PFD report

Max TURBUTT · Prevention of Future Deaths report

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Issued 18 Oct 2022•Inner North London

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
2

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 raised2

  1. Failure to provide an accessible alternative contact when a personal advisor or social worker is unavailable
    Part of recurring concern: Unreliable access to required social-worker supportPart of recurring concern: Unreliable communication access for people requiring support
  2. Failure of the crisis number to provide a responsive service
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.3

  1. Action

    Advise young adults immediately when their allocated Personal Advisor is off long-term sick, providing the Team Manager’s name and Duty contact number.

    Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.
  2. Action

    Require the relevant staff member to add a mobile-phone voice message identifying whom to contact during their absence.

    Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.
  3. Action

    Ensure an out-of-office email reply is added when a staff member is absent on a long-term basis.

    Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.

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 provide an accessible alternative contact when a personal advisor or social worker is unavailable

Wider context from the report

“Max’s father told me at inquest that in March and April 2022, Max tried to contact his personal advisor at the 18+ Service at Thistley Hill in Dover on several occasions over a number of weeks, but found her phone always to be switched off. There was no redirect and no out of office on her email. Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick. A crisis number was given and Mr Turbutt called it, but it was simply an answerphone. This arrangement does not seem adequate for a vulnerable person in need. ”

Is this part of a recurring concern?

Yes — Unreliable access to required social-worker support; Unreliable communication access for people requiring support.

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 of the crisis number to provide a responsive service

Wider context from the report

“Max’s father told me at inquest that in March and April 2022, Max tried to contact his personal advisor at the 18+ Service at Thistley Hill in Dover on several occasions over a number of weeks, but found her phone always to be switched off. There was no redirect and no out of office on her email. Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick. A crisis number was given and Mr Turbutt called it, but it was simply an answerphone. This arrangement does not seem adequate for a vulnerable person in need. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Advise young adults immediately when their allocated Personal Advisor is off long-term sick, providing the Team Manager’s name and Duty contact number.

Verbatim wording from the response

“In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

Source location

Response from Kent County Council
Page 3 · response
Published 20 October 2022

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

Require the relevant staff member to add a mobile-phone voice message identifying whom to contact during their absence.

Verbatim wording from the response

“In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

Source location

Response from Kent County Council
Page 3 · response
Published 20 October 2022

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

Ensure an out-of-office email reply is added when a staff member is absent on a long-term basis.

Verbatim wording from the response

“In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:”

Source location

Response from Kent County Council
Page 3 · response
Published 20 October 2022

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

  1. 1

    The service had only three working days’ notice of the Personal Advisor’s absence and had seen no indications that Max’s mental health was deteriorating.

    Stated by Kent County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 service had only three working days’ notice of the Personal Advisor’s absence and had seen no indications that Max’s mental health was deteriorating.

Verbatim wording from the response

“Max’s PA went off work officially on sick leave on the 20th April 2022 and there were only 3 working days after this time, before Max’s tragic death. I am advised that the Council was aware that Max had fluctuating mental health issues and had sought to support him intensively the previous year when I am advised Max was very unwell. Sadly, during their communications with Max, the PA had not seen any indications during March or early April 2022 to indicate that his mental health was deteriorating. The PA was advised by Max that he was in regular touch with his GP surgery and had family locally who were supporting him to collect his medication.”

Source location

Response from Kent County Council
Page 2 · response
Published 20 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