27 Feb 2019 Janie McFadyen · Prevention of Future Deaths report Manchester City
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Concerns raised 5 Lack of clarity about when and in what circumstances a person leaving the program should be reported as missing View source Lack of appropriate recognised and regularly updated role training for unit staff View source Lack of appropriate protocols, policies, processes or guidance for identified operational issues View source Inappropriate placement of missing-person reporting responsibility on family members View source Lack of clear and cohesive arrangements for seeking NHS drug, alcohol and mental health support or Police advice View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Review, amend and update residents’ records, including intake, support, risk, welfare, medical, medication, missing-person, departure and financial documentation.
Stated completedThe respondent said that this action was complete when they made their response on 27 February 2019. View source
Action
Review, amend and update Victory Homes policies and procedures against safeguarding, charity-law and other applicable regulatory requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 February 2019. View source
Action
Provide and maintain mandatory safeguarding, first-aid, fire-safety, food-safety and monitoring training, with supervision and refresher training where required.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 February 2019. View source
Action
Implement safeguarding, missing-person, medication, eligibility, health, welfare, fire-safety, drug-testing and related operational policies and procedures.
Stated completedThe respondent said that this action was complete when they made their response on 27 February 2019. View source See 1 more action
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AI-generated summary
Janie McFadyen · 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
Janie McFadyen left a drug rehabilitation facility in Manchester on 23 November 2017 and was found unconscious on derelict land on 25 November 2017. She died after suffering cardiac arrests; the inquest recorded hypothermia and the use of Diazepam, Zopiclone, Cocaine and Heroin, with a drug-related conclusion. The principal concerns included the lack of appropriate protocols and staff training, unclear arrangements for accessing health and police guidance, and the failure to clearly determine when a person leaving the facility should be reported missing.
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 Victory Outreach Manchester; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when and in what circumstances a person leaving the program should be reported as missing
Wider context from the report “1 The clear lack of the apparent existence of appropriate protocols, policies, processes or other guidance to deal with the large number of issues identified above
2. The lack of an apparent clear and cohesive set of arrangements for seeking help and guidance from primary or secondary NHS drug/alcohol and mental health services or seeking advice from the Police about a Missing Persons Policy
3 A complete lack of clarity about when and in what circumstances who leaves the program should be reported to the Police as being a missing person. It is suggested that the deceased would have fallen into the category of a High Risk Missing Person in all the circumstances and that there should be established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of a family to decide whether or not they wish to report an individual as a missing person to the Police
5 It is suggested that every person who works at either the male or female unit has appropriate and recognised training for their roles and this is regularly reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way elsewhere in England and Wales, a similar program of review identified in paragraphs 1-5 immediately above should be undertaken.
” 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 Victory Outreach Manchester; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate recognised and regularly updated role training for unit staff
Wider context from the report “1 The clear lack of the apparent existence of appropriate protocols, policies, processes or other guidance to deal with the large number of issues identified above
2. The lack of an apparent clear and cohesive set of arrangements for seeking help and guidance from primary or secondary NHS drug/alcohol and mental health services or seeking advice from the Police about a Missing Persons Policy
3 A complete lack of clarity about when and in what circumstances who leaves the program should be reported to the Police as being a missing person. It is suggested that the deceased would have fallen into the category of a High Risk Missing Person in all the circumstances and that there should be established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of a family to decide whether or not they wish to report an individual as a missing person to the Police
5 It is suggested that every person who works at either the male or female unit has appropriate and recognised training for their roles and this is regularly reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way elsewhere in England and Wales, a similar program of review identified in paragraphs 1-5 immediately above should be undertaken.
” 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 Victory Outreach Manchester; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate protocols, policies, processes or guidance for identified operational issues
Wider context from the report “1 The clear lack of the apparent existence of appropriate protocols, policies, processes or other guidance to deal with the large number of issues identified above
2. The lack of an apparent clear and cohesive set of arrangements for seeking help and guidance from primary or secondary NHS drug/alcohol and mental health services or seeking advice from the Police about a Missing Persons Policy
3 A complete lack of clarity about when and in what circumstances who leaves the program should be reported to the Police as being a missing person. It is suggested that the deceased would have fallen into the category of a High Risk Missing Person in all the circumstances and that there should be established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of a family to decide whether or not they wish to report an individual as a missing person to the Police
5 It is suggested that every person who works at either the male or female unit has appropriate and recognised training for their roles and this is regularly reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way elsewhere in England and Wales, a similar program of review identified in paragraphs 1-5 immediately above should be undertaken.
