7 Jan 2026 Joshua Lee Allcock · Prevention of Future Deaths report Black Country
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Concerns raised 4 Use of insensitive Capillary Refill Time testing for dehydration assessment View source Lack of clear national guidance on autism assessment View source Failure to provide onward referral to dieticians experienced in autism and ARFID View source Risk of dehydration among autistic children in similar circumstances View source See 1 more concern
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Joshua Lee Allcock · 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
Joshua Lee Allcock, a five-year-old boy with complex medical needs and a limited diet, developed severe dehydration after entering foster care and died on 3 January 2023 despite hospital treatment. Concerns included the lack of a formal autism diagnosis and related dietary support, variation in autism assessment practice, and the potential for the capillary refill time test to provide misleading reassurance when assessing dehydration in children with similar circumstances.
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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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Use of insensitive Capillary Refill Time testing for dehydration assessment
Wider context from the report “5. The expert evidence also indicated that the Capillary Refill Time (CRT) test used to assess dehydration by checking peripheral blood flow is a very insensitive test and can provide misleading reassurance . Therefore, my concern is that young children with similar circumstances to Joshua maybe at risk when assessing levels of dehydration . NHS England may wish to consider reviewing their guidance for health professionals.
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear national guidance on autism assessment
Wider context from the report “2. My concern is that Joshua was never formally diagnosed with Autism and there appears to be nationally, a variation in practice before an assessment for autism can be made . Some areas specify 3 years of age or above but there is no clear national 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide onward referral to dieticians experienced in autism and ARFID
Wider context from the report “3. Regrettably, without a formal diagnosis of autism being made, there was no onward referral to dieticians with experience of autism and therefore an understanding of the link between autism and Avoidant restrictive food intake disorder (ARFID) .
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Risk of dehydration among autistic children in similar circumstances
Wider context from the report “4. In addition, I heard expert evidence that Joshua’s death wasn’t an isolated incident and another autistic child died in very similar circumstances by developing dehydration .
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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 written information and escalation guidance in placement planning for children with complex health or dietary needs.
Verbatim wording from the response “12. Children’s services have reinforced expectations that placement planning for children with known or suspected complex health or dietary needs must include clear, written information for carers with explicit guidance on escalation should concerns arise. This oversight is applied to all children who enter care from senior managers through the local authority Legal Gateway Panel where these decisions are made, and locality area managers then oversee the implementation of these recommendations.” Source location 2026-0012 - Response from Walsall Metropolitan Borough Council
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How this respondent action was interpreted
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PFD Monitor interpretation Incorporate ARFID into mandatory training and workshops for social workers and foster carers.
Verbatim wording from the response “19. The significance of ARFID was brought out in the inquest for Joshua, this condition and its impact is being incorporated into mandatory training for social workers and foster carers on working with disabled children and those with complex needs. Mandatory service workshops will also be used to share learning about ARFID and autism, so all social workers and carers understand this condition. These workshops will cover all practitioners working in Children’s Social Care and will be completed by May 2026.” Source location 2026-0012 - Response from Walsall Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and roll out foster-carer training on autism, special educational needs and ARFID.
Verbatim wording from the response “20. The training provided to foster carers has also been reviewed, with a specific focus on supporting children with autism and special educational needs. This training is being updated to include ARFID and will be rolled out as a part of the mandatory training for all foster carers, to cover all local authority carers across 2026.” Source location 2026-0012 - Response from Walsall Metropolitan Borough Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning about autism, ARFID and dehydration risks with safeguarding partners.
