Recipient

Westmorland and Furness Council

First report 14 Nov 2023•Latest report 14 Nov 2023

Recipient record

Reports, concerns and published responses

Local government · English unitary authority. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 200%
Concerns addressed: 6
Stated actions: 17

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

200%published responses found

17stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Westmorland and Furness Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

14 Nov2023
Cumbria
Concerns raised5
1. Failure to generate required referrals before acknowledging notifications
2. Case allocation and deallocation without action or explanatory recording
3. Reablement Team closure of cases contrary to a social worker's care-assessment recommendation without further discussion or rationale
1. Failure of co-existing teams and systems to communicate and cross-reference effectively
2. Triage failing to give sufficient regard to safeguarding concerns personally witnessed by practitioners
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Conduct regular case-file audits of chronology and completed actions.
  Stated completed
2. Action
  Establish twice-daily multidisciplinary discussions to resolve concerns about incoming referrals and agree appropriate action promptly.
  Stated completed
3. Action
  Require recorded explanations for case deallocation and provide management oversight of all case closures.
  Stated completed
1. Action
  Require staff to acknowledge action-requiring case notes only after completing the requested task.
  Stated completed
2. Action
  Establish weekly meetings between reablement and adult social care teams to discuss cases, highlight concerns and agree actions.
  Stated completed
3. Action
  Conduct a quality assurance and process-mapping review of reablement referrals to identify required improvements, including triage and delay reduction.
  Stated in progress
4. Action
  Implement the Self-Neglect Strategy requiring face-to-face visits, capacity consideration, dynamic risk assessment, professional challenge and supervisory support.
  Stated completed
5. Action
  Introduce decision-making guidance for Single Point of Access and practitioner teams, including timely collaborative decisions, multidisciplinary input and streamlined referral allocation.
  Stated completed
Respondent positions 1
1. Position
  Adult Social Care says the referral was not rejected; it was triaged below the statutory safeguarding-enquiry threshold, with social work support considered appropriate.
  Disputes the concern
AI-generated summary

Gerald Goodwin · 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

Gerald Goodwin, who had Alzheimer’s dementia and had consumed a significant amount of alcohol, was struck by a train while walking along a railway track on 10 November 2022; his death was confirmed at 00:17 on 11 November 2022. The principal concerns were that safeguarding and care-assessment referrals were rejected, closed, or not actioned, with multiple teams and systems failing to communicate effectively and potentially exposing other vulnerable adults to risk.

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 Westmorland and Furness Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to generate required referrals before acknowledging notifications
Wider context from the report
“(3) Fortunately, the Closure Team noticed that the Reablement Team were seeking to close a case in which another social worker had recommended a Care Assessment. They sent the case to the 'Short Term Allocation Tray'. This should have resulted in a referral but that did not happen. I am concerned that in a future case a referral might not be generated and a person's needs overlooked. The witness statement prepared by the Service Manager indicated 'we are looking at a way of ensuring that notifications requiring an action are only acknowledged once the task is complete'. This indicates that such work has not yet borne fruit and the risk still exists. ”
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 Westmorland and Furness Council; that does not assign responsibility.
PFD Monitor interpretation
Case allocation and deallocation without action or explanatory recording
Wider context from the report
“(4) Thereafter Mr Goodwin's case was allocated and de-allocated to a social worker within the space of one day, without anything being done. It is said that there is no note or explanation for this. I am concerned that, once again, the ability of a case to be allocated and deallocated within a short period and without anything having been done may enable a case to 'fall through the cracks'. Indeed, the referral for the care assessment was not ultimately actioned until 25th November 2022, 2 weeks after Mr Goodwin died. ”
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 Westmorland and Furness Council; that does not assign responsibility.
PFD Monitor interpretation
Reablement Team closure of cases contrary to a social worker's care-assessment recommendation without further discussion or rationale
Wider context from the report
“(2) The witness statement on behalf of the Adult Social Care team explains that after the refusal to conduct a safeguarding enquiry, Mr Goodwin was nevertheless referred for the Social Work team to 'engage' with him. A social worker took steps to engage with Mr Goodwin and his family and concluded that a care assessment was appropriate. Despite this the 'Reablement Team' referred the case for closure indicating that they did not consider that such an assessment was required. I am concerned that this indicates further circumstances in which the needs of a vulnerable person might be overlooked. After a social worker considered that a care assessment was needed the Reablement Team appear to be able to come to an alternative view and close the case without further discussion or rationale. In another case this might lead to a vulnerable person being disregarded. ”
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 Westmorland and Furness Council; that does not assign responsibility.
PFD Monitor interpretation
Failure of co-existing teams and systems to communicate and cross-reference effectively
Wider context from the report
“(5) More generally, it is striking how many different teams and systems appear to co-exist and require mutual communication and cross referencing. I am concerned that the above narrative demonstrates that those systems do not function effectively. I am concerned that this exposes other vulnerable adults to risk. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Westmorland and Furness Council; that does not assign responsibility.
PFD Monitor interpretation
Triage failing to give sufficient regard to safeguarding concerns personally witnessed by practitioners
Wider context from the report
“(1) The Liaison and Diversion of Lancashire and South Cumbria NHS Foundation Trust had contact with Mr Goodwin in September and October 2022. Liaison and Diversion Team members visited Mr Goodwin at home and concluded that he was at risk of self-neglect. They noted his appearance, his living conditions and the fact that he was not taking prescribed medication. On any view Mr Goodwin was vulnerable: he suffered from Alzheimer's dementia, and was thought to misuse alcohol. The Liaison and Diversion Team considered that there were safeguarding concerns in respect of Mr Goodwin and referred him to the Adult Social Care team of Cumbria Council. I understand that the team in question now forms part of Westmorland and Furness Council. Despite this referral from practitioners who had personally visited Mr Goodwin, it was rejected at triage on 5th October 2022. I am concerned that this indicates that an approach to triage is being taken which pays insufficient regard to the concerns of practitioners who had personally witnessed apparent safeguarding concerns. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct regular case-file audits of chronology and completed actions.

Verbatim wording from the response
“Regular case file audits are already in place which do look at the case chronology to ensure that appropriate actions have been taken.”

Source location
Response from Adult Social Services
Page 4 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish twice-daily multidisciplinary discussions to resolve concerns about incoming referrals and agree appropriate action promptly.

Verbatim wording from the response
“• All duty officers for the day must prioritise participation in the twice daily SPA Multidisciplinary calls unless they are out on a duty visit.”

Source location
Response from Adult Social Services
Page 2 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require recorded explanations for case deallocation and provide management oversight of all case closures.

Verbatim wording from the response
“Following completion of the witness statement a process was put in place and a directive was shared with Adult Social Care staff on 10th October 2023. This instructs staff that if a case is picked up to be allocated and is subsequently de-allocated this must be recorded as a case note on the electronic case recording system with a clear explanation of why the case is being closed, thus ensuring a clear audit trail is in place. We have also implemented a system where there is management oversight of all case closures to provide increased governance in this area.”

Source location
Response from Adult Social Services
Page 4 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require staff to acknowledge action-requiring case notes only after completing the requested task.

Verbatim wording from the response
“Following completion of the witness statement a process was put in place in place and a directive was shared with Adult Social Care staff on 10th October 2023. This instructs staff that when they receive a case note asking for an action to be completed, the case note is only acknowledged once the task has been carried out. This will ensure that when there are competing demands for practitioners the case note notification will serve as a prompt and a task is not overlooked.”

Source location
Response from Adult Social Services
Page 4 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish weekly meetings between reablement and adult social care teams to discuss cases, highlight concerns and agree actions.

Verbatim wording from the response
“In some situations the threshold for a statutory safeguarding enquiry is not met and this can also apply in circumstances where self-neglect is a factor. In this case the practitioner recognised that although a formal safeguarding enquiry was not necessary, there needed to be further involvement via Adult Social Care in order to engage with Mr. Goodwin regarding the concerns that had been raised. As stated earlier reablement was identified as appropriate but it was an error not to refer the case back to the social work team when Mr Goodwin declined reablement input. It is recognised that the reablement team and the social work team should have worked together more closely in relation to Mr. Goodwin in order to promote engagement. We now have weekly meetings between reablement and adult social care which provides an opportunity for similar situations to be discussed.”

Source location
Response from Adult Social Services
Page 3 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a quality assurance and process-mapping review of reablement referrals to identify required improvements, including triage and delay reduction.

Verbatim wording from the response
“Adult Social Care and Cumbria Care Services (who operate the reablement service) have set up a task and finish group to undertake a quality assurance review and to identify required process changes.”

Source location
Response from Adult Social Services
Page 3 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the Self-Neglect Strategy requiring face-to-face visits, capacity consideration, dynamic risk assessment, professional challenge and supervisory support.

Verbatim wording from the response
“A Self-Neglect Strategy was put in place under the direction of the Westmorland and Furness Council Principal Social Worker and this was implemented on 1st July 2023. This strategy aims to strengthen Adult Social Care’s practice and response to people who are or may be self-neglecting.”

Source location
Response from Adult Social Services
Page 1 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce decision-making guidance for Single Point of Access and practitioner teams, including timely collaborative decisions, multidisciplinary input and streamlined referral allocation.

Verbatim wording from the response
“In respect of making improvements to the triaging process new guidance on ‘Decision Making for Single Point of Access and Practitioner Teams’ has also been introduced under the direction of the Principal Social Worker. This guidance was introduced in September 2023.”

Source location
Response from Adult Social Services
Page 2 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Adult Social Care says the referral was not rejected; it was triaged below the statutory safeguarding-enquiry threshold, with social work support considered appropriate.

Verbatim wording from the response
“The referral in question was received by Adult Social Care on 5th October 2022. The referral identified potential safeguarding concerns and was therefore considered initially by the Safeguarding Team which sits within Adult Social Care. It was decided at that stage that the threshold for a statutory safeguarding enquiry was not met and the provision of social work support was considered to be more appropriate. The fact that the initial triage concluded that the threshold for a statutory safeguarding enquiry was not met does not mean that any safeguarding issues would not be addressed. The approach would generally be that the individual should be given the opportunity to engage with a Care Act assessment and potentially treatment but that any safeguarding issues would also be addressed if they emerged during the process.”

Source location
Response from Adult Social Services
Page 1 · response
Published 22 November 2023
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to generate required referrals before acknowledging notifications

Case allocation and deallocation without action or explanatory recording

Reablement Team closure of cases contrary to a social worker's care-assessment recommendation without further discussion or rationale

Failure of co-existing teams and systems to communicate and cross-reference effectively

Triage failing to give sufficient regard to safeguarding concerns personally witnessed by practitioners

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.8

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 8

Respondent positions 1