PFD report

CHRISTOPHER WATSON · Prevention of Future Deaths report

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Issued 1 Apr 2015•Norfolk

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to make direct contact with vulnerable people to ensure they understand available help
    Part of recurring concern: Failure to use direct contact to assess vulnerable people’s safety risks and understanding
  2. Failure to assess capacity where required
    Part of recurring concern: Failure to recognise impaired decision-making capacity in care decisionsPart of recurring concern: Unreliable assessment and recording of patients’ mental capacity
  3. Failure to verify receipt, accessibility and understanding of letters before closing the file
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Implement contact-monitoring and risk-escalation requirements, including recording contact attempts, assessing risk, arranging visits, and escalating delayed contact to senior staff.

    Stated by Norfolk County CouncilStated completedThe respondent said that this action was complete when they made their response on 1 April 2015.
  2. Action

    Stop sending letters that close concerns without confirmed contact and require face-to-face contact when telephone contact fails.

    Stated by Norfolk County CouncilStated completedThe respondent said that this action was complete when they made their response on 1 April 2015.
  3. Action

    Formalise the contact-monitoring and risk-escalation requirements as a new Operational Instruction.

    Stated by Norfolk County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 1 April 2015.

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

  1. Position

    No concern is identified regarding Adult Social Services’ actions before the letter was sent.

    Stated by Norfolk County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to make direct contact with vulnerable people to ensure they understand available help

Wider context from the report

“(2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. “painfully thin, unwashed and dishevelled”. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed. ”

Is this part of a recurring concern?

Yes — Failure to use direct contact to assess vulnerable people’s safety risks and understanding.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to assess capacity where required

Wider context from the report

“(2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. “painfully thin, unwashed and dishevelled”. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed. ”

Is this part of a recurring concern?

Yes — Failure to recognise impaired decision-making capacity in care decisions; Unreliable assessment and recording of patients’ mental capacity.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to verify receipt, accessibility and understanding of letters before closing the file

Wider context from the report

“(1) There is no concern over the actions of ASC prior to the letter being sent to Mr Watson. The concern is over the contents of the letter to the effect that if the person does not require action then they are to ignore the letter and the file is then closed. No steps are taken to ensure that the person actually receives, opens and understands the letter or whether they can read for instance. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Implement contact-monitoring and risk-escalation requirements, including recording contact attempts, assessing risk, arranging visits, and escalating delayed contact to senior staff.

Verbatim wording from the response

“I can confirm that staff have been reminded to record all the steps they have taken to make contact with the person about whom concerns have been raised. At each attempt, the level of risk must be assessed and recorded. If the risk to the person is thought to be significant, staff have been instructed that an immediate home visit will be arranged. Even where the risk to the person is thought to be low, if the time taken to make contact extends to two days, the case must be escalated to a senior member of staff; either a Practice Consultant or Team Manager. The manager will”

Source location

2015-0133-Response-by-Norfolk-County-Council
Page 1 · response
Published 1 April 2015

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

Stop sending letters that close concerns without confirmed contact and require face-to-face contact when telephone contact fails.

Verbatim wording from the response

“I can confirm that action has been taken to ensure that practice across all Adult Social Services teams has been changed. An instruction has been issued to staff to ensure that the practice of sending a letter to individuals about whom concerns have been raised is ceased with immediate effect. In cases where the Department is unable to contact an individual by telephone, staff have been instructed to ensure that face-to-face contact is made with the person.”

Source location

2015-0133-Response-by-Norfolk-County-Council
Page 1 · response
Published 1 April 2015

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

Formalise the contact-monitoring and risk-escalation requirements as a new Operational Instruction.

Verbatim wording from the response

“be required to make a timely and appropriate decision regarding the next course of action. For example, this may mean a welfare check or emergency visit. This advice has been re-issued to staff in the form of a best practice factsheet. It is also being formalised as a new Operational Instruction which will be completed shortly.”

Source location

2015-0133-Response-by-Norfolk-County-Council
Page 2 · response
Published 1 April 2015

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

No concern is identified regarding Adult Social Services’ actions before the letter was sent.

Verbatim wording from the response

“(1) There is no concern over the actions of ASC prior to the letter being sent to Mr Watson. The concern is over the contents of the letter to the effect that if the person does not require action then they are to ignore the letter and the file is then closed. No steps are taken to ensure that the person actually receives, opens and understands the letter or whatever they can read for instance.”

Source location

2015-0133-Response-by-Norfolk-County-Council
Page 1 · response
Published 1 April 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026