PFD report

Laura Page · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 28 May 2014•Leicester City and South Leicestershire

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Lack of maintained and audited analysis of failed visits and untoward outcomes
    Part of recurring concern: Failure of care and safety auditing to identify deficiencies
  2. Failure of clinicians to respond robustly to failed home visits
  3. Lack of specific time targets for escalation action
    Part of recurring concern: Unreliable escalation policy for care concerns
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.7

  1. Action

    Reconsider and clarify the threshold for requesting welfare checks in the failed-visit flowchart.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 May 2014.
  2. Action

    Reinforce staff expectations to engage patients, follow the operational procedure when engagement fails, and communicate failures during handovers.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 May 2014.
  3. Action

    Conduct weekly audits of failed visits and monitor compliance through key performance indicators.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 May 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Key fobs are not considered a practical resolution to failed patient engagement; police access is available and obtaining access has been considered.

    Stated by Leicestershire Partnership NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 maintained and audited analysis of failed visits and untoward outcomes

Wider context from the report

“Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning. (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate. (2) The escalation policy should be reviewed to consider specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies.

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 clinicians to respond robustly to failed home visits

Wider context from the report

“Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning. (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate. (2) The escalation policy should be reviewed to consider specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. ”

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

Lack of specific time targets for escalation action

Wider context from the report

“Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning. (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate. (2) The escalation policy should be reviewed to consider specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. ”

Is this part of a recurring concern?

Yes — Unreliable escalation policy for care concerns.

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 to maintain an appropriate threshold for requesting welfare checks

Wider context from the report

“Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning. (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate. (2) The escalation policy should be reviewed to consider specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. ”

Is this part of a recurring concern?

Yes — Unreliable welfare-check processes for people whose health is of concern; Unreliable welfare-check request handling and follow-up.

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

Reconsider and clarify the threshold for requesting welfare checks in the failed-visit flowchart.

Verbatim wording from the response

“(3) The threshold for requesting a welfare check should be reconsidered.”

Source location

2014-0254-Response
Page 2 · response
Published 28 May 2014

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

Reinforce staff expectations to engage patients, follow the operational procedure when engagement fails, and communicate failures during handovers.

Verbatim wording from the response

“We are aware that the difficulty in this case was essentially one of communication. We have endeavoured to make it clear to staff that they must do all that they can to engage with a patient. Where they are unable to do so, this must be dealt with in accordance with the Operational Procedure. This will enhance communication within the team so that a failure to engage will be seen by the relevant team. This will assist in the handover meetings.”

Source location

2014-0254-Response
Page 2 · response
Published 28 May 2014

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

Conduct weekly audits of failed visits and monitor compliance through key performance indicators.

Verbatim wording from the response

“The Crisis Service Manager is now undertaking a weekly audit check on failed visits to assure compliance in line with the new process, and is monitored through key line performance indicators.”

Source location

2014-0254-Response
Page 2 · response
Published 28 May 2014

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

Notify crisis teams of the Regulation 28 outcome and disseminate the standardized failed-visit process through meetings, email, flowcharts, and updated procedures.

Verbatim wording from the response

“The teams within the Crisis Service were notified of the outcome and the contents of the Regulation 28 at their team meetings and via email communication.”

Source location

2014-0254-Response
Page 1 · response
Published 28 May 2014

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

Consider obtaining access through police-held key fobs for appropriate failed-visit situations.

Verbatim wording from the response

“In terms of the issue of key fobs, this is not a practical resolution to the problem of a failure to engage with the patient. However, the Police do have access to such fobs and consideration has been given to this in terms of obtaining access.”

Source location

2014-0254-Response
Page 2 · response
Published 28 May 2014

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

Review escalation arrangements and establish specific time targets for action in the failed-visit flowchart.

Verbatim wording from the response

“(2) The escalation policy should be reviewed to consider specific time targets for action.”

Source location

2014-0254-Response
Page 2 · response
Published 28 May 2014

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

Implement a standardized failed-visit process requiring qualified-practitioner visits where possible and escalation when staffing cannot be secured.

Verbatim wording from the response

“A clear process has also been developed and put in place to ensure that all failed visits are dealt with following the same process. This is detailed in the attached flow chart (Annex).”

Source location

2014-0254-Response
Page 1 · response
Published 28 May 2014

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

Key fobs are not considered a practical resolution to failed patient engagement; police access is available and obtaining access has been considered.

Verbatim wording from the response

“In terms of the issue of key fobs, this is not a practical resolution to the problem of a failure to engage with the patient. However, the Police do have access to such fobs and consideration has been given to this in terms of obtaining access.”

Source location

2014-0254-Response
Page 2 · response
Published 28 May 2014

Open published response
Back to top

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