PFD report

Colin Robert GUMM · Prevention of Future Deaths report

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Issued 26 Apr 2023•Lincolnshire

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
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised6

  1. Failure to identify and assess conflicting evidence about alcohol provision
    Part of recurring concern: Failure to reconcile conflicting information in safety assessments
  2. Failure to take safeguarding action to mitigate identified risks
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and notices
  3. Lack of safeguarding review and monitoring during periods of ongoing care
    Part of recurring concern: Failure to maintain effective safeguarding review and monitoring
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    The authority was not responsible for monitoring or reviewing care when it had no commissioned care involvement or safeguarding referral.

    Stated by Lincolnshire County CouncilOutside remitThe respondent said that this matter was outside its role or authority.

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 identify and assess conflicting evidence about alcohol provision

Wider context from the report

“6.Conflicting evidence was provided by bluebird care that : Registered Manager (02/02/2023) - "the only drink we pour for him is water, we never poured alcohol for him" "26th November 2021 14:24 from carer's log - "water and whiskey provided on top of ongoing medication" EMAS report (12/04/2022) - "bottles of alcohol were found by his bed and enquired with the carers ,however they believed he doesn't drink a lot as he was unable to pour on his own". If that is right somebody was pouring for him. Shouldn't all this have been picked up by the safeguarding assessment? ”

Is this part of a recurring concern?

Yes — Failure to reconcile conflicting information in safety assessments.

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 take safeguarding action to mitigate identified risks

Wider context from the report

“5.The outcome from the admitted "limited information gathered" was that no risk was identified and no action taken. Despite the toxicology report still to be received the enquiry was closed and never reopened. As a result no appropriate action was taken to mitigate any risks to others. ”

Is this part of a recurring concern?

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

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

Lack of safeguarding review and monitoring during periods of ongoing care

Wider context from the report

“2. It was not until April 2021, 3 years later and despite care packages being in place and funded by Lincolnshire county Council, that the deceased became known again to Adult Social Care where it was deemed necessary to provide ongoing support of the Wellbeing team and Adult Social Care until his passing in November 2021.This was as a result of a referral from the GP. What happened in those 3 years by way of observations upon the deceased by safeguarding and if none shouldn't there have been something in place? Nothing has been evidenced to date. Shouldn't measures have been in place to review/monitor? ”

Is this part of a recurring concern?

Yes — Failure to maintain effective safeguarding review and monitoring.

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 identify and assess signs of underweight and clinical dehydration

Wider context from the report

“3.EMAS make there own safeguarding referral on 29th November 2021 as he appeared to them on the one time they saw the deceased that he was underweight and showing signs of clinical dehydration. If they were able to observe this why is none else in Adult Social Care making the same assessment during his lifetime? ”

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

Premature closure of section 42 safeguarding enquiries without gathering material information

Wider context from the report

“7.Instead the s.42 reporter according to the live evidence of the principal practitioner of the Adult Safeguarding team of the day, appears to have collated only limited information and closed the inquiry down prematurely without looking at material documents or even awaiting the toxicology report. At the very least it should be reopened to see if there was any missed opportunities from which lessons could be learnt and future deaths prevented and to embody the whole purpose of a s.42 assessment in deciding what action to take to support and protect the person in question. It being reiterated that this assessment was only commissioned after the deceased had passed away. ”

Is this part of a recurring concern?

Yes — Failure to act appropriately on safeguarding referrals and notices; Unreliable adult safeguarding threshold assessment and response.

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 complete Adult Social Care assessments

Wider context from the report

“1. Adult Social Care were first involved in 2017 due to the deceased self neglecting. It is recorded assessments were not able to be completed. ”

Is this part of a recurring concern?

Yes — Untimely or incomplete community care assessments.

Open source report

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 authority was not responsible for monitoring or reviewing care when it had no commissioned care involvement or safeguarding referral.

Verbatim wording from the response

“This factual basis is incorrect. There were no packages of care provided or funded by Lincolnshire County Council (‘LCC’) between 2017 and April 2021. Furthermore, there was never any doubt about Mr Gumm's capacity to make his own decisions about his own care and support and in fact he made his own private arrangements. As LCC were not involved in the commissioning of any care for him, LCC would only become involved if a safeguarding concern was raised or if he had changed his mind about wanting support and was eligible for that support. Aside from the referral already referred to in the safeguarding statement, there were no safeguarding referrals which came to the attention of LCC in those 3 years. So, in summary there would not have been, nor should there have been, observations of him by safeguarding nor reviews of his care as this was not the responsibility of LCC.”

Source location

Response from Lincolnshire County Council
Page 2 · response
Published 3 May 2023

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

The authority had no opportunity to observe privately arranged care unless a safeguarding referral was made.

