amendments to their policies following its publication. On this basis the latest timeframe for implementation of any changes to our Highway Policy will be September 2018.” Source location 2017-0090-Response-by-Surrey-County-Council_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare additional highway-inspector training on risk assessment for vulnerable road users, including cyclists.
Verbatim wording from the response “Inspector training requirements are set out in the Code of Practice and SCC is satisfied that it is compliant in this regard. To enhance the existing training regime SCC are preparing additional training for the highway inspectors in relation to the risk assessment for vulnerable users, which includes for cyclists. This additional training will be completed by the end of August 2017. Ongoing training requirements will be further reviewed following the completion of the review of the highway policy.” Source location 2017-0090-Response-by-Surrey-County-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 Highway inspectors already consider risks to cyclists when assessing defects, and the relevant assessment complied with the highway policy.
Verbatim wording from the response “In relation to the matter of assessment, highway inspectors, when assessing any defect in the highway, are required not only to apply the defect criteria set out in the policy but also to consider the particular circumstances of the locus including the potential danger created by the defect to all road users, cyclists as well as vehicle drivers. Cyclists are entitled to, and do, use all parts of Surrey’s road network. Highway Inspectors take this into account when assessing potential defects. ████████ the Highway Inspector who identified the defect scrutinised at the inquest, gave evidence that he took into account the potential dangers to cyclists when he categorised the defect. SCC is satisfied that ████████ assessment fully complied with its highway policy.” Source location 2017-0090-Response-by-Surrey-County-Council_Redacted
Open published response
16 Jun 2016 Mr Reece Atkinson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Build-up of wet soil and sandy deposits on the roadside near the entrance to Albury Sandpit 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
Mr Reece Atkinson · 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
On 2 December 2015, 18-year-old Mr Reece Atkinson sustained fatal head injuries when his car left the road and collided with a tree on the A25 Sheer Road in Albury. The inquest identified wet soil and sandy deposits near the Albury Sandpit entrance, which may present a risk to drivers.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Build-up of wet soil and sandy deposits on the roadside near the entrance to Albury Sandpit
Wider context from the report “During the course of the inquest the evidence revealed the presence of a build-up of wet soil and sandy deposits on the side of the road on the A25 Sheer Road in Albury close to the entrance to Albury Sandpit.
Contamination on the side of the road close to the entrance to the Albury Sandpit on the A25 Sheer Road in Albury may present a risk to drivers.
” Open source report
25 May 2016 Christopher James B Sears · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Inability of schools to inform bus companies about concerns without a formal diagnosis View source Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training View source Failure to provide Basic Life Support training as routine secondary education View source Lack of a Basic Life Support qualification requirement for pupil-transport drivers View source Absence of emergency-response protocols for drivers driving buses View source Inability to put protective measures in place for bus transport concerns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher James B Sears · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher James B Sears, a 13-year-old boy, died on 13 November 2014 after a seizure-like episode on a school bus; resuscitation attempts were unsuccessful. The report raised concerns about the absence of Basic Life Support training and emergency protocols for school-bus drivers, delays in calling emergency services, and difficulties alerting the bus company where there was no formal diagnosis.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Inability of schools to inform bus companies about concerns without a formal diagnosis
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training
Wider context from the report “1. There is no requirement for bus companies tendering for contracts from Local Authorities to transport pupils/students to ensure all their drivers have undergone training in Basic Life Support .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Basic Life Support training as routine secondary education
Wider context from the report “5. Basic Life Support training is not taught as a matter of course to young adults in secondary education and is not part of the national curriculum .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a Basic Life Support qualification requirement for pupil-transport drivers
Wider context from the report “2. There is no requirement for drivers transporting pupils/students to hold a Basic Life Support qualification .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of emergency-response protocols for drivers driving buses
Wider context from the report “3. No protocols were in place to assist a driver as to what to do in an emergency situation whilst driving a bus including the need to call the emergency services at the earliest opportunity .
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Inability to put protective measures in place for bus transport concerns
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place .
” Open source report
31 Mar 2016 John Watt · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of a safe or controlled pedestrian crossing means for the A25 at Abinger Hammer 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
John Watt · 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
John Watt, a 91-year-old man, was struck by a car while attempting to cross the A25 Guildford Road at Abinger Hammer on 27 May 2015 and died from his injuries. The inquest heard that there was no safe or controlled means for pedestrians to cross the road in the village, and raised consideration of providing one.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe or controlled pedestrian crossing means for the A25 at Abinger Hammer
Wider context from the report “A Means of Crossing the A25 Guildford Road at Abinger Hammer
Evidence at inquest indicated that there is no safe or controlled means for a pedestrian to cross the road in the village .