Verbatim wording from the response “17. The local authority supports early diagnosis of autism where this is appropriate and is committed to multi-agency working to identify and assess health needs early for children, especially those with complex needs. An understanding of Joshua’s autism and the likelihood that he experienced ARFID, would have brought to the fore a different understanding of how to support his dietary needs. In particular, this would have meant understanding his highly restrictive diet and working with this condition, and professionals would have been attentive to the importance of consistency when he came into care at a point when everything in his life changed. The local authority will continue to work with safeguarding partners to ensure that learning regarding autism, ARFID and the risk of dehydration is shared across agencies.” Source location 2026-0012 - Response from Walsall Metropolitan Borough Council
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25 Apr 2024 Mr David WELLINGTON · Prevention of Future Deaths report Black Country
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Concerns raised 5 Failure to ensure emergency-service access to the service road View source Lack of signs warning road users of pedestrians View source Lack of a designated and separated pedestrian route to the flats View source Lack of a speed limit for vehicles using the service road View source Failure to keep the service road clear of obstructions View source See 2 more concerns
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AI-generated summary
Mr David WELLINGTON · 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
Mr David Wellington died at the scene after being struck by a reversing Renault box van while he was a pedestrian on a service road in Walsall on 12 December 2023. The concerns included the absence of a designated pedestrian route, road markings, pedestrian separation, warning signs and a speed limit, as well as obstructions affecting pedestrian visibility and emergency-service access.
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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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure emergency-service access to the service road
Wider context from the report “5. The manual operation of the barrier coupled with the obstructions in the service road itself present a risk to the ability of emergency services (Fire & Ambulance) to access the service road and operate effectively within the service road area if needed. The police investigation noted that the skip and bins had to be moved out of the way on the day of the incident involving Mr Wellington to make room for the emergency services. In my view this presents a risk of future deaths.
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signs warning road users of pedestrians
Wider context from the report “6. There appear to be no signs alerting anyone using the access road to the potential presence of pedestrians within the service road area and no speed limit for vehicles using the service road. In my view this presents a risk of future deaths.
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a designated and separated pedestrian route to the flats
Wider context from the report “1. I heard evidence at inquest that the service road provides access to the shops that face onto Leamore Lane for delivery purposes. The service road opening is off Bloxwich Road and has a barrier which is operated manually, being opened for deliveries normally by the shop keepers. I heard evidence that the service road is a single carriageway which is used by both vehicles AND pedestrians. As you enter the road, the road is lined with metal fencing on the left side of the road which has openings onto two pathways for access to the flats on Comwall Close (incorrectly referred to as Camwell Close in the Police report).
2. There is no designated pathway for pedestrians when using the service road for the purpose of accessing the nearby flats. Designated pedestrian access from Leamore Lane and Bloxwich Road via a pathway still requires a pedestrian to cross the service road itself. Pedestrian access is not sited on the same side as the flats. In my view this presents a risk of future deaths.
3. There are no road markings designating a pedestrian route nor any clear and designated pathway separating a pedestrian route to the flats from the service road itself. In my view this presents a risk of future deaths.
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a speed limit for vehicles using the service road
Wider context from the report “6. There appear to be no signs alerting anyone using the access road to the potential presence of pedestrians within the service road area and no speed limit for vehicles using the service road . In my view this presents a risk of future deaths.
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to keep the service road clear of obstructions
Wider context from the report “4. On the day of the collision, there were two large council bins intruding into the carriageway positioned just before the opening of the pathway. There were also two vehicles parked stationary at the side of the service road and a blue skip in the roadway. It was obvious from the evidence that the service road was being used for purposes other than which it was designed and that there were a number of obstructions present in the service road presenting a risk to pedestrians using the service road to access the flats and therefore reducing their visibility to vehicles using the service road. In my view this presents a risk of future deaths.
” 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 Alter trade-waste collections so crews access the rear of shops, collect bins there, and leave the service road clear.
