20 Jan 2023 Michael John Holmes · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Lack of expertise to assess and control cattle trampling risks on small farms View source Unclear requirements for bringing dogs onto public footpaths near cattle View source Unpredictable aggressive cattle reactions to dogs in fields View source Insufficient oversight and management of public rights of way near grazing cattle View source Cattle trampling hazard when walkers with dogs encounter cows with calves View source Failure to separate walkers from cattle on rights of way View source See 3 more concerns
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Michael John Holmes · 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
Michael John Holmes died after being knocked down and trampled by cattle while walking dogs with his wife on a public footpath through a field. The report raised concerns about the risks of walkers, particularly those accompanied by dogs, coming into contact with cattle and calves, and about the management and separation of public footpaths from grazing cattle.
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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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of expertise to assess and control cattle trampling risks on small farms
Wider context from the report “4.1. The current potential for a hazard to be created by walkers on public footpaths moving in proximity to a farmer’s grazing cattle, requires management of these competing interests. It was contended at the inquest that the farmer is subject to a statutory duty to carry out a risk assessment in accordance with the Management of Health & Safety at Work Regulations 1999. It was contended that a landowner must conduct his business around the existing public footpath, irrespective of which came into existence first. Whilst not disputing the legal duty imposed on a farmer in these circumstances, the potential mischief left unguarded in that analysis, is that Small & Medium Enterprises (SME’s) such as small family farms may lack the expertise to recognise the problem, carry out an effective risk assessment in relation to cattle trampling risks and devise reasonably practicable control measures.
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Unclear requirements for bringing dogs onto public footpaths near cattle
Wider context from the report “2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most common factors in trampling incidents are cows with calves and walkers with dogs. Mr & Mrs Holmes had two dogs on leads at the time. The inquest heard evidence about four previous incidents in the incident field, three of which involved walkers accompanied by dogs. There appears to be a strong correlation between trampling incidents and walkers with dogs.
2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well, particularly when the calves are young.
2.3. Evidence was given at the inquest to the effect that dogs are regarded as a ‘usual accompaniment’ and are thus entitled to be brought onto a Right of Way. This proposition lacks clarity. There is also uncertainty as to whether dogs are required to be on a lead when on a public footpath.
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Unpredictable aggressive cattle reactions to dogs in fields
Wider context from the report “3.1. It is difficult to predict whether a particular cow will react aggressively to the presence of a dog in a field. It was suggested during the inquest, the risk of such a reaction is highest in the months after the birth of a calf.
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient oversight and management of public rights of way near grazing cattle
Wider context from the report “4.2. To avoid the harm envisaged by further deaths in comparable circumstances, the HSE and Local Authorities should explore ways to apply their expertise in collaboration with landowners (of the type involved in this inquest), whether on a paid or voluntary basis. The maintenance of safe public rights of way could be said to require oversight and management by public bodies as well as the landowners 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Cattle trampling hazard when walkers with dogs encounter cows with calves
Wider context from the report “2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most common factors in trampling incidents are cows with calves and walkers with dogs . Mr & Mrs Holmes had two dogs on leads at the time. The inquest heard evidence about four previous incidents in the incident field, three of which involved walkers accompanied by dogs. There appears to be a strong correlation between trampling incidents and walkers with dogs.
2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well, particularly when the calves are young.
2.3. Evidence was given at the inquest to the effect that dogs are regarded as a ‘usual accompaniment’ and are thus entitled to be brought onto a Right of Way. This proposition lacks clarity. There is also uncertainty as to whether dogs are required to be on a lead when on a public footpath.
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to separate walkers from cattle on rights of way
Wider context from the report “1.2. Statistics from the Health & Safety Executive (‘HSE’) indicate that on average 6 people have died each year from injuries sustained in cattle trampling incidents. 11 people died in 2020, one of whom was Mr Holmes. Such incidents are avoidable if walkers and cattle are separated. In my judgment, this unacceptable situation necessitates a review of the arrangements in which walkers are brought into contact with cows and their calves, by virtue of rights of way .
” 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 Pursue diversion of three public footpaths, including the incident-field route, to separate walkers from grazing cattle by making and referring diversion orders for determination.
Verbatim wording from the response “Following this incident, in January 2021 ████████ applied to the Council pursuant to s119 Highways Act 1980 to divert three public footpaths in Hollinghurst Farm that passed through fields that were used for grazing cattle, including Siltington 35.” Source location Response from Wakefield 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 Risk assessment and control of cattle hazards rests with landowners and other duty holders, rather than the HSE or local authorities.