” 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 Victory Outreach Manchester; that does not assign responsibility.
PFD Monitor interpretation Inappropriate placement of missing-person reporting responsibility on family members
Wider context from the report “1 The clear lack of the apparent existence of appropriate protocols, policies, processes or other guidance to deal with the large number of issues identified above
2. The lack of an apparent clear and cohesive set of arrangements for seeking help and guidance from primary or secondary NHS drug/alcohol and mental health services or seeking advice from the Police about a Missing Persons Policy
3 A complete lack of clarity about when and in what circumstances who leaves the program should be reported to the Police as being a missing person. It is suggested that the deceased would have fallen into the category of a High Risk Missing Person in all the circumstances and that there should be established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of a family to decide whether or not they wish to report an individual as a missing person to the Police
5 It is suggested that every person who works at either the male or female unit has appropriate and recognised training for their roles and this is regularly reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way elsewhere in England and Wales, a similar program of review identified in paragraphs 1-5 immediately above should be undertaken.
” 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 Victory Outreach Manchester; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and cohesive arrangements for seeking NHS drug, alcohol and mental health support or Police advice
Wider context from the report “1 The clear lack of the apparent existence of appropriate protocols, policies, processes or other guidance to deal with the large number of issues identified above
2. The lack of an apparent clear and cohesive set of arrangements for seeking help and guidance from primary or secondary NHS drug/alcohol and mental health services or seeking advice from the Police about a Missing Persons Policy
3 A complete lack of clarity about when and in what circumstances who leaves the program should be reported to the Police as being a missing person. It is suggested that the deceased would have fallen into the category of a High Risk Missing Person in all the circumstances and that there should be established procedures for dealing with such situations.
4. The inappropriateness of attempting to place the responsibility on members of a family to decide whether or not they wish to report an individual as a missing person to the Police
5 It is suggested that every person who works at either the male or female unit has appropriate and recognised training for their roles and this is regularly reviewed and updated
6. If other similar units run by Victory Outreach are operated in the same way elsewhere in England and Wales, a similar program of review identified in paragraphs 1-5 immediately above should be undertaken.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, amend and update residents’ records, including intake, support, risk, welfare, medical, medication, missing-person, departure and financial documentation.
Verbatim wording from the response “2. Residents Files have been reviewed, amended and updated as detailed in the table below. Copies of these can be found in the Victory Homes Supporting Document File content list number 3.” Source location Response from Victory Outreach
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, amend and update Victory Homes policies and procedures against safeguarding, charity-law and other applicable regulatory requirements.
Verbatim wording from the response “Meanwhile, since the Coroner’s Report, there have been improvements and changes in regard to developing certain processes and procedures important in maintaining a high level of accountability, safeguarding, improved channels of communication and the reporting structure and its mechanisms.” Source location Response from Victory Outreach
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 and maintain mandatory safeguarding, first-aid, fire-safety, food-safety and monitoring training, with supervision and refresher training where required.
Verbatim wording from the response “Training | Training Provider | Date completed | Date to be Completed
Urban Training Center (UTC) Leadership Training | West Coast UTC Los Angeles | September 2012 to March 2013 |
Children and Young People Safeguarding Basic Awareness Training | Griffin Care Limited
████████
████████
████████
████████ | 7th May 2018 |
First Aid Training | Tutorcare Limited
Spectrum House,Beehive Ring Road, Gatwick,RH6 0LG
████████
████████
Email:
info@tutorcareltd.co.uk
████████
████████
████████ | 7th September 2018 |
Fire Safety - Marshal Training | http://www.ukfiretraining.com/
████████
Meridian House, Saxon Business Park, Hanbury Rd, Stoke Prior, Bromsgrove B60 4AD | 20th August 2018 |
Monitoring and Evaluation | Salfordcvs.co.uk | 24th April 2019 |
Medication Awareness Training | Training being sorted | |” Source location Response from Victory Outreach
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 safeguarding, missing-person, medication, eligibility, health, welfare, fire-safety, drug-testing and related operational policies and procedures.
Verbatim wording from the response “1. Policies and Procedures as detailed in the table below and copies of these can be found in the Victory Homes Supporting Document File content list number 2.” Source location Response from Victory Outreach
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations