Diane Margaret Austin-Martin · Prevention of Future Deaths report

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Issued 14 Sep 2022•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

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. Lack of a mechanism for Social Services to be aware of vulnerable people's moves
  2. Loss of agency visibility of vulnerable people after initial contact
    Part of recurring concern: Failure to maintain contact with vulnerable people after initial engagement
  3. Lack of a mechanism to ensure appropriate quality of privately arranged care
    Part of recurring concern: Inadequate assurance and review of commissioned care services and care packages

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Department of Health and Social Care

    Local authority safeguarding duties provide a mechanism to investigate private home-care arrangements where poor quality places an adult at risk.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Department of Health and Social Care

    Established GP registration processes, assessment, referrals and follow-up were considered appropriate for managing the patient’s long-term conditions.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. Department of Health and Social Care

    The local Safeguarding Adults Board should provide further case information and consider whether a Safeguarding Adults Review is required.

    Redirects 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

Lack of a mechanism for Social Services to be aware of vulnerable people's moves

Wider context from the report

“1. The inquest heard evidence that there was no clear mechanism to ensure that Social Services were aware of her move despite her vulnerability having being identified whilst she resided in Northern Ireland. As a consequence Social Services were unsighted as to her being resident in Stockport; ”

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

Loss of agency visibility of vulnerable people after initial contact

Wider context from the report

“4. After her initial claim for payment and her initial GP visit she dropped out of sight of agencies until she was found. ”

Is this part of a recurring concern?

Yes — Failure to maintain contact with vulnerable people after initial engagement.

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 a mechanism to ensure appropriate quality of privately arranged care

Wider context from the report

“2. DWP were aware of her presence and payments were made recognising her needs but there was no mechanism to ensure that the care provided was of an appropriate quality; 3. The inquest heard that where a private care arrangement exists as in this case there is no mechanism to ensure that the care is of a sufficient and appropriate quality in contrast to a resident of a care home; ”

Is this part of a recurring concern?

Yes — Inadequate assurance and review of commissioned care services and care packages.

Open source report

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

Local authority safeguarding duties provide a mechanism to investigate private home-care arrangements where poor quality places an adult at risk.

Verbatim wording from the response

“Adult safeguarding is relevant because local authorities have a duty, under the Care Act 2014, to make enquiries when they suspect that an adult with care and support needs is a) at risk of abuse or neglect and b) unable to protect themselves as a result of those needs. You were concerned that there is no mechanism to ensure that domiciliary care is of a sufficient and appropriate quality, in contrast to regulation of care homes. While it is correct that CQC does not inspect unregulated home care settings, local authority adult safeguarding duties do provide a mechanism by which to investigate private home care arrangements if the quality of care puts the cared-for person at risk of harm.”

Source location

Response from Department of health and Social Care
Page 2 · response
Published 6 October 2022

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

Established GP registration processes, assessment, referrals and follow-up were considered appropriate for managing the patient’s long-term conditions.

Verbatim wording from the response

“Your fourth and final concern noted that Ms Austin Martin dropped out of sight of agencies. NHS England has noted that there are robust processes in place across the Stockport GP population around the management of newly registered patients. The expectation is that following registration, an initial appointment will be offered to the patient which would include an assessment of medical needs, the prescribing of medications, and a plan agreed for how care will be managed moving forward and when any regular medications will be reviewed. The GP Practice where this patient was registered, have confirmed that Ms Austin-Martin was seen at a face-to-face consultation on 6th November 2019 shortly after registering on 30th October.”

Source location

Response from Department of health and Social Care
Page 2 · response
Published 6 October 2022

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

The local Safeguarding Adults Board should provide further case information and consider whether a Safeguarding Adults Review is required.

Verbatim wording from the response

“In relation to the second and third concerns you raised, adult safeguarding is particularly relevant. Given that it is good practice for a local authority’s Safeguarding Adults Board (SAB) to work with coroners, you may wish to write to the local SAB for further information about this case, including whether the SAB has considered a Safeguarding Adults Review (SAR).”

Source location

Response from Department of health and Social Care
Page 1 · response
Published 6 October 2022

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