PFD report

Oliver Brassington Weston · Prevention of Future Deaths report

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Issued 20 Dec 2021•Lancashire and Blackburn with Darwen

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
10

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised10

  1. Lack of critical appraisal of inspections
    Part of recurring concern: Unreliable Ofsted inspection processesPart of recurring concern: Unreliable interpretation and use of evidence in regulatory inspections
  2. Deficient preplanning of monitoring visits
  3. Failure of inspectors to consider relevant safeguarding documentation
    Part of recurring concern: Unreliable Ofsted inspection processes
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 critical appraisal of inspections

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

Is this part of a recurring concern?

Yes — Unreliable Ofsted inspection processes; Unreliable interpretation and use of evidence in regulatory inspections.

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

Deficient preplanning of monitoring visits

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

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 of inspectors to consider relevant safeguarding documentation

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

Is this part of a recurring concern?

Yes — Unreliable Ofsted inspection processes.

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

Drawing unsupportable conclusions from available documentation

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

Is this part of a recurring concern?

Yes — Unreliable Ofsted inspection processes.

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 enquiry during inspections

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

Is this part of a recurring concern?

Yes — Unreliable Ofsted inspection processes; Unreliable interpretation and use of evidence in regulatory inspections.

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

Misinterpretation of available evidence during inspections

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

Is this part of a recurring concern?

Yes — Unreliable Ofsted inspection processes; Unreliable interpretation and use of evidence in regulatory inspections.

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 of inspectors to consider significant information indexed in the file

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

Is this part of a recurring concern?

Yes — Unreliable Ofsted inspection processes.

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 documented determination of whether a monitoring or inspection visit was required following the death of a looked after child

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

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 clarify matters of concern with absent home managers and Responsible Individuals

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

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

Lack of guidance for senior managers on exceptional circumstances for report publication

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of ████████ known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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