PFD report

Joanna HILLARD · Prevention of Future Deaths report

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Issued 5 Mar 2026•Somerset

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
4

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.

Report evidence summary

Concerns raised2

  1. Failure of capacity law to recognise the effects of coercive and controlling behaviour on decision-making ability
  2. Lack of understanding of the effects of controlling and coercive behaviour on decision-making capacity
    Part of recurring concern: Failure to recognise and respond to coercive and controlling behaviour
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.1

  1. Position

    The MCA need not override unsafe or unwise decisions where capacity exists because safeguarding, civil and criminal routes are available.

    Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 capacity law to recognise the effects of coercive and controlling behaviour on decision-making ability

Wider context from the report

“I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests. I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 understanding of the effects of controlling and coercive behaviour on decision-making capacity

Wider context from the report

“I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests. I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to coercive and controlling behaviour.

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

The MCA need not override unsafe or unwise decisions where capacity exists because safeguarding, civil and criminal routes are available.

Verbatim wording from the response

“Although section 76 Serious Crime Act 2015 offence post-dates the MCA, it was developed and updated alongside the modern adult safeguarding framework (including the Care Act 2014 and the Domestic Abuse Act 2021) and is supported by statutory guidance: Controlling or coercive behaviour: statutory guidance framework - GOV.UK. The MCA remains relevant where coercion or undue influence interacts with an impairment or disturbance of the mind or brain so that the person cannot make the specific decision, in such cases, practitioners should complete and record a decision-specific capacity assessment. Where an adult has capacity, the MCA is not a general route to override unsafe or unwise decisions, and other safeguarding, civil and criminal routes may be more appropriate.”

Source location

2026-0128 - Response from Department of Health and Social Care
Page 2 · response
Published 26 March 2026

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.4

  1. 1

    Establish links between general practices and local specialist services for referrals.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
  2. 2

    Introduce specialist support workers linked to groups of general practices to support staff and advocate for victims.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
  3. 3

    Clarify in the updated Mental Capacity Act Code of Practice that assuming capacity does not remove the need for assessment.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
  4. 4

    Provide domestic-abuse and sexual-violence training to all general-practice staff.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.

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 links between general practices and local specialist services for referrals.

Verbatim wording from the response

“The model will include:”

Source location

2026-0128 - Response from Department of Health and Social Care
Page 2 · response
Published 26 March 2026

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

Introduce specialist support workers linked to groups of general practices to support staff and advocate for victims.

Verbatim wording from the response

“The model will include:”

Source location

2026-0128 - Response from Department of Health and Social Care
Page 2 · response
Published 26 March 2026

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

Clarify in the updated Mental Capacity Act Code of Practice that assuming capacity does not remove the need for assessment.

Verbatim wording from the response

“The PFD report also indicates that a capacity assessment was undertaken. This underlines that the presumption of capacity does not remove the need to assess where there is a proper basis for doing so. We will make clear in the updated MCA Code of Practice (to be consulted on) that practitioners should not equate “assume capacity” with “do not assess”.”

Source location

2026-0128 - Response from Department of Health and Social Care
Page 3 · response
Published 26 March 2026

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

Provide domestic-abuse and sexual-violence training to all general-practice staff.

Verbatim wording from the response

“The model will include:”

Source location

2026-0128 - Response from Department of Health and Social Care
Page 2 · response
Published 26 March 2026

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

Official responses located
1/1

Data last updated 7 September 2026