PFD report

Roy Adrian CURTIS · Prevention of Future Deaths report

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Issued 4 Dec 2020•Milton Keynes

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised2

  1. Failure to give urgent adult social care assessment referrals sufficient priority within social services
    Part of recurring concern: Unreliable referral urgency categorisation and prioritisationPart of recurring concern: Unreliable social care referral pathways
  2. Overly bureaucratic procedure for allocating and responding to urgent adult social care assessment referrals
    Part of recurring concern: Unreliable social care referral pathways
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

    Employ a link social worker for the acute mental health ward to coordinate required social care assessments before discharge.

    Stated by Milton Keynes City CouncilStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
  2. Action

    Embed identification of inpatients needing social care support in discharge planning to enable timely assessment before discharge.

    Stated by Milton Keynes City CouncilStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
  3. Action

    Monitor team practice and monthly performance, including assessment timelines and casework reviews, through the Adult Leadership Team.

    Stated by Milton Keynes City CouncilStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.

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

  1. Position

    The out-of-hours team does not complete adult social care assessments; required assessments are referred to the Access Team.

    Stated by Milton Keynes 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 give urgent adult social care assessment referrals sufficient priority within social services

Wider context from the report

“That the procedure for allocating and responding to a referral for an urgent adult social care assessment is overly bureaucratic and they are not afforded the priority within social services that they so obviously require. ”

Is this part of a recurring concern?

Yes — Unreliable referral urgency categorisation and prioritisation; Unreliable social care referral pathways.

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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

Overly bureaucratic procedure for allocating and responding to urgent adult social care assessment referrals

Wider context from the report

“That the procedure for allocating and responding to a referral for an urgent adult social care assessment is overly bureaucratic and they are not afforded the priority within social services that they so obviously require. ”

Is this part of a recurring concern?

Yes — Unreliable social care referral pathways.

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

Employ a link social worker for the acute mental health ward to coordinate required social care assessments before discharge.

Verbatim wording from the response

“We recognise that we did not get our response right for Mr Curtis. We have learnt from his untimely death and have reviewed and improved our practice. There is now a link social worker employed to work with the acute mental health hospital ward who is responsible for coordinating social care assessments before discharge when needed.”

Source location

2020-0272-Response-from-Milton-Keynes-Council-Redacted
Page 2 · response
Published 5 January 2021

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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

Embed identification of inpatients needing social care support in discharge planning to enable timely assessment before discharge.

Verbatim wording from the response

“Mr Curtis should have been seen and offered an assessment whilst still an inpatient at the Campbell Centre, an approach that is now well embedded across health and social care. Identifying people who are in patients who need support are in discharge planning meetings and is now straightforward and should not be subject to any delays or unnecessary bureaucracy.”

Source location

2020-0272-Response-from-Milton-Keynes-Council-Redacted
Page 1 · response
Published 5 January 2021

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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

Monitor team practice and monthly performance, including assessment timelines and casework reviews, through the Adult Leadership Team.

Verbatim wording from the response

“We will continue to monitor the practice of our teams, with a focus on learning and improving outcomes for vulnerable people. We formally review our performance each month via our Adult Leadership Team meeting, with Heads of Service responsible for the performance in their area. This monitoring includes the timelines for assessments and case work review.”

Source location

2020-0272-Response-from-Milton-Keynes-Council-Redacted
Page 3 · response
Published 5 January 2021

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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 out-of-hours team does not complete adult social care assessments; required assessments are referred to the Access Team.

Verbatim wording from the response

“Outside of office hours the Milton Keynes Council’s Out of hours Social Care responds to urgent requests for assistance. The team operates between 1700 and 0900 and at all hours over the weekends and bank holidays. The Out of Hours team do not complete ASC assessment but will deal with urgent matters e.g. a missing person, requests for additional care and Mental Health Act assessments. The Out of Hours Team will complete a referral into the Access Team should an adult social care assessment be required.”

Source location

2020-0272-Response-from-Milton-Keynes-Council-Redacted
Page 2 · response
Published 5 January 2021

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

    Revise mandatory autism training for all adult social care staff to include awareness of suicidality and associated risks.

    Stated by Milton Keynes City CouncilStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
  2. 2

    Update practice guidance for unsuccessful contact attempts, including repeated contact, home visits, professional checks and welfare referrals where concerns persist.

    Stated by Milton Keynes City CouncilStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.

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

Revise mandatory autism training for all adult social care staff to include awareness of suicidality and associated risks.

Verbatim wording from the response

“We have reviewed the Autism training to include awareness of suicidality and risks, this training is mandatory for all ASC staff.”

Source location

2020-0272-Response-from-Milton-Keynes-Council-Redacted
Page 2 · response
Published 5 January 2021

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

Update practice guidance for unsuccessful contact attempts, including repeated contact, home visits, professional checks and welfare referrals where concerns persist.

Verbatim wording from the response

“It can be challenging and sometimes take time to contact a person referred for an assessment. Our MKC Adult Social Care Practice Guidance has been updated regarding how to manage situations where contact has not been possible. This includes:”

Source location

2020-0272-Response-from-Milton-Keynes-Council-Redacted
Page 2 · response
Published 5 January 2021

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