Verbatim wording from the response “Waste bins
In the absence of anywhere, other than the service road, more suitable to leave the trade waste bins for collection, the council is in the process of altering the procedure for collecting trade waste from the rear of the shops. The proposal is in the future the crew of the waste collection lorry will be provided with a key to the barrier across the service road. The waste collection lorry will reverse along the service road to the rear of the shops. Any trade waste bins will be collected from the rear of the shops. The waste collection lorry will then drive forwards along the service road towards Bloxwich Road, locking the barrier behind it. There will thus be no need for trade waste bins to be left on the carriageway of the service road.” Source location 2024-0233 Response from Walsall MBC
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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 assess an alternative pedestrian-safety scheme involving a diverted entrance, crossing, and footway, including highway-engineer review and landowner negotiations.
Verbatim wording from the response “A senior council officer, in consultation with other officers, is considering a scheme for stopping up a pedestrian entrance from the service road to the ████████ estate, the provision of a crossing diagonally across the service road behind the barrier, and a footway along the Watmos land beside the service road leading to Bloxwich Road. We enclose a rough sketch of this scheme. This would require consideration by the highway engineers, and negotiation with ████████, which owns the land along which the proposed footway would run. The scheme also assumes that any long lessee of a flat in the ████████ estate would be agreeable to a change in the pedestrian rights of access to that flat from the service road.” Source location 2024-0233 Response from Walsall MBC
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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 Notify shop and maisonette lessees that skips are prohibited on the service road and require written council consent for any placement.
Verbatim wording from the response “Skips
As can be seen from the opening paragraphs of this response the council owns the service road but the occupiers of adjoining premises have private rights of way along it. Those rights of way allow for people to pass and re-pass along the service road. They do not give anyone the right to place a skip on the service road. A wrongly placed skip could obstruct the rights of way of others along the service road. The council does, however, recognise that there are occasions when skips do need to be placed near buildings. The council has thus written to all of the lessees of the shops and the maisonettes facing Leamore Lane to remind them that they are not permitted to place skips on the service road.” Source location 2024-0233 Response from Walsall MBC
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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 Complete consideration of removing the barrier and determine that removal would exacerbate access obstruction.
Verbatim wording from the response “Whilst the council recognises that the presence of the barrier poses an obstruction to the private rights of way along the service road, that obstruction was requested by those entitled to have vehicular access to their premises along the service road. The reality is that the barrier poses less of an obstruction to vehicular access than that caused by the unauthorised parking of vehicles behind the shops. The council has carried out the exercise of considering whether the concerns set out in the Prevention of Future Deaths Report could be met by the removal of the barrier. The historical experience of the service road being blocked by unauthorised vehicles has led the council to conclude that the problem of obstruction of access would be exacerbated, rather than lessened, by the removal of the barrier.” Source location 2024-0233 Response from Walsall MBC
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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 Consider safely installing a designated pedestrian pathway while assessing required carriageway and footway widths and access implications.
Verbatim wording from the response “The council has considered the possibility that a designated pathway could be installed with the consent of all those with rights of access along the service road. It has thus considered how such a pathway could be safely installed.” Source location 2024-0233 Response from Walsall MBC
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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 There is no evidence that excessive speed caused the accident or that maximum-speed signs would reduce the risk of future deaths.
Verbatim wording from the response “The council notes that the most unfortunate accident which led to the death of Mr Wellington was caused by a van reversing along the service road behind the shops. The council does not have any evidence of the speed at which the van was being reversed, so it has assumed that it was being driven at a very low speed. It has also assumed that it was being driven at a speed below any speed limit which could reasonably have been imposed if the council had the power to impose a speed limit. In the absence of any evidence of vehicles being driven along the service road at excessive speed, or of speed having played any part in the accident which led to the most unfortunate death of Mr Wellington, the council does not have any material which would indicate that signs indicating a maximum speed would reduce the risk of future deaths.” Source location 2024-0233 Response from Walsall MBC
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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 proposed alternative pedestrian scheme cannot be implemented without agreement from the neighbouring landowner and affected leaseholders.