Verbatim wording from the response “This is a national issue that would require response by the Secretary of State and the HSE. No action is proposed by Wakefield Council in the absence of change to the statutory framework within which it operates.” Source location Response from Wakefield 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 Clarification of dogs’ legal status on rights of way is a national issue for the Secretary of State and wider stakeholder engagement.
Verbatim wording from the response “These are identified as national issues requiring consideration and response by the Secretary of State and wider engagement with key stakeholders. Wakefield Council, as with other local authorities, is a creature of statute with its authority and powers arise from a statutory framework. In the case of Public Rights of Way (PROW), these statutory duties and powers arise from the Highways Act 1980 and any associated case law. It is proposed that Wakefield Council could not act in isolation without a change in the legal framework within which the Council operates.” Source location Response from Wakefield 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 Public-body oversight of landowners’ cattle risks is considered unworkable because public bodies cannot monitor land use continuously.
Verbatim wording from the response “To suggest that the HSE and LAs could apply their expertise to landowners on a paid or voluntary basis would not be workable and could be said to dilute the responsibility of the duty holder. Advice on how to assess and manage risk is provided through the HSE and as with any other business it is incumbent on the duty holder to manage those risks.” Source location Response from Wakefield Council
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30 Apr 2021 Eliot Peter Burton · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 5 Lack of on-site supervision at a remote site View source Insufficient prevention of access to the site via the adjacent weir View source Failure to protect deep water channels from falls View source Trespassing by young people onto the site View source Failure to take effective action to reduce the risk of harm from child trespass View source See 2 more concerns
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AI-generated summary
Eliot Peter Burton · 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
Eliot Peter Burton, aged 15, was found drowned at an unmanned hydroelectric plant after entering the site as a trespasser and falling into an outlet channel. The concerns included repeated trespassing by young people, deep uncovered channels with limited or no edge protection, difficult access to the site via the adjacent weir, and limited effective action to reduce the risks to children.
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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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site supervision at a remote site
Wider context from the report “1. The site is always unmanned . It is located in a remote area
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient prevention of access to the site via the adjacent weir
Wider context from the report “4. Despite perimeter fencing, it is known that one route for children to gain entry to the site is by crossing the River Calder at the Kirkthorpe weir adjacent to the site . There are few, if any impediments to prevent access to the weir from the river bank opposite the site .
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to protect deep water channels from falls
Wider context from the report “3. There are deep uncovered channels on the site to conduct water through the facility . It is foreseeable that a trespasser would be in a precarious situation if they were to fall into the water, as Elliot Burton did. Many of the channels are uncovered, and /or have no edge protection .
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Trespassing by young people onto the site
Wider context from the report “2. It is known that in the years 2018-2021, young people have trespassed onto the site .
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take effective action to reduce the risk of harm from child trespass
Wider context from the report “5. Despite the passage of some 21 months since Elliot Burton’s death, little effective action has been taken to reduce the risk of children being harmed if they are tempted to trespass on this site .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct post-construction reviews and further feasibility assessments to evaluate the implemented measures and identify additional safety improvements.
Verbatim wording from the response “4.1 After the tragedy that resulted in the death of Elliott Burton, Wakefield Council has been actively pursuing safety measures to prevent further deaths at the location of the Kirkthorpe Weir since August 2019. We have worked closely with the HSE throughout and all the associated parties involved. We have taken a lead to progress new and improved safety measures on both sides of the river. These endeavours are not without significant challenges due to the physical locale and natural elements to contend with. We are however confident that the schemes we are aiming to complete over the coming months will reduce the risk of recurrence as much as is possible. After the construction phases are complete we are planning several reviews and further feasibilities – to ascertain if the measures we have implemented are as effective as anticipated or if more can be achieved.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and replace prominent danger signage, including emergency-location information, around the weir and water’s edge.
Verbatim wording from the response “2.4 It was apparent from both visits that the west bank area was frequented by a popular spot to swim and fish by members of the public. It was agreed that some immediate measures could be taken to highlight the dangers of the fast flowing water. The Council and YHP over the coming weeks instigated the updating and adding of additional safety signage. This included warning of the dangers of the water, fall from heights and the Weir itself. Many of these signs were promptly vandalised and removed by persons unknown. The Council have been actively checking and replacing these since the incident. The signage has evolved to larger and more prominent notifications, and we have added the “What 3 Words” location data to each. This is a system the emergency services use to locate accurately anyone in distress in remote areas.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue scheduled manned security inspections at Kirkthorpe Weir and extend the inspection regime to other accessible water sites across the district.