Consideration should be given to providing a safe system of allowing pedestrians to cross the A25 at Abinger Hammer.
” 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 Inspect the existing vehicle-activated sign east of Felday Road.
Verbatim wording from the response “There is also a solar powered electronic vehicle activated sign that illuminates to drivers to remind them of the 30 mph speed limit and to “SLOW DOWN” if they are travelling too fast on the westbound approach to the pedestrian desire line near the Post Office/Tea Room. It is thought that the operation of the sign may be sporadic depending on the level of sunlight, number of activations and battery longevity. Consequently funding will be sought to undertake an inspection of the sign and to overhaul it if necessary.” Source location John-WATT-Response
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 Request funding and undertake a feasibility study for a safe pedestrian crossing facility at the location.
Verbatim wording from the response “2.3 Commissioning of a feasibility study for a crossing (based on some of the findings described above)” Source location John-WATT-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate providing signs warning drivers that pedestrians cross the A25 near the village green.
Verbatim wording from the response “In the short term it is proposed to investigate the provision of signs to warn drivers that pedestrians are crossing the A25 in the vicinity of the village green.” Source location John-WATT-Response
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 fatal collision did not form part of a pattern of similar incidents supporting casualty-reduction justification for crossing facilities.
Verbatim wording from the response “It would appear that the circumstances that led to the fatal accident involving Mr Watt, in the vicinity of the Kingfisher Farm Shop entrance, did not form part of a pattern of similar incidents at the same location. The only other personal casualty took place over 100m to the west and involved an accident, described above, that could have taken place at any location.” Source location John-WATT-Response
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 County Councillors decide which highway schemes to prioritise and where available resources are allocated.
Verbatim wording from the response “If the feasibility study concludes that there is a justifiable need for some work to take place, and the proposed solution is suitable for the location, then the proposal would be added to the Integrated Transport Schemes (ITS) List of schemes for possible future funding. The Mole Valley Forward Programme of schemes for design and construction is made up from schemes on the ITS List and this programme is presented to the Mole Valley Local Committee each year for decision. The County Councillors are responsible for deciding which schemes to prioritise and where to allocate resources. County Councillors will take into account representations from the public, the advice from the engineers and the availability of funding. It can take over 18 months before any improvement works are implemented, even if a scheme is approved and funding available.” Source location John-WATT-Response
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 A formal crossing may be unsuitable because carriageway width, available land, lighting, power, conservation-area and environmental constraints limit feasible options.
Verbatim wording from the response “The proposed feasibility study for improved crossing facilities would consider the extent of the public highway to assess whether there is sufficient width for the provision of suitably sized areas for pedestrians to wait to cross. The availability of an electrical power supply should also be considered (there is no street lighting on this road), as should the position of the bus stops in relation to the crossing point. Kerb build outs, to narrow the carriageway, would not be appropriate at this location given the nature and volume of traffic that uses the A25 through Abinger Hammer. There is insufficient carriageway width to provide a central pedestrian refuge island.” Source location John-WATT-Response
Open published response
26 Jan 2014 Lillian Rose Robinson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Poor note taking in patient care records View source Use of unqualified medical carers to evaluate capacity appropriateness in patients with mild/moderate dementia View source Lack of communication between hospital and home regarding mental capacity assessment View source Failure of patient care notes to support continuity of care View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Lillian Rose Robinson · 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
Lillian Rose Robinson was admitted to Brockhurst Care Home, transferred to Upper Halliford nursing home after deteriorating, and died from bronchopneumonia on 28 December 2012. The substantive concerns were communication about mental-capacity assessments, unqualified carers evaluating capacity in patients with mild or moderate dementia, and poor note-taking and continuity of care.
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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Poor note taking in patient care records
Wider context from the report “Poor note taking and continuity of patient care notes
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Use of unqualified medical carers to evaluate capacity appropriateness in patients with mild/moderate dementia
Wider context from the report “Unqualified medical carers evaluating the appropriateness of capacity in patients with mild/moderate dementia
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between hospital and home regarding mental capacity assessment
Wider context from the report “Lack of communication between hospital and home re mental capacity assessment
” 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 Surrey County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of patient care notes to support continuity of care
Wider context from the report “Poor note taking and continuity of patient care notes
” 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