Verbatim wording from the response “An alternative proposal
The council takes very seriously the fact that an accident occurred on its land. That was made more serious by the fact that this was a fatal accident. It regards the Prevention of Future Deaths Report as a request to take whatever action might be possible to deal with the concerns raised in that report. The council has thus considered what scheme might be implemented which takes account of all of the concerns set out in the report. Those considerations have included the taking of steps which are beyond the present powers of the council and would require the express consent of other parties.” Source location 2024-0233 Response from Walsall MBC
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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 council cannot unilaterally designate part of the service road as a pedestrian pathway because all access-rights holders must consent.
Verbatim wording from the response “Designated pathway
As has been set out above all those persons who have rights of way along the service road are entitled to exercise those rights across the full width of the service road. It would be the duty of anyone using the service road to do so in a way which did not interfere with the use of it by anyone else. The council is thus not entitled unilaterally to designate parts of the service road as a pathway, leaving the rest of the service road for vehicular use.” Source location 2024-0233 Response from Walsall MBC
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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 council cannot legally impose an enforceable speed limit because the service road is not a highway.
Verbatim wording from the response “Speed limit
As the service road is not a highway the council cannot impose a legally enforceable speed limit along the service road.” Source location 2024-0233 Response from Walsall MBC
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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 service road is too narrow to provide both a sufficiently wide carriageway and a safe 1.5-metre footway.
Verbatim wording from the response “The service road at the point where the barrier is installed is 4.85m wide. A modest reduction in the width of the service road at this point would not be sufficient to accommodate a footway approaching 1.5m in width. Whilst it would be possible to lay out a separate footway along one side of the service road, neither the footway nor the remaining carriageway would be sufficiently wide to allow proper use of either.” Source location 2024-0233 Response from Walsall MBC
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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 Retaining the barrier is considered preferable because removing it would worsen obstruction caused by unauthorised vehicle parking.
Verbatim wording from the response “Whilst the council recognises that the presence of the barrier poses an obstruction to the private rights of way along the service road, that obstruction was requested by those entitled to have vehicular access to their premises along the service road. The reality is that the barrier poses less of an obstruction to vehicular access than that caused by the unauthorised parking of vehicles behind the shops. The council has carried out the exercise of considering whether the concerns set out in the Prevention of Future Deaths Report could be met by the removal of the barrier. The historical experience of the service road being blocked by unauthorised vehicles has led the council to conclude that the problem of obstruction of access would be exacerbated, rather than lessened, by the removal of the barrier.” Source location 2024-0233 Response from Walsall MBC
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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 Marking a designated footway may not improve pedestrian safety and could increase risk by creating false reassurance while reversing vehicles remain hazardous.
Verbatim wording from the response “Road markings providing a designated footway
There was a time when shared spaces were popular. These were spaces which were shared by both vehicles and pedestrians. The DfT stopped promoting shared spaces in 2018. This may have been because of the risks to partially sighted road users. Any attempts to mark out parts of the service road for use by vehicles and parts for use by pedestrians would be met with the practical problem that the service road is not wide enough to accommodate both a carriageway for vehicles and a footway for pedestrians. It is thus questionable whether marking out a designated footway on the service road would in fact increase the safety of a pedestrian. There is the risk that a marked out footway would give the impression to a pedestrian that he or she would be safe to use that footway. That might be leading the pedestrian into a false sense of security.” Source location 2024-0233 Response from Walsall MBC
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10 Sep 2019 Gurdeep Singh Dundhal · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 5 Delays in organising timely mental health assessments View source Failure to obtain and have available key information and documentation for mental health assessments View source Failure to undertake internal investigations into assessment delays and resource concerns View source Failure to engage with other agencies to learn lessons from complex cases View source Failure to place patients on the recommended Mental Health Act section View source See 2 more concerns
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AI-generated summary
Gurdeep Singh Dundhal · 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
Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.
