31 Mar 2026 Mr John Hay · Prevention of Future Deaths report Northamptonshire
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Concerns raised 5 Unclear process for escalating cases to obtain medical input View source Failure of the care team to assess situations and make care decisions View source Unclear process for notifying the responsible person about missing or spent medication View source Failure to complete and clinically review care-plan risk assessments View source Insufficient coverage of blood-thinner-related scenarios in care-plan risk assessments View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Make contact management a key focus of future monitoring visits at the Care Bureau and wider provider services.
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AI-generated summary
Mr John Hay · 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 John Hay, who lived alone and received domiciliary care, suffered an unwitnessed fall at home on 26 September 2024 and later died from a subdural haemorrhage on 2 October 2024. The report raised concerns about incomplete risk assessment, unclear escalation for medical input after a fall, and unclear processes for addressing missing or spent medication.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Unclear process for escalating cases to obtain medical input
Wider context from the report “2. The process/system for escalation to get medical input was unclear. In the current case, it was accepted with the benefit of hindsight that when a frail elderly person on blood thinners suffers a fall, a medical assessment should probably be done. However, after the morning visit, it was Mr Hay himself who made the decision (despite having suffered a fall and having a diagnosis of dementia) without input from his family. At the time of the evening visit, the care team contacted the son for a decision rather than simply assessing the situation and making a decision.
” 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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the care team to assess situations and make care decisions
Wider context from the report “2. The process/system for escalation to get medical input was unclear. In the current case, it was accepted with the benefit of hindsight that when a frail elderly person on blood thinners suffers a fall, a medical assessment should probably be done. However, after the morning visit, it was Mr Hay himself who made the decision (despite having suffered a fall and having a diagnosis of dementia) without input from his family. At the time of the evening visit, the care team contacted the son for a decision rather than simply assessing the situation and making a decision.
” 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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Unclear process for notifying the responsible person about missing or spent medication
Wider context from the report “3. The process/system by which missing or spent medication is actioned was unclear. In the current case, Mr Hay’s son was responsible for ordering medication. However, the system by which the care team would notify him was unclear.
” 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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and clinically review care-plan risk assessments
Wider context from the report “1. The Risk Assessment in the Care Plan is neither completed nor reviewed with nursing or medical input , but includes, amongst other things, actions to be taken when a person is on blood thinners. In the present case, the only scenario covered was in relation to a person who has “heavy bleeding”. The obligation to complete the risk assessment and determine actions falls upon the care team, none of whom have any medical training, aside from basic first aid.
” 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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient coverage of blood-thinner-related scenarios in care-plan risk assessments
Wider context from the report “1. The Risk Assessment in the Care Plan is neither completed nor reviewed with nursing or medical input, but includes, amongst other things, actions to be taken when a person is on blood thinners. In the present case, the only scenario covered was in relation to a person who has “heavy bleeding” . The obligation to complete the risk assessment and determine actions falls upon the care team, none of whom have any medical training, aside from basic first aid.
” 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 Make contact management a key focus of future monitoring visits at the Care Bureau and wider provider services.
Verbatim wording from the response “Furthermore, West Northamptonshire Council has engaged with the Adult Quality Team, who have been made aware of your concerns. They have confirmed that contact management will be a key focus during future monitoring visits at the Care Bureau, as well as across wider provider services.” Source location Response from West Northamptonshire 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 Implemented measures are considered sufficient to address the concerns and reduce the likelihood of similar issues arising.
Verbatim wording from the response “Taking all of the above into account, West Northamptonshire Council is satisfied that appropriate measures have been implemented to address the concerns and reduce the likelihood of similar issues arising in the future.” Source location Response from West Northamptonshire Council
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Concerns raised 4 Failure to identify vulnerable individuals living on campsites View source Lack of knowledge about outreach service provision to homeless people View source Lack of knowledge about statutory duties to house vulnerable individuals living on campsites View source Lack of knowledge about available housing options for vulnerable people living on campsites View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Make repeated contact with campsite occupants and offer housing, support or voluntary reconnection assistance.
View source
Action
Ensure Street Outreach Workers respond to rough-sleeping reports, conduct at least two weekly outreach sessions, and visit identified campsites.
View source
Action
Use the Multi Agency Assessment Panel to agree housing and support plans for rough sleepers, including those unable or unwilling to access the Nightshelter.
View source
Action
Operate an all-year-round Nightshelter accommodating up to 20 homeless men with immediate safe, warm and dry accommodation.
View source
Action
Provide crisis support and advice to newly rough-sleeping people and help them access housing and support.
View source
Action
Operate a weekday Housing Advice Drop-In at Oasis House to help homeless people access housing and support.
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AI-generated summary
Vadims ALEKSEJEVS · 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
Vadims ALEKSEJEVS, who had been living in a tent after becoming homeless, was found unresponsive outdoors on 9 November 2016 and pronounced deceased that morning. The circumstances involved synthetic cannabinoid use, alcohol intoxication and hypothermia. Concerns included whether homeless people had access to outreach from adult social care or addiction services, the presence of other vulnerable people at the campsite, and the availability of housing options or statutory housing duties.
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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify vulnerable individuals living on campsites
Wider context from the report “4) It is not known if the campsite houses other vulnerable individuals, such as children or the elderly .
” 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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge about outreach service provision to homeless people
Wider context from the report “3) It is not known if adult social care or addiction services provide any form of outreach service to the homeless .
” 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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge about statutory duties to house vulnerable individuals living on campsites
Wider context from the report “5) It is unclear if there are any other housing options available or indeed if there is any statutory duty to house vulnerable individuals living on such campsites .
” 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 West Northamptonshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge about available housing options for vulnerable people living on campsites
Wider context from the report “5) It is unclear if there are any other housing options available or indeed if there is any statutory duty to house vulnerable individuals living on such campsites.
” 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 Make repeated contact with campsite occupants and offer housing, support or voluntary reconnection assistance.
Verbatim wording from the response “As soon as the Council’s Street Outreach Workers become aware of a ‘campsite’, they will make contact with the occupants and offer them advice and assistance. Repeated attempts will be made to engage with the occupants with a view to them being offered housing and support or, alternatively, a voluntary reconnection to their country of origin.” Source location Vadims-ALEKSEJEVS-response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure Street Outreach Workers respond to rough-sleeping reports, conduct at least two weekly outreach sessions, and visit identified campsites.
Verbatim wording from the response “As soon as the Council’s Street Outreach Workers become aware of a ‘campsite’, they will make contact with the occupants and offer them advice and assistance. Repeated attempts will be made to engage with the occupants with a view to them being offered housing and support or, alternatively, a voluntary reconnection to their country of origin.” Source location Vadims-ALEKSEJEVS-response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Multi Agency Assessment Panel to agree housing and support plans for rough sleepers, including those unable or unwilling to access the Nightshelter.
Verbatim wording from the response “For those who want to leave the streets and access housing and support, there are clear pathways to help achieve this quickly and effectively. Even those who are unable or unwilling to access the Nightshelter are able to work with the Street Outreach Workers to come off the streets by accessing housing and support through Northampton’s Multi Agency Assessment Panel. The Assessment Panel is attended by a wide range of housing and support providers, and members of the Panel work together to agree housing and support plans for each individual presented to the Panel by the Street Outreach Workers.” Source location Vadims-ALEKSEJEVS-response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate an all-year-round Nightshelter accommodating up to 20 homeless men with immediate safe, warm and dry accommodation.
Verbatim wording from the response “In February 2017, the Council opened an all-year-round Nightshelter in the former British Rail Sports & Social Club in St Andrew’s Road, Northampton. With the capacity to accommodate up to 20 homeless men, Northampton’s Nightshelter is the first of ten objectives in ‘TOGETHER we change lives’.” Source location Vadims-ALEKSEJEVS-response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide crisis support and advice to newly rough-sleeping people and help them access housing and support.
Verbatim wording from the response “The Street Outreach Workers provide crisis support and advice to those they find sleeping rough who are new to the streets, and are able to help them to access housing and support quickly and effectively, preventing any further deterioration whilst on the streets.” Source location Vadims-ALEKSEJEVS-response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a weekday Housing Advice Drop-In at Oasis House to help homeless people access housing and support.
Verbatim wording from the response “They also offer a Housing Advice Drop-In at Oasis House, Monday to Friday from 9.00am until 1.00pm, and this complements the opening hours of the Hope Centre (a day centre for vulnerable people, including homeless people and rough sleepers) which is also based at Oasis House. The Hope Centre encourages homeless people to work with the Street Outreach Workers and access the Housing Advice Drop-In and Nightshelter.” Source location Vadims-ALEKSEJEVS-response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Northamptonshire County Council’s Adult Social Care team commissions homeless outreach from Bridge and S2S.
Verbatim wording from the response “(3) It is not known if adult social care or addiction services provide any form of outreach service to the homeless.” Source location Vadims-ALEKSEJEVS-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 has no statutory duty to house everyone who is homeless and provides accommodation only where homelessness legislation requires it.
Verbatim wording from the response “The Council does not have a statutory duty to house everyone who is homeless.” Source location Vadims-ALEKSEJEVS-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 Collected intelligence indicates that the campsites contain no women, children, elderly men or disabled men.
Verbatim wording from the response “Based on the intelligence we have gathered, we are satisfied that that there are no women or children – and no men who are elderly or disabled – living on the ‘campsites’.” Source location Vadims-ALEKSEJEVS-response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing procedures, severe-weather provision, outreach and housing pathways are considered sufficient to address future winter rough-sleeping risks.
Verbatim wording from the response “Although the circumstances of this case may present themselves again in future winters, the Council has clear procedures in place to help those who want to access housing and support, and to help everyone during periods of severe weather.” Source location Vadims-ALEKSEJEVS-response
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Request correction
Addressed to Northampton Borough Council, now represented here by West Northamptonshire Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations