PFD report

Jacqueline Elizabeth Smith · Prevention of Future Deaths report

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Issued 21 Aug 2023•West London

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
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
5

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.

Concerns raised4

  1. Lack of clear options and forward planning after failure of an assistance plan
  2. Insufficient staff training for dealing with complex hoarder cases
    Part of recurring concern: Inadequate staff training for managing complex care needs
  3. Council hoarder-support guidance failing to support tenant assistance
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.3

  1. Action

    Deliver mandatory hoarding training to all Housing Management officers by the end of November 2023.

    Stated by London Borough of HillingdonStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
  2. Action

    Develop and use an Operational Guidance Note covering hoarding case progression, recording, management oversight, tailored plans, handovers and ongoing review.

    Stated by London Borough of HillingdonStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
  3. Action

    Use one revised hoarding flow chart that prompts safety referrals and supports consistent risk assessment and tenant-focused casework.

    Stated by London Borough of HillingdonStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.

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 clear options and forward planning after failure of an assistance plan

Wider context from the report

“(4) It was entirely unclear what options were available (if any) when the first plan of assistance completely failed, leaving the vulnerable tenant excluded from her property with no forward plan. ”

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

Insufficient staff training for dealing with complex hoarder cases

Wider context from the report

“(1) The inquest identified that there was insufficient staff training to deal with complex hoarder cases. ”

Is this part of a recurring concern?

Yes — Inadequate staff training for managing complex care needs.

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

Council hoarder-support guidance failing to support tenant assistance

Wider context from the report

“(3) The council "flow chart" was clearly not fit for purpose to assist staff in progressing hoarder support and assistance and was focussed on enforcement procedures rather than tenant support. The inquest was advised that the council's approach was not enforcement, but their documentation did not support this. ”

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

Failure to request required fire and environmental health assessments

Wider context from the report

“(2) Other safety assessments such as a fire assessment and/or environmental health assessment were not requested despite their being a clear need. ”

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

Deliver mandatory hoarding training to all Housing Management officers by the end of November 2023.

Verbatim wording from the response

“Although training has previously been delivered to Housing Management staff by Hoarding UK, further training will be delivered to all Officers within Housing Management by the end of November 2023 as part of mandatory annual refresher training across the Service.”

Source location

Response from London Borough of Hillingdon
Page 3 · response
Published 6 September 2023

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

Develop and use an Operational Guidance Note covering hoarding case progression, recording, management oversight, tailored plans, handovers and ongoing review.

Verbatim wording from the response

“The flow chart will form part of an Operational Guidance Note for staff which will provide further clarity on key stages of casework progression such as flagging hoarding cases in management by the Panel on the Housing Management data base (NEC Software Solutions) and referencing the case on the tenancy management file within Civica workflow to ensure any staff member working on the same tenancy is aware of the vulnerability and plan associated with live hoarding casework. This will also support management oversight of live casework.”

Source location

Response from London Borough of Hillingdon
Page 4 · response
Published 6 September 2023

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

Use one revised hoarding flow chart that prompts safety referrals and supports consistent risk assessment and tenant-focused casework.

Verbatim wording from the response

“The London Borough of Hillingdon has considered the concerns the Coroner has raised and has reviewed the flow charts and amalgamated them into one flow chart for all Officers. This action was completed at the end of September 2023. This single flow chart now ensures that all Officers are prompted to make referrals to the LFB and ASC as well as Environmental Health and the resident’s GP where appropriate, and this step becomes protocol for all cases of hoarding in management.”

Source location

Response from London Borough of Hillingdon
Page 3 · response
Published 6 September 2023

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.2

  1. 1

    Arrange suitable storage at the outset of future decluttering and record it in the tailored action plan and Operational Guidance Note.

    Stated by London Borough of HillingdonStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
  2. 2

    Extend mandatory annual-leave handovers to managers who carry caseloads.

    Stated by London Borough of HillingdonStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.

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

Arrange suitable storage at the outset of future decluttering and record it in the tailored action plan and Operational Guidance Note.

Verbatim wording from the response

“It is accepted that leaving Mrs Smith’s possessions in the void property caused her distress and, in future, the London Borough of Hillingdon will ensure that suitable storage is arranged at the outset of the declutter and referenced in the tailored action plan and Operational Guidance Note.”

Source location

Response from London Borough of Hillingdon
Page 6 · response
Published 6 September 2023

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

Extend mandatory annual-leave handovers to managers who carry caseloads.

Verbatim wording from the response

“The London Borough of Hillingdon recognises the importance of aftercare following the decluttering of a home. The Welfare Reform & Tenancy Support Manager was the Lead Officer dealing with the case. She was due to go on leave in the aftercare period and it is recognised that a better handover should have taken place before she commenced her period of annual leave. It is standard practice in the London Borough of Hillingdon for every Officer to complete a handover to their manager just before they go on annual leave. With immediate effect, the London Borough of Hillingdon has made sure that this standard practice is extended to include handovers by managers who themselves carry a caseload. Handover arrangements generally will be specifically covered in the Operational Guidance Note for staff and covered during the training for all Housing Management staff in November 2023.”

Source location

Response from London Borough of Hillingdon
Page 6 · response
Published 6 September 2023

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

Data last updated 7 September 2026