PFD report

Geoffrey Stuart CHENEY · Prevention of Future Deaths report

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Issued 18 Oct 2024•West Yorkshire (Western)

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
6

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 raised1

  1. Failure to assess whether an item could be removed
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.2

  1. Action

    Review service-level agreements with housing providers and local authorities to establish clear processes for adaptation-related requests.

    Stated by G P Homecare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2024.
  2. Action

    Update the Housing Assistance Policy and operational process to assess adaptations for risks or safeguarding concerns and remove them where necessary.

    Stated by Kirklees Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Requests to alter or remove property adaptations must be authorised and acted on by Kirklees Council and its housing arrangements.

    Stated by G P Homecare LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 whether an item could be removed

Wider context from the report

“From the evidence it was clear that there was an assumption that ████████ could not be removed and as a result no attempt was made to see if it was actually possible to have ████████ removed ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Review service-level agreements with housing providers and local authorities to establish clear processes for adaptation-related requests.

Verbatim wording from the response

“We have also reviewed how we can ensure that any concerns about residents in extra care schemes can be followed up and escalated. I have attached a copy of our action plan which sets out details of the action being taken, which includes.”

Source location

Response from Radis Community Care
Page 3 · response
Published 18 October 2024

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

Update the Housing Assistance Policy and operational process to assess adaptations for risks or safeguarding concerns and remove them where necessary.

Verbatim wording from the response

“Kirklees Council have a Housing Assistance Policy which lays out how we deliver adaptations. Previously there was nothing in the policy with regard to removing adaptations should they present a risk to a person.”

Source location

Response from Kirklees Council
Page 1 · response
Published 18 October 2024

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

Requests to alter or remove property adaptations must be authorised and acted on by Kirklees Council and its housing arrangements.

Verbatim wording from the response

“I also note the evidence of ████████, another contract manager for Pinnacle Housing Group that they had not received any written requests to remove the hoists from Mr Cheney's property either from Mr Cheney himself, his family, his social worker, the Council or any other party, and that they would refer any request to and only act on the instruction of the Council. I note that he has not commented on the request being made to the Pinnacle Housing Group caretaker on site.”

Source location

Response from Radis Community Care
Page 2 · response
Published 18 October 2024

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

Property maintenance, repair and alteration at Woodland Court are outside the care provider’s control and remit.

Verbatim wording from the response

“Woodland Court is owned by Kirklees Council and managed on their behalf by Pinnacle Housing Group, who are responsible for all aspects of building maintenance and safety. Residents enter into a tenancy agreement with Pinnacle Housing Group and Radis Community Care has no control over the maintenance or adaptation of the building or individual properties.”

Source location

Response from Radis Community Care
Page 1 · response
Published 18 October 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Produce a one-page fact sheet guiding service managers’ responses to residents with mental health concerns, including emergency actions.

    Stated by G P Homecare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2024.
  2. 2

    Introduce a wellbeing policy covering reporting and escalation of concerns about residents without commissioned care.

    Stated by G P Homecare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2024.
  3. 3

    Implement a more robust mechanism for communicating, recording and reporting concerns about extra-care residents without commissioned care.

    Stated by G P Homecare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2024.
  4. 4

    Raise a Safeguarding Adults Review referral to identify learning and improvements in joined-up working and policy alignment.

    Stated by Kirklees Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 18 October 2024.

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

Produce a one-page fact sheet guiding service managers’ responses to residents with mental health concerns, including emergency actions.

Verbatim wording from the response

“We have also reviewed how we can ensure that any concerns about residents in extra care schemes can be followed up and escalated. I have attached a copy of our action plan which sets out details of the action being taken, which includes.”

Source location

Response from Radis Community Care
Page 3 · response
Published 18 October 2024

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 a wellbeing policy covering reporting and escalation of concerns about residents without commissioned care.

Verbatim wording from the response

“We have also reviewed how we can ensure that any concerns about residents in extra care schemes can be followed up and escalated. I have attached a copy of our action plan which sets out details of the action being taken, which includes.”

Source location

Response from Radis Community Care
Page 3 · response
Published 18 October 2024

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 a more robust mechanism for communicating, recording and reporting concerns about extra-care residents without commissioned care.

Verbatim wording from the response

“We have also reviewed how we can ensure that any concerns about residents in extra care schemes can be followed up and escalated. I have attached a copy of our action plan which sets out details of the action being taken, which includes.”

Source location

Response from Radis Community Care
Page 3 · response
Published 18 October 2024

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

Raise a Safeguarding Adults Review referral to identify learning and improvements in joined-up working and policy alignment.

Verbatim wording from the response

“For additional information, on internal review of this case we are not entirely satisfied that a multi-agency approach was taken, and Kirklees Council will raise a Safeguarding Adults Review (SAR) referral as soon as possible.”

Source location

Response from Kirklees Council
Page 2 · response
Published 18 October 2024

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