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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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in organising timely mental health assessments
Wider context from the report “1. There was a delay in organising the assessment of Mr Dundhal when he was detained on S5(2) of the Mental Health Act on 11/04/19. The evidence confirmed there appeared to be confusion as to who was undertaking the assessment between Walsall MBC and Birmingham City Council . In addition there was a lack of resources to enable the assessment to be carried out in a timely manner . This meant the assessment was carried out just a few hours before the time period for the S5(2) was to expire.
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and have available key information and documentation for mental health assessments
Wider context from the report “2. Evidence at the inquest from the approved Mental health practitioner confirmed that key information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19. I was unable to confirm which at the inquest. This meant the true nature of Mr Dundhal’s long term condition was not known and the assessors were unable to see the “bigger picture”. The delay in arranging the assessment contributed to the lack of available 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake internal investigations into assessment delays and resource concerns
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19 . They have also failed to engage with other agencies to ensure lessons are learnt. It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others.
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with other agencies to learn lessons from complex cases
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19. They have also failed to engage with other agencies to ensure lessons are learnt . It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others .
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to place patients on the recommended Mental Health Act section
Wider context from the report “3. When Mr Dundhal was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3 . No explanation was available for this . Evidence at the inquest suggested this was a decision made by the Approved Mental health practitioner from Birmingham City Council. Consideration needs to given as to why a S3 was not put in place in accordance with the recommendation .
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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 discussions with a neighbouring authority to improve access to relevant records.
Verbatim wording from the response “Instructions have therefore been given that not only should records be sought at the earliest opportunity, but whenever an assessment is postponed the period of postponement is used for the purpose of requesting records to be made available. Walsall Council proposes to keep this matter under review. Despite this, Walsall Council has opened discussions with a neighbouring authority to see whether records can be more readily available.” Source location 2019-0294-Response-by-Walsall-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop cross-agency practices for assessing patients from other authorities, including arrangements with neighbouring authorities.
Verbatim wording from the response “The review has also opened discussions with a partner authority to consider improvements that can be made.” Source location 2019-0294-Response-by-Walsall-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a procedure requiring Walsall hospitals to notify the Council promptly when any patient may require assessment.
Verbatim wording from the response “The staffing levels have been increased. There is therefore a provision for a duty AMHP to be able to call for additional staff if they should be needed. In addition to that an on call manager is now available to provide assistance. A procedure is being developed which will request all hospitals in Walsall to notify Walsall Council as soon as there may be a need for an assessment to be carried out on any patient in their hospital, whether or not that patient is ordinarily resident in Walsall.” Source location 2019-0294-Response-by-Walsall-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 a manager on duty or on call at all times to assist staff.
Verbatim wording from the response “The staffing levels have been increased. There is therefore a provision for a duty AMHP to be able to call for additional staff if they should be needed. In addition to that an on call manager is now available to provide assistance. A procedure is being developed which will request all hospitals in Walsall to notify Walsall Council as soon as there may be a need for an assessment to be carried out on any patient in their hospital, whether or not that patient is ordinarily resident in Walsall.” Source location 2019-0294-Response-by-Walsall-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a procedure for staff to request information promptly from other authorities and NHS services when Walsall assessment may be required.
Verbatim wording from the response “A procedure is also being developed to ensure that whenever another authority agrees to undertake an assessment of a patient in Walsall that the progress of the assessment is notified to Walsall Council and that Walsall Council’s staff will take action in any case in which it appears that there may be a delay in the carrying out of an assessment. In addition to that a procedure is being developed for Walsall Council’s staff to request information from other authorities and other parts of the NHS whenever it appears that a patient may need to be assessed by Walsall Council. This is to avoid delays which may be occasioned by the need to wait for information.” Source location 2019-0294-Response-by-Walsall-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 AMHP on-call assistance to support the duty AMHP whenever needed.
Verbatim wording from the response “There has been an increase in AMHPs employed by Walsall Council. There have been changes in working practices to avoid the previous practice of an AMHP being on duty for 12 hours followed by a period of being on call for a further period of 12 hours. In addition to that AMHPs will be available on call to assist the AMHP on duty whenever that may be needed. There will also be a manager on duty or on call, and thus available to provide assistance, at all times of the day and night. Walsall Council has opened discussions with its neighbouring authorities to formalise practices of asking neighbouring authorities to carry out reviews within the borough of Walsall. There will be a procedure for staff to ensure that the assessment has been carried out and completed in good time and for staff to be called on to assist if need be.” Source location 2019-0294-Response-by-Walsall-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 Increase AMHP staffing and provide additional staffing capacity when the duty AMHP requires assistance.
Verbatim wording from the response “The staffing levels have been increased. There is therefore a provision for a duty AMHP to be able to call for additional staff if they should be needed. In addition to that an on call manager is now available to provide assistance. A procedure is being developed which will request all hospitals in Walsall to notify Walsall Council as soon as there may be a need for an assessment to be carried out on any patient in their hospital, whether or not that patient is ordinarily resident in Walsall.” Source location 2019-0294-Response-by-Walsall-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 Require staff to seek records at the earliest opportunity and use any assessment postponement to obtain them.
Verbatim wording from the response “Walsall Council has no direct access to any records held by other parties. In view of the need for confidentiality and the data protection legislation it is unlikely that third parties would be in a position to allow Walsall Council direct access to their records. At present the only steps which can be taken by Walsall Council to ensure that records are available is to see that they are requested at the earliest opportunity. In this case it would have been better if the AMHP on duty on the evening of Saturday 13 April 2019 had, instead of merely requesting the following day’s duty AMHP to carry out the assessment, himself made the requests for the records to be provided.” Source location 2019-0294-Response-by-Walsall-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 Meet regularly with other agencies to identify service improvements.
Verbatim wording from the response “It is intended that Walsall Council should meet regularly with other agencies to identify areas where improvements can be made.” Source location 2019-0294-Response-by-Walsall-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a procedure to monitor assessments undertaken by other authorities and trigger Walsall action when delays appear likely.
Verbatim wording from the response “A procedure is also being developed to ensure that whenever another authority agrees to undertake an assessment of a patient in Walsall that the progress of the assessment is notified to Walsall Council and that Walsall Council’s staff will take action in any case in which it appears that there may be a delay in the carrying out of an assessment. In addition to that a procedure is being developed for Walsall Council’s staff to request information from other authorities and other parts of the NHS whenever it appears that a patient may need to be assessed by Walsall Council. This is to avoid delays which may be occasioned by the need to wait for information.” Source location 2019-0294-Response-by-Walsall-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 Develop a procedure ensuring assessments are completed promptly and staff assistance is provided when necessary.
Verbatim wording from the response “There has been an increase in AMHPs employed by Walsall Council. There have been changes in working practices to avoid the previous practice of an AMHP being on duty for 12 hours followed by a period of being on call for a further period of 12 hours. In addition to that AMHPs will be available on call to assist the AMHP on duty whenever that may be needed. There will also be a manager on duty or on call, and thus available to provide assistance, at all times of the day and night. Walsall Council has opened discussions with its neighbouring authorities to formalise practices of asking neighbouring authorities to carry out reviews within the borough of Walsall. There will be a procedure for staff to ensure that the assessment has been carried out and completed in good time and for staff to be called on to assist if need be.” Source location 2019-0294-Response-by-Walsall-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 Walsall Council cannot directly access records held by other parties because confidentiality and data protection requirements restrict access.
Verbatim wording from the response “Walsall Council has no direct access to any records held by other parties. In view of the need for confidentiality and the data protection legislation it is unlikely that third parties would be in a position to allow Walsall Council direct access to their records. At present the only steps which can be taken by Walsall Council to ensure that records are available is to see that they are requested at the earliest opportunity. In this case it would have been better if the AMHP on duty on the evening of Saturday 13 April 2019 had, instead of merely requesting the following day’s duty AMHP to carry out the assessment, himself made the requests for the records to be provided.” Source location 2019-0294-Response-by-Walsall-Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Walsall Council disputes that it should have known about the detention or assessment need before being contacted by another authority.
