PFD report

DERRICK ARTHUR PLATER · Prevention of Future Deaths report

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Issued 21 Mar 2014•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.

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Concerns
1

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

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 raised1

  1. Failure to ensure clear, disseminated and understood guidelines or protocols for when care home visits should be undertaken during assessment and placement
Responses linked to these concerns

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

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

  1. Position

    A social worker’s pre-placement visit would not provide added assurance or be likely to prevent similar deaths.

    Stated by Cambridgeshire 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 ensure clear, disseminated and understood guidelines or protocols for when care home visits should be undertaken during assessment and placement

Wider context from the report

“I was told that it was not the time normal practice to undertake a visit of the care home being considered for placement, notwithstanding that Mr Plater had complex needs having undergone a laryngectomy and had a stoma. Accordingly there was a total reliance upon assurances given by the care home in considering whether it could in fact meet the assessed needs. It was indicated that if similar circumstances arose today it is likely that a visit would be undertaken. However the witness was unable to confirm whether there were guidelines or protocols for when a visit should be undertaken as part of the assessment and placing process. I am therefore concerned that: 1. If there are guidelines and/or protocols for when a visit of care home should be considered and/or undertaken as part of the assessment and placement process there may need to be a review of the dissemination and awareness of any such guidelines and/or protocols 2. If there are no such guidelines and/or protocols there may need to be a review as to whether such should be drawn up ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 social worker’s pre-placement visit would not provide added assurance or be likely to prevent similar deaths.

Verbatim wording from the response

“In Mr Platter’s case, where there were complex health and social care needs, a visit to the home by a social worker would not, in my opinion, have provided any added assurance because social workers are not professionally competent to make judgments on whether Mr Plater’s health needs were likely to be met at Goodwins Hall. Therefore, I believe that it is unlikely that a pre-placement visit in these circumstances would help to prevent future deaths in similar circumstances.”

Source location

2014-0130-Response
Page 2 · response
Published 21 March 2014

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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

Social workers are not professionally competent to judge whether complex health needs can be met by the care home.

Verbatim wording from the response

“In Mr Platter’s case, where there were complex health and social care needs, a visit to the home by a social worker would not, in my opinion, have provided any added assurance because social workers are not professionally competent to make judgments on whether Mr Plater’s health needs were likely to be met at Goodwins Hall. Therefore, I believe that it is unlikely that a pre-placement visit in these circumstances would help to prevent future deaths in similar circumstances.”

Source location

2014-0130-Response
Page 2 · response
Published 21 March 2014

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Other statements in published responses

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

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The care home’s Registered Manager determines whether assessed needs can be met, while hospital staff assess ongoing health needs.

    Stated by Cambridgeshire County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 care home’s Registered Manager determines whether assessed needs can be met, while hospital staff assess ongoing health needs.

Verbatim wording from the response

“At the Inquest into Mr Plater's death, ████████ Cambridgeshire County Council’s witness, tried to explain that under the terms of the care home’s registration with the Care Quality Commission the Registered Manager, in each home, is responsible for determining whether the assessed needs can be met in their care home.”

Source location

2014-0130-Response
Page 1 · response
Published 21 March 2014

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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