PFD report

Mr Robert Hammond · Prevention of Future Deaths report

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Issued 6 Dec 2021•Warwickshire

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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Failure to complete Working with Risk documentation
  2. Failure to complete initial assessment and care plan documentation
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 complete Working with Risk documentation

Wider context from the report

“During the inquest there was evidence that Working with Risk (WWR) documentation was not completed on approximately the first nine contacts with Mr Hammond. The 1st contact was on 23rd December 2020 where 2 hours had been allocated for this task as well as the initial assessment and care plan – none of the written documents were completed. The WWR documents were also not completed (on subsequent contacts) on 31/12/20, 3/01/21, 4/01/21,5/01/21, 6/01/21, 7/01/21, 8/01/21, 10/01/21 and 11/01/21. The Trust was unable to give an explanation for these failures. As a result, the care plan for Mr Hammond was unsatisfactory. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 complete initial assessment and care plan documentation

Wider context from the report

“During the inquest there was evidence that Working with Risk (WWR) documentation was not completed on approximately the first nine contacts with Mr Hammond. The 1st contact was on 23rd December 2020 where 2 hours had been allocated for this task as well as the initial assessment and care plan – none of the written documents were completed. The WWR documents were also not completed (on subsequent contacts) on 31/12/20, 3/01/21, 4/01/21,5/01/21, 6/01/21, 7/01/21, 8/01/21, 10/01/21 and 11/01/21. The Trust was unable to give an explanation for these failures. As a result, the care plan for Mr Hammond was unsatisfactory. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report
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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