PFD report

Joan Mary PRESCOTT · Prevention of Future Deaths report

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Issued 30 Jun 2021•Plymouth, Torbay and South Devon

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
0

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 consider safeguarding during welfare visits
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 consider safeguarding during welfare visits

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] Safeguarding Consideration at the time of the visit – There was no reference in the recordings to a discussion on safeguarding being considered. Again, on interviewing the social workers they felt there was a need for GP involvement and for an admission, not safeguarding at that stage (missed opportunity). The social workers formed an opinion that the initial focus was not on the state of the property, which was a known situation, but on the immediate presenting potential physical and mental health needs, hence their plan to recommend to re-contact GP for involvement. There is a clear recording of this reflection and decision in notes following visit. Following the welfare visit the GP was made aware (24/04/2020) of findings via the Duty Worker. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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