PFD report

Jessica Zoe EASTLAND-SEARES · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 10 Dec 2023•West Sussex, Brighton and Hove

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
16

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 raised1

  1. Inadequate community provision for the care and treatment of autistic people
    Part of recurring concern: Insufficient social and community care provision to meet care and discharge needsPart of recurring concern: Unreliable implementation of autism care and support servicesPart of recurring concern: Unreliable timely provision of appropriate care packages
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.11

  1. Action

    Invest an additional £121 million to improve community support for autistic people and people with learning disabilities.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
  2. Action

    Publish the updated draft Autism Act statutory guidance for public consultation.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  3. Action

    Update Autism Act statutory guidance to improve outcomes and clarify local authority responsibilities for autistic adults’ social care.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.

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

  1. Position

    Local authorities are responsible for planning and shaping local care markets because they are best placed to understand local population needs.

    Stated by Department of Health and Social CareRedirects 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

Inadequate community provision for the care and treatment of autistic people

Wider context from the report

“Sadly this case exposes the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions into inpatient mental health facilities and also A&E attendances. Despite a report from the Health and Social Care committee from 2021 this case showed that there does not seem to have been any real improvement and more lives are likely to be lost. Reading from this report, it says “The conclusion of this report was that Autistic people (and people with learning disabilities) have the right to live independent, free and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so.” The report identified that “the community support and provision for autistic people (and those with learning difficulties) and financial investment in those services is significantly below the level required to meet the needs of those individuals and to provide adequate support for them in the community. ” The Inquest heard that two years on there still remains an acute shortage of provision. Evidence was heard that East Sussex Council had tried over 30 providers to help put in place support for Jessie but they could not find a placement for her so the only provision that they were able to offer was supported housing with temporary care agency staff. This provision broke down which exacerbated Jessie’s mental health. This then led to a Hosptial mental inpatient admission. ”

Is this part of a recurring concern?

Yes — Insufficient social and community care provision to meet care and discharge needs; Unreliable implementation of autism care and support services; Unreliable timely provision of appropriate care packages.

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

Invest an additional £121 million to improve community support for autistic people and people with learning disabilities.

Verbatim wording from the response

“This financial year, we are investing an additional £121m to improve community support for autistic people and people with a learning disability, including funding for Children and Young People’s keyworkers. In addition, all Integrated Care Boards are expected to have an Executive Lead on learning disability and autism. This lead will support the board in planning to meet the needs of its local population of autistic people and people with a learning disability, and to have effective oversight of, and support improvements in, the quality of care for people in a mental health, learning disability and autism inpatient setting.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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

Publish the updated draft Autism Act statutory guidance for public consultation.

Verbatim wording from the response

“We are currently prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people in line with the national Strategy. This will include setting out guidance on how local authorities can meet their responsibilities relating to social care provision for autistic adults. We expect to publish the updated draft Statutory Guidance for public consultation, this year.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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

Update Autism Act statutory guidance to improve outcomes and clarify local authority responsibilities for autistic adults’ social care.

Verbatim wording from the response

“We are currently prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people in line with the national Strategy. This will include setting out guidance on how local authorities can meet their responsibilities relating to social care provision for autistic adults. We expect to publish the