Verbatim wording from the response

“Adult social care was not involved in the provision of Mr Gumm’s care and therefore had no opportunity to be sighted on it unless a referral of a safeguarding nature was made. No such referral was made. Bluebird Care was the agency providing his privately arranged care.”

Source location

Response from Lincolnshire County Council
Page 4 · response
Published 3 May 2023

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

The Commercial Team and, where appropriate, CQC decide assurance actions after limited safeguarding fact-finding.

Verbatim wording from the response

“However, if necessary, limited fact-finding enquiries will be made by the safeguarding team in order to ascertain whether further consideration of potential risk to others is required. This information is shared with the Commercial Team and, if appropriate, CQC, who will consider the information and decide any assurance actions, which may include if appropriate, a visit to the provider. Every contract for services with the council has its own contracts officer allocated to that provider. In the first instance, depending on the circumstances, it is likely that the contracts office will visit.”

Source location

Response from Lincolnshire County Council
Page 6 · response
Published 3 May 2023

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

The toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.

Verbatim wording from the response

“Mr Gumm had sadly died and therefore this ended the Local Authority's legal duty to take steps to safeguard Mr Gumm under s.42. However, the Safeguarding Team did progress with a s.42 enquiry (although it should have been recorded as a non s.42 enquiry at that time) to seek wider assurance in relation to the care providers involved and any potential wider risks. (LCC’s processes in relation to s.42 enquiries and more generally is explored below in the section on action by LCC). Proportionate enquiries/fact-findings was undertaken (in so far as the council were able to do so given the circumstances) and no concerns were identified in relation to the services provided to the deceased.”

Source location

Response from Lincolnshire County Council
Page 5 · response
Published 3 May 2023

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

The statutory safeguarding duty did not apply to a deceased individual, so a section 42 enquiry was inappropriate in these circumstances.

Verbatim wording from the response

“Pursuant to LCC’s duties under s.42, a Local Authority is not required by law to carry out enquiries for those individuals who do not meet the criteria for safeguarding as set out in this section of the Act. In particular, the care act duty can have no application to a deceased individual as the purpose of the enquiry is to decide what action is to be taken in relation to the individual and by whom. In some cases, LCC may have had a safeguarding referral during the individual’s life and appropriate information about LCC’s safeguarding actions will be provided to the coroner.”

Source location

Response from Lincolnshire County Council
Page 6 · response
Published 3 May 2023

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

Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.

Verbatim wording from the response

“We can only reiterate that LCC was not providing care to Mr Gumm at the time. LCC are not therefore in a position to determine whose evidence can or should be believed”

Source location

Response from Lincolnshire County Council
Page 5 · response
Published 3 May 2023

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 council quality-assurance and multi-agency arrangements provide appropriate assurance about risks to other individuals.

Verbatim wording from the response

“However, the council also has significant other quality assurance methods which may be used to monitor and improve services and work with the regulator who has the power to take formal action or in the worst-case scenario work with the regulator, who has the authority to close down an unsafe provision.”

Source location

Response from Lincolnshire County Council
Page 6 · response
Published 3 May 2023

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

Capacity to refuse services meant the authority could not compel assessment or acceptance of care.

Verbatim wording from the response

“The coroner had evidence within the safeguarding statement that the recorded assessments were not able to be completed due to the individual's lack of engagement with the authority. Where an individual has capacity to refuse to engage with a service, they are entitled to do so. LCC are not able to force an individual to accept services or an assessment.”

Source location

Response from Lincolnshire County Council
Page 1 · response
Published 3 May 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.1

  1. 1

    Review safeguarding processes for concerns raised after an adult’s death.

    Stated by Lincolnshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The factual basis was incorrect: no council-funded care packages existed between 2017 and April 2021.

    Stated by Lincolnshire County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Review safeguarding processes for concerns raised after an adult’s death.

Verbatim wording from the response

“LCC has already reviewed its safeguarding processes in relation to matters where the safeguarding concerns are raised when the adult is deceased.”

Source location

Response from Lincolnshire County Council
Page 6 · response
Published 3 May 2023

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

The factual basis was incorrect: no council-funded care packages existed between 2017 and April 2021.

Verbatim wording from the response

“This factual basis is incorrect. There were no packages of care provided or funded by Lincolnshire County Council (‘LCC’) between 2017 and April 2021. Furthermore, there was never any doubt about Mr Gumm's capacity to make his own decisions about his own care and support and in fact he made his own private arrangements. As LCC were not involved in the commissioning of any care for him, LCC would only become involved if a safeguarding concern was raised or if he had changed his mind about wanting support and was eligible for that support. Aside from the referral already referred to in the safeguarding statement, there were no safeguarding referrals which came to the attention of LCC in those 3 years. So, in summary there would not have been, nor should there have been, observations of him by safeguarding nor reviews of his care as this was not the responsibility of LCC.”

Source location

Response from Lincolnshire County Council
Page 2 · response
Published 3 May 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