Verbatim wording from the response “Walsall Council points out that it did not know that Gurdeep Singh Dundhal was in Lakeside View Hospital and needed to be assessed, and could not reasonably have been expected to have known that, until after more than 24 hours had elapsed since his detention under s. 5 (2) of the Mental Health Act 1983 when it was contacted about him. That contact came from Birmingham City Council in a telephone call. During that telephone conversation Birmingham City Council agreed to carry out the assessment of Gurdeep Singh Dundhal. Walsall Council had no cause for concern about the assessment being carried out until Saturday 13 April 2019 at 17:35 when it was contacted by Lakeside View who said that the assessment had still not been carried out.” Source location 2019-0294-Response-by-Walsall-Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Birmingham City Council, as the patient’s home authority, was responsible for arranging the assessment and initially agreed to undertake it.
Verbatim wording from the response “Gurdeep Singh Dundhal was detained under s.5 (2) of the Mental Health Act 1983 at 11.50am on Thursday 11 April 2019. Walsall Council was not then told of his detention. Lakeside View Hospital, where Gurdeep Singh Dundhal was detained, had informed Birmingham City Council of his detention. This was not only an understandable move but a sensible one. Lakeside View Hospital had been treating Gurdeep Singh Dundhal since mid-March 2019. He had been referred there by the Mental Health Team from Birmingham City Council who had been providing his care in the community for approximately 3 years. As his home authority it was Birmingham City Council which was responsible, in March 2019, for arranging his detention under s.2 of the Mental Health Act 1983 for assessment.” Source location 2019-0294-Response-by-Walsall-Council
Open published response
1 Jul 2019 Mr Peter Lawrence (PL) · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Lack of a joint multidisciplinary and interagency care plan for responding to relapse indicators View source Excessive reliance on mental health tribunal decisions in care planning View source Inadequate follow-up engagement and monitoring after discharge View source Failure to provide assertive care coordination for patients at risk of disengagement and relapse View source Failure to coordinate multidisciplinary review and mental health act assessment when considering hospital admission View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr Peter Lawrence (PL) · 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
Mr Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.
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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a joint multidisciplinary and interagency care plan for responding to relapse indicators
Wider context from the report “2. There was a lack of a joint multi-disciplinary/agency care plan (between Local authority and Mental Health Trust) which could have resulted in delays in a timely response to known relapse indicators .
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on mental health tribunal decisions in care planning
Wider context from the report “5. When PL was successful at the mental health tribunal and was discharged from Section 3 following his last admission to hospital in October 2017 against the view of the multidisciplinary team. The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate follow-up engagement and monitoring after discharge
Wider context from the report “5. When PL was successful at the mental health tribunal and was discharged from Section 3 following his last admission to hospital in October 2017 against the view of the multidisciplinary team. The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assertive care coordination for patients at risk of disengagement and relapse
Wider context from the report “3. A more assertive approach with consistency of care coordinator for a patient with a history of disengagement and relapse could possibly have been implemented reducing the likelihood of disengagement with services and promoted necessary concordance with medication .
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate multidisciplinary review and mental health act assessment when considering hospital admission
Wider context from the report “4. A decision to admit to hospital under the mental health act following concerns being raised about self-care and disengagement could potentially have followed a coordinated MDT review and mental health act assessment and prevented deterioration in his mental health.
” Open source report
30 Nov 2017 Sarah Athermith · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Lack of effective protection or warning at the level crossing View source Pedestrian confusion about the presence of a further train on the opposite track View source Obscured visibility of opposing trains for train drivers 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
Sarah Athermith · 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 26 September 2017, Sarah Athermith was struck and fatally injured by a train while crossing the unprotected Wallows Lane railway crossing after stopping for another train. Concerns included the lack of a warning system for approaching trains, the risk of pedestrians becoming confused when trains pass in opposite directions, and the obstruction of drivers’ views by double-height freight carriages.