Verbatim wording from the response “3.1 In recognition of the demanding challenges to construct suitably designed physical barriers on both sides of the river in a short time, the Council has been undertaking regular manned security inspections to discourage anyone entering the water, and highlighting the dangers. This is undertaken specifically on hot weather days, holidays and alike as well as periodically through each month. This regime is recorded and has been in place since the summer of 2020. This security detail has also been extended to other still and flowing water body sites across the district where public have regular access.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress detailed design, approvals, procurement and construction of a physical riverside barrier protecting the Yorkshire Hydro Plant perimeter.
Verbatim wording from the response “1.3 The current strategy and plans are to undertake comprehensive physical works and construction projects. This is with aim to design and build robust physical barriers in the challenging and changing environments on the embankments adjacent the Kirkthorpe Weir. The result will be to prevent as far as reasonably practicable, trespass to the Yorkshire Hydro Plant and access to the Weir on both sides of the river in this locale. This project is working in Partnership with the Yorkshire Hydro Plant – Foresight Group (YHP) and the Canals and River Trust (CRT). Wakefield Council have also been working in close liaison with the Health and Safety Executive from the outset of this case.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and procure approximately 300 metres of west-bank fencing with robust signage, conservation information boards and a safe viewing platform.
Verbatim wording from the response “3.6 Phase 3 is running in parallel to Phase 2. This is a solely Council led initiative, the concept of which was supported by the HSE. This is to add further fenced protection to the west bank of the river based on our revised risk assessment of the site.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the west-bank risk assessment and erect fenced barriers to restrict access to the weir and water’s edge.
Verbatim wording from the response “2.5 In January 2020 the Council revised the risk assessment for the west bank. This resulted in not only replacing numerous signs, but we also erected several new fenced barriers in attempt to improve safety and restricting access to the Weir and waters’ edge. The fencing construction at that time was limited. This area is heavy in vegetation, trees and swathes of wild Japanese knotweed. It has therefore been a very challenging environment to place physical barriers successfully.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Physical safety measures are constrained by the weir’s listed status, required planning approvals, ecological considerations and the need to protect habitats.
Verbatim wording from the response “2.7 Further challenges to enable physical measures more quickly have been that the Weir construct itself is a listed structure. As such conservation planning consents and change to consider Historic England Planning approvals. Ecological factors have also had to be considered in terms of the fish passes on the Weir for example, and DEFRA generally. This impacts on the final” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some proposed river barriers were rejected because their designs could create foreseeable risks or fail in flood conditions.
Verbatim wording from the response “2.6 During this time, consultation with all 3 parties and the HSE were looking at the more challenging aspect of preventing trespass to YHP from the river and particularly gaining access by members of the public traversing the Weir. Several engineering solutions were considered each with their own difficulties with construction in a fast flowing river. Some solutions were dismissed. They may have prevented trespass, but their inherent design upon scrutiny, potentially caused other foreseeable risks. Other solutions may not have withstood flood waters.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Construction timing is constrained by river conditions, including a requirement not to undertake works during flooding.
Verbatim wording from the response “3.2 There are 3 Phases of work associated with the safety works at Kirkthorpe Weir. Phase 1 has been the measures taken to date as noted. Phase 2 is a joint approach to design a suitable physical barrier to the perimeter of the YHP site on the river side. The concept of this has been in the feasibility and design stages since June 2020, with the first designs suggested in October 2020.” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Canals and Rivers Trust is responsible for upkeep and maintenance of its weir structure and the waterway.
Verbatim wording from the response “2.1 Wakefield Council has taken a significant lead in formulating a safety strategy for the area surrounding Kirkthorpe Weir. The Council owns the land on both sides of the river at this point. The west bank is part of the area known as the Southern Washlands and has nearby fishing lakes, country side walks and public footpaths. The east bank is the location of the YHP Plant. The plant owners lease the land, but have full responsibility as occupier for their own construction, operations and buildings with demise. This includes their security and perimeter management. CRT have ownership of approximately half of the Victorian weir construct. The council own the other half - but CRT take responsibility for its upkeep and general maintenance. The waterway” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Yorkshire Hydro Plant owners are responsible for security and perimeter management of their leased plant, buildings and operational area.
Verbatim wording from the response “2.1 Wakefield Council has taken a significant lead in formulating a safety strategy for the area surrounding Kirkthorpe Weir. The Council owns the land on both sides of the river at this point. The west bank is part of the area known as the Southern Washlands and has nearby fishing lakes, country side walks and public footpaths. The east bank is the location of the YHP Plant. The plant owners lease the land, but have full responsibility as occupier for their own construction, operations and buildings with demise. This includes their security and perimeter management. CRT have ownership of approximately half of the Victorian weir construct. The council own the other half - but CRT take responsibility for its upkeep and general maintenance. The waterway” Source location 2021-0131-Response-from-Wakefield-Council-Redacted
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24 Sep 2020 June Mavis Winterbottom · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 4 Failure to identify urgent cases that drift outside normal hours View source Lack of an ambulance escalation safety net when Adult Social Care cannot respond promptly View source Failure of urgent referrals to receive a timely response View source Failure to establish accountability with an identified manager View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
June Mavis Winterbottom · 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
June Mavis Winterbottom, aged 90, lived alone in sheltered accommodation and was found semi-conscious in her own faeces and vomit, covered in pressure sores, after an urgent Adult Social Care referral received no contact. She was taken to hospital and treated for urosepsis, but died later that day. The report identified ineffective urgent-referral handling, unclear accountability, and no safety net for calling an ambulance when Adult Social Care could not respond promptly.
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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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify urgent cases that drift outside normal hours
Wider context from the report “(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance
(2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20.
(3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient.
(4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours . Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager.
(5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason.
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an ambulance escalation safety net when Adult Social Care cannot respond promptly
Wider context from the report “(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance
(2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20.
(3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient.
(4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager.
(5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason.
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of urgent referrals to receive a timely response
Wider context from the report “(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance
(2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20.
(3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient.
(4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager.
(5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason.
” 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 Wakefield City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish accountability with an identified manager
Wider context from the report “(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance
(2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20.
(3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient.
(4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager.
(5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed a referral-transfer process requiring dashboard entry and direct confirmation with the worker on shift.
Verbatim wording from the response “Further work was then undertaken over the next four weeks to ensure that the referral transfer process was robust, with the following specific actions being implemented:” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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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 Enable all Adult Triage workers to view both East and West Urgent Response Dashboards and monitor submitted referrals.
Verbatim wording from the response “• We have ensured that all Adult Triage workers in Social Care Direct can view the Urgent Response Dashboards for both East and West to check the progress of any referrals they sent through.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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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 Establish an on-call rota identifying a manager responsible for out-of-hours periods.
Verbatim wording from the response “• A Team Managers on call rota was set up, to ensure that there was always a clearly identified manager responsible for out of hours, whether evenings or weekends.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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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 Revise and simplify the rota, adding contact numbers for workers, managers and teams.
Verbatim wording from the response “• The rota format was revised and simplified so that it is clearer to identify who is working.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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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 Distribute weekly rota emails with working arrangements and out-of-hours shift guidance, including instructions to check both Urgent Response Dashboards.
Verbatim wording from the response “• A weekly email is distributed across the Adult Social Care service, containing the rota which in turn contains clear working arrangement guidance. It makes it clear who is working and when, and in what role.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require core-hours Urgent Response workers to communicate follow-up requirements directly to extended-hours workers.
Verbatim wording from the response “• The Urgent Response workers covering core hours will directly communicate with the extended hours workers regarding anything which needs following up from the day.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a dedicated out-of-hours workforce system for handling referrals.
Verbatim wording from the response “At this time, WMDC Adult Social Care had realigned its workforce in order to support the Covid response as directed by the Department for Health and Social Care. In particular, the national guidance required Adult Social Care to facilitate urgent hospital discharges between 8am and 8pm, to ease the mounting pressure on overburdened hospitals. WMDC Adult Social Care had implemented a new system of workers covering referrals outside of usual working hours in the weeks prior to this referral being received. There were also further changes to usual working practices in that significant numbers of staff were working remotely from home due to the Covid situation. Nevertheless, action should have resulted from the referral during the evening of 2nd June 2020 and I offer my sincere apologies to Mrs Winterbottom’s family.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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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 Instruct out-of-hours Approved Mental Health Professionals to check the Urgent Response Dashboard when starting evening duty.
Verbatim wording from the response “• Additionally, the Social Care Direct Manager has instructed the Out of Hours Approved Mental Health Professionals (“AMHP”) to check the Urgent Response dashboard when they come on duty in the evening (although it is recognised that they will always have to prioritise Mental Health Act assessments over other work).” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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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 Give Social Care Direct access to extended-hours rotas, staff mobile numbers and a manager escalation contact for urgent referrals.
Verbatim wording from the response “On the 3rd June 2020, senior managers worked immediately to improve the system.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.
Verbatim wording from the response “I trust that the above information addresses the matters of concern you raise, and provides sufficient reassurance that Adult Social Care in Wakefield have already appropriately reviewed our systems following the death of Mrs Winterbottom, and taken action to ensure the robustness of our systems. As a consequence, Adult Social Care do not feel that there are any additional actions which need to be taken resulting from your issuance of the Regulation 28 Report.” Source location 2020-0183-Response-from-Wakefield-Council_Redacted.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations