PFD report

Reece William NELSON · Prevention of Future Deaths report

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Issued 12 Dec 2023•North Lincolnshire and Grimsby

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
3

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. Lack of alternative contact arrangements during Care Coordinator absence
    Part of recurring concern: Unreliable communication access for people requiring support
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

    Implement sickness-absence cover arrangements through the Revised Policy, including patient notification, alternate support, duty-worker escalation, home-visit cover and caseload allocation.

    Stated by NAViGO Health and Social Care CICStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
  2. Action

    Continue operating the Revised Policy and maintain audited processes for informing new and existing staff about sickness-absence cover arrangements.

    Stated by NAViGO Health and Social Care CICStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2024.

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 alternative contact arrangements during Care Coordinator absence

Wider context from the report

“On the morning of Reece Nelson's death his family attempted to contact his Care Coordinator due to concerns regarding his mental state. The Care Coordinator was on sick leave, however this information was not reported to the family and therefore no return call was made to them. Had the family been made aware that the Care Coordinator was on sick leave they would have tried alternative routes to contact the mental health services to seek assistance. There should be a system in place whereby alternative contact details are provided in the event of a staff member being absent ”

Is this part of a recurring concern?

Yes — Unreliable communication access for people requiring support.

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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

Implement sickness-absence cover arrangements through the Revised Policy, including patient notification, alternate support, duty-worker escalation, home-visit cover and caseload allocation.

Verbatim wording from the response

“In the event a Care Coordinator rings in sick or any other sickness absence period, the Team Leader will go through staff diaries and task admin to phone each patient to let them know their worker is off sick, the Team Leader will also determine whether alternate support is required in the absence of their Care Coordinator. In the event other support is required the Team Leader is to liaise with the duty person to arrange this. The team are to be made aware and relevant duties allocated in the morning huddle by the Team Leader. All patients will be made aware that they can contact our duty worker for support at any time during office hours Monday to Friday 9am to 5pm. The duty worker is able to conduct a home visit where needed.”

Source location

Response from Navigo
Page 2 · response
Published 8 January 2024

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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

Continue operating the Revised Policy and maintain audited processes for informing new and existing staff about sickness-absence cover arrangements.

Verbatim wording from the response

“5 Navigo will continue to operate in accordance with the Revised Policy and will ensure processes to inform both new and existing staff members of the cover arrangements remain in place and are audited.”

Source location

Response from Navigo
Page 3 · response
Published 8 January 2024

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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-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Develop and implement a communications plan adding urgent-assistance contact details to Navigo work-phone voicemails, with an assurance plan to monitor compliance.

    Stated by NAViGO Health and Social Care CICStated plannedThe respondent said that this action was planned when they made their response on 8 January 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

Develop and implement a communications plan adding urgent-assistance contact details to Navigo work-phone voicemails, with an assurance plan to monitor compliance.

Verbatim wording from the response

“6 Voicemail messages on Navigo work phones will include contact details for urgent assistance. A communications plan will be developed for its implementation and an assurance plan to monitor compliance.”

Source location

Response from Navigo
Page 3 · response
Published 8 January 2024

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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