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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of effective protection or warning at the level crossing
Wider context from the report “1. Evidence emerged during the inquest that the Wallows Lane level crossing is an unprotected crossing and there is no method of warning of an approaching train .
2. There are whistle boards (train drivers should sound their whistles/horns on approach) in place to warn users. However, the crossing relies on users actively stopping, looking and listening for approaching trains before deciding if it is safe to cross .
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Pedestrian confusion about the presence of a further train on the opposite track
Wider context from the report “3. There is a clear and present danger that pedestrians can become confused , as happened in this case when two trains pass each other at the same time and do not realise there is a further train on the opposite rail track .
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Obscured visibility of opposing trains for train drivers
Wider context from the report “4. It also emerged that the freight train carriages were double height and obscured the opposite train drivers view .
” 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 Urgently review revised Network Rail closure applications and supporting evidence, while continuing to provide guidance and support through the closure process.
Verbatim wording from the response “25. As in the past, WMBC are undertaking an urgent review of the NR’s revised closure application and will continue to provide assistance and guidance to NR in the closure application process.” Source location 2017-0350-Response-by-Walsall-Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation If technological safety improvements are required, Network Rail must consider converting the crossing into a controlled crossing as landowner and operator.
Verbatim wording from the response “30. If NR determines (whether as a result of the Coroner’s Regulation 28 Report or for any other reason) that a technological safety improvement is required, NR as the landowner and operator will have to consider converting the Wallows Lane Railway Crossing into a controlled crossing using suitable methods.” Source location 2017-0350-Response-by-Walsall-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 Council cannot convert the crossing into a controlled crossing because it is neither the landowner nor the operator and lacks legal authority.
Verbatim wording from the response “29. As WMBC is not the landowner or the operator on which the Wallows Lane Railway Crossing is located, it has no authority or legal power to convert the Wallows Lane Railway Crossing into a controlled crossing using suitable methods.” Source location 2017-0350-Response-by-Walsall-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 Network Rail must make the level-crossing closure application; the Council’s role is to advise and consider it as highway authority.
Verbatim wording from the response “5. The closure application needs to be made by Network Rail (“NR”) and will then be advised upon and considered WMBC as the Highway Authority.” Source location 2017-0350-Response-by-Walsall-Council
Open published response
16 Aug 2017 Spencer Lloyd Hurst · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Lack of fencing or other appropriate measures to mitigate lake swimming risks View source Lack of adequate warning notices about the risks of swimming in the lake View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Spencer Lloyd Hurst · 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 the evening of 20 June 2017, 15-year-old Spencer Lloyd Hurst went into a lake with friends, got into trouble while swimming, and went below the surface. His body was recovered by emergency services shortly afterwards and he was pronounced deceased. Concerns included the absence of adequate warnings, fencing, or other measures to mitigate the risks of swimming, despite a similar death at the same location in 2007.
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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of fencing or other appropriate measures to mitigate lake swimming risks
Wider context from the report “1. Evidence emerged during the investigation and pre-inquest hearing review that another young male had died in very similar circumstances at the same location on the 11 June 2007.
2. Despite this being the second death, evidence emerged that there have been no adequate notices displayed to warn of the risks of swimming in the lake and no evidence of any fencing or appropriate measures taken to mitigate the risks .
” 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 Walsall Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate warning notices about the risks of swimming in the lake
Wider context from the report “1. Evidence emerged during the investigation and pre-inquest hearing review that another young male had died in very similar circumstances at the same location on the 11 June 2007.
2. Despite this being the second death, evidence emerged that there have been no adequate notices displayed to warn of the risks of swimming in the lake and no evidence of any fencing or appropriate measures taken to mitigate the risks.
” 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