PFD report

Bradley David Griffiths · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 11 Mar 2016•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
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.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Failure to ensure onward transfer and continuity of health visiting records after family relocation
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

    Incorporate the No Trace and case-supervision arrangements into the Health Visiting Standards document.

    Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2015.
  2. Action

    Keep the arrangements under review to identify additional improvements that could strengthen the process.

    Stated by Coventry and Warwickshire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2015.
  3. Action

    Complete a No Trace checklist and conduct a follow-up review after three months for children whose records cannot be transferred or traced.

    Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2015.

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

  1. Position

    Existing no-trace checks, supervisory review and Health Visiting Standards are considered sufficient to prevent recurrence.

    Stated by Coventry and Warwickshire Partnership NHS TrustExisting 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 to ensure onward transfer and continuity of health visiting records after family relocation

Wider context from the report

“Evidence was heard from ████████ who was Bradley’s Health Visitor. ████████ explained that she only saw Bradley once which was for the first visit on the 30th April 2012. Although two appointments were made with Bradley's Mum for the 6 week routine check to take place, his Mum did not keep them. After the second failed appointment ████████ telephoned Bradley’s Mum on the 26th June 2012 and was informed by her that she had separated from Bradley’s father and she and Bradley were living in the Northampton area with friends and that she had registered with a new G.P. However she would not tell ████████ where she was living or the details of the new GP. As a result ████████ sent Bradley’s records to the "No Trace" storage at the Child Health Department with the expectation they would be sent to the next assigned Health Visitor. ”

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

Incorporate the No Trace and case-supervision arrangements into the Health Visiting Standards document.

Verbatim wording from the response

“• Completing a ‘No Trace’ process/checklist, and a follow up review after 3 months;”

Source location

2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Page 2 · response
Published 11 March 2015

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

Keep the arrangements under review to identify additional improvements that could strengthen the process.

Verbatim wording from the response

“The arrangements described above were later incorporated into the Health Visiting Standards document (August 2014). We have kept these arrangements under review, as part of normal process, to ascertain whether any additional improvements can be made to strengthen the process in place.”

Source location

2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Page 2 · response
Published 11 March 2015

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

Complete a No Trace checklist and conduct a follow-up review after three months for children whose records cannot be transferred or traced.

Verbatim wording from the response

“At the time of Bradley’s death, our processes for the Transfer Out of case notes and information, did not robustly account for instances where families did not provide a forwarding GP address, or where they preferred incorrect details. Following the incident of Bradley’s death in 2012, the Trust had recognised the concerns that you have raised following the inquest in your PFD report. We can confirm that we had taken steps to develop and then implement robust arrangements for ensuring children’s ‘Transferred Out of Area’ records and arrangements for ensuring appropriate levels of contact with receiving areas, are carefully considered; and in circumstances where staff are unable to locate a child/family. The arrangements that we had already proactively put into place were:”

Source location

2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Page 2 · response
Published 11 March 2015

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 Pre-School Manager supervision of each case before assigning No Trace status, ensuring all avenues to locate the child or family have been considered.

Verbatim wording from the response

“At the time of Bradley’s death, our processes for the Transfer Out of case notes and information, did not robustly account for instances where families did not provide a forwarding GP address, or where they preferred incorrect details. Following the incident of Bradley’s death in 2012, the Trust had recognised the concerns that you have raised following the inquest in your PFD report. We can confirm that we had taken steps to develop and then implement robust arrangements for ensuring children’s ‘Transferred Out of Area’ records and arrangements for ensuring appropriate levels of contact with receiving areas, are carefully considered; and in circumstances where staff are unable to locate a child/family. The arrangements that we had already proactively put into place were:”

Source location

2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Page 2 · response
Published 11 March 2015

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

Existing no-trace checks, supervisory review and Health Visiting Standards are considered sufficient to prevent recurrence.

Verbatim wording from the response

“• Completing a ‘No Trace’ process/checklist, and a follow up review after 3 months;”

Source location

2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Page 2 · response
Published 11 March 2015

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