PFD report

Mrs Leesley · Prevention of Future Deaths report

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Issued 12 Dec 2016•South Yorkshire (Western)

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
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

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Concerns raised1

  1. Failure to act on safeguarding referrals
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and notices
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.4

  1. Action

    Complete the ongoing investigation into the missing safeguarding referral, including the IT audit and Serious Incident review, and produce the resulting incident report.

    Stated by Sheffield City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017.
  2. Action

    Implement an email-journaling facility to retain audit logs and track emails sent, received, deleted and other mailbox actions.

    Stated by Sheffield City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017.
  3. Action

    Remind all Adult Access staff of email-handling procedures to reduce the risk of safeguarding referrals being deleted or left unactioned.

    Stated by Sheffield City CouncilStated completedThe respondent said that this action was complete when they made their response on 12 February 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The GP surgery must make the request for the forensic report from its NHS mail provider.

    Stated by Sheffield City CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Failure to act on safeguarding referrals

Wider context from the report

“During the inquest, evidence showed the GP made a safeguarding report on 4.3.16, but for reasons unknown, despite there being an automated acknowledgment, the referral was not acted upon. It was unclear whether this was a case of unanimous error or IT error. ”

Is this part of a recurring concern?

Yes — Failure to act appropriately on safeguarding referrals and notices.

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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

Complete the ongoing investigation into the missing safeguarding referral, including the IT audit and Serious Incident review, and produce the resulting incident report.

Verbatim wording from the response

“4. IT systems audit”

Source location

2016-0442-Response-by-Sheffield-City-Council-1
Page 4 · response
Published 12 February 2017

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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 an email-journaling facility to retain audit logs and track emails sent, received, deleted and other mailbox actions.

Verbatim wording from the response

“3.1.4 The IT systems operating in the Adult Access Team are designed to prevent emails, including those that contain safeguarding referrals, from being accidentally deleted. To completely delete an email, it would have to be deleted from the inbox folder and then separately deleted from the deleted folder; two distinct actions. The Local Authority is putting in place a Journal function integrated into the IT system that will make it easier to retrieve and track deleted emails. Journal function enables the Local Authority to track every action in a specified mailbox, In this case the Mailbox for the Adult Access Team.”

Source location

2016-0442-Response-by-Sheffield-City-Council-1
Page 2 · response
Published 12 February 2017

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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

Remind all Adult Access staff of email-handling procedures to reduce the risk of safeguarding referrals being deleted or left unactioned.

Verbatim wording from the response

“3.2.5 However, to further reduce the risk of a report not being actioned, all staff working within Adult Access team have been reminded of the existing procedures and process for handling emails to further reduce the risk of emails being deleted or not actioned correctly.”

Source location

2016-0442-Response-by-Sheffield-City-Council-1
Page 3 · response
Published 12 February 2017

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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

Amend automated safeguarding-referral acknowledgements to instruct senders to confirm receipt if Adult Access does not respond within two working days.

Verbatim wording from the response

“3.1.1 On 9th December 2016, the final day of the inquest, ████████, Advanced Practitioner in the Community Access Prevention Team, amended the wording of the automated response generated when a safeguarding report is received by the Adult Access Team.”

Source location

2016-0442-Response-by-Sheffield-City-Council-1
Page 1 · response
Published 12 February 2017

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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 GP surgery must make the request for the forensic report from its NHS mail provider.

Verbatim wording from the response

“5.2 ████████ has requested a forensic report and audit log via the Accenture agency responsible for the IT System at the GP surgery used to send the email.”

Source location

2016-0442-Response-by-Sheffield-City-Council-1
Page 5 · response
Published 12 February 2017

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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

There is no evidence that the referral was not actioned because of human error, and the circumstances appear isolated.

Verbatim wording from the response

“There is no available evidence to suggest that non-action was the result of human error either by action or omission on this occasion.”

Source location

2016-0442-Response-by-Sheffield-City-Council-1
Page 3 · response
Published 12 February 2017

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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

Existing email-handling procedures and staff reminders have adequately addressed and minimised the risk of received referrals being missed through human error.

Verbatim wording from the response

“3.2.5 However, to further reduce the risk of a report not being actioned, all staff working within Adult Access team have been reminded of the existing procedures and process for handling emails to further reduce the risk of emails being deleted or not actioned correctly.”

Source location

2016-0442-Response-by-Sheffield-City-Council-1
Page 3 · response
Published 12 February 2017

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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