PFD report

Charlotte Duffield · Prevention of Future Deaths report

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Issued 5 Oct 2021•Cumbria

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 take safeguarding action following significant safety concerns
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and notices
  2. Failure to make an in-person visit after unanswered safeguarding contact attempts
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and notices
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.5

  1. Action

    Deliver training sessions across partner organisations to embed revised self-neglect policy, procedure and guidance.

    Stated by Cumbria County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
  2. Action

    Complete a systematic review of safeguarding adults self-neglect policies and procedures to clarify roles, responsibilities and duties.

    Stated by Cumbria County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
  3. Action

    Implement a countywide operational Safeguarding Adults service with a dedicated team providing consistent responses to safeguarding concerns.

    Stated by Cumbria County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.

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 following significant safety concerns

Wider context from the report

“(1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS ████████ of Cumbria Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken. (2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person. ”

Is this part of a recurring concern?

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

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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

Failure to make an in-person visit after unanswered safeguarding contact attempts

Wider context from the report

“(1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS ████████ of Cumbria Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken. (2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person. ”

Is this part of a recurring concern?

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

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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

Deliver training sessions across partner organisations to embed revised self-neglect policy, procedure and guidance.

Verbatim wording from the response

“4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance.”

Source location

2021-0334-Response-from-Cumbria-County-Council_Published
Page 1 · response
Published 14 October 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

Complete a systematic review of safeguarding adults self-neglect policies and procedures to clarify roles, responsibilities and duties.

Verbatim wording from the response

“1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system.”

Source location

2021-0334-Response-from-Cumbria-County-Council_Published
Page 1 · response
Published 14 October 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

Implement a countywide operational Safeguarding Adults service with a dedicated team providing consistent responses to safeguarding concerns.

Verbatim wording from the response

“3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect.”

Source location

2021-0334-Response-from-Cumbria-County-Council_Published
Page 1 · response
Published 14 October 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

Review and revise operational guidance for self-neglect concerns to require face-to-face visits for assessment and safety assurance.

Verbatim wording from the response

“2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards.”

Source location

2021-0334-Response-from-Cumbria-County-Council_Published
Page 1 · response
Published 14 October 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

Undertake a practice learning session with the involved team to establish a clear operational response to self-neglect concerns.

Verbatim wording from the response

“5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns.”

Source location

2021-0334-Response-from-Cumbria-County-Council_Published
Page 2 · response
Published 14 October 2021

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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