PFD report

SAM MALCOLM TAYLOR · Prevention of Future Deaths report

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Issued 30 Jun 2023•Herefordshire

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
11

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 progress applications to establish vulnerability
    Part of recurring concern: Unreliable vulnerability assessment in emergency accommodation decisions
  2. Lack of an effective system for identifying process failure
  3. Failure to make contact with the deceased or approved contacts
    Part of recurring concern: Failure to make required contact with approved family and support contacts
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.6

  1. Action

    Complete the overhaul of housing systems, procedures and operating practices.

    Stated by Herefordshire CouncilStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
  2. Action

    Strengthen housing processes from first contact through decision-making and provide ongoing management guidance to frontline officers.

    Stated by Herefordshire CouncilStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
  3. Action

    Roll out partnership working with health colleagues to share relevant information for decision-making.

    Stated by Herefordshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.

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

  1. Position

    A vulnerability assessment was not required initially because the applicant owed a Prevention Duty; it became relevant only if a Relief Duty arose.

    Stated by Herefordshire 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 progress applications to establish vulnerability

Wider context from the report

“(2) Evidence suggests that in reality Mr Taylor would have met the threshold for vulnerability set out in the Housing Act 1996 but the failure to progress the application resulted in this never being established. ”

Is this part of a recurring concern?

Yes — Unreliable vulnerability assessment in emergency accommodation decisions.

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

Lack of an effective system for identifying process failure

Wider context from the report

“(3) A system for identifying process failure should be in place and effective. ”

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 make contact with the deceased or approved contacts

Wider context from the report

“(1) A prevention duty was owed to the deceased and due to Herefordshire Council communication process failure, contact was not made with him or those with whom he had approved contact prior to his death. ”

Is this part of a recurring concern?

Yes — Failure to make required contact with approved family and support contacts.

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

Complete the overhaul of housing systems, procedures and operating practices.

Verbatim wording from the response

“4. A significant overhaul of systems, procedures and operating practices is required.”

Source location

Response from Herefordshire Council
Page 2 · response
Published 7 July 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

Strengthen housing processes from first contact through decision-making and provide ongoing management guidance to frontline officers.

Verbatim wording from the response

“• An experienced interim service manager has been in post since April 2023 and is leading the service improvement and development work which has already delivered strengthened processes, from first point of contact through to decision making, reviewed housing procedures to ensure they align with the Homelessness Reduction Act and is providing ongoing comprehensive management guidance and support to front line officers. Additional experienced interim capacity has also been brought into the service at the front line to support the embedding of the changes.”

Source location

Response from Herefordshire Council
Page 2 · response
Published 7 July 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

Roll out partnership working with health colleagues to share relevant information for decision-making.

Verbatim wording from the response

“The wider recommendations in relation to partnership working will roll out from January 2024. This will specifically include working with health colleagues in relation to ensuring that relevant information is shared to feed into any decision making processes.”

Source location

Response from Herefordshire Council
Page 3 · response
Published 7 July 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

Develop and roll out a case-auditing programme within the quality-assurance framework.

Verbatim wording from the response

“A programme of case auditing is also being developed in line with the directorate’s overall quality assurance framework which will roll out from October 2023.”

Source location

Response from Herefordshire Council
Page 4 · response
Published 7 July 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

Operate supervision, CRM oversight and weekly case reviews to identify and address process failures.

Verbatim wording from the response

“Herefordshire Council can confirm that a system for identifying any process failure is now in place and operating. The system covers:”

Source location

Response from Herefordshire Council
Page 4 · response
Published 7 July 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

Review housing procedures to align them with the Homelessness Reduction Act.

Verbatim wording from the response

“• An experienced interim service manager has been in post since April 2023 and is leading the service improvement and development work which has already delivered strengthened processes, from first point of contact through to decision making, reviewed housing procedures to ensure they align with the Homelessness Reduction Act and is providing ongoing comprehensive management guidance and support to front line officers. Additional experienced interim capacity has also been brought into the service at the front line to support the embedding of the changes.”

Source location

Response from Herefordshire Council
Page 2 · response
Published 7 July 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

A vulnerability assessment was not required initially because the applicant owed a Prevention Duty; it became relevant only if a Relief Duty arose.

Verbatim wording from the response

“At the point at which Mr Taylor contacted the service, he was not homeless in line with relevant legislation and it was not anticipated that he would be homeless until after the weekend; hence he was owed a Prevention duty at the time of contact with the service. He was made aware that should his circumstances change, then a Relief duty would be owed.”

Source location

Response from Herefordshire Council
Page 3 · response
Published 7 July 2023

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.5

  1. 1

    Deliver a comprehensive training programme for housing officers alongside the operational overhaul.

    Stated by Herefordshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
  2. 2

    Review implementation-plan progress weekly with the Head of Service and Service Manager.

    Stated by Herefordshire CouncilStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  3. 3

    Recruit permanently to the Head of Housing post.

    Stated by Herefordshire CouncilStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
  4. 4

    Add experienced interim management and frontline capacity to lead and embed service improvements.

    Stated by Herefordshire CouncilStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  5. 5

    Establish a unified housing management structure led by a Head of Housing.

    Stated by Herefordshire CouncilStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.

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

Deliver a comprehensive training programme for housing officers alongside the operational overhaul.

Verbatim wording from the response

“• The overhaul of systems, procedures and operating practices is in progress and is expected to be fully delivered by October 2023, alongside a comprehensive training programme for officers.”

Source location

Response from Herefordshire Council
Page 3 · response
Published 7 July 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

Review implementation-plan progress weekly with the Head of Service and Service Manager.

Verbatim wording from the response

“I can confirm that the Corporate Director reviews progress on a weekly basis with the Head of Service and Service Manager.”

Source location

Response from Herefordshire Council
Page 3 · response
Published 7 July 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

Recruit permanently to the Head of Housing post.

Verbatim wording from the response

“• The new structure is in place which brings together all specific housing services under a newly created post of Head of Housing. This post is being delivered through an acting up arrangement by an existing very experienced senior manager to deliver the immediate improvements identified through the review. Permanent recruitment to the post will take place by the end of December.”

Source location

Response from Herefordshire Council
Page 2 · response
Published 7 July 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

Add experienced interim management and frontline capacity to lead and embed service improvements.

Verbatim wording from the response

“• An experienced interim service manager has been in post since April 2023 and is leading the service improvement and development work which has already delivered strengthened processes, from first point of contact through to decision making, reviewed housing procedures to ensure they align with the Homelessness Reduction Act and is providing ongoing comprehensive management guidance and support to front line officers. Additional experienced interim capacity has also been brought into the service at the front line to support the embedding of the changes.”

Source location

Response from Herefordshire Council
Page 2 · response
Published 7 July 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 a unified housing management structure led by a Head of Housing.

Verbatim wording from the response

“1. A new management and staffing structure is proposed, bringing together all specific housing services under a single management team, led by a new Head of Housing reporting directly to the Corporate Director.”

Source location

Response from Herefordshire Council
Page 2 · response
Published 7 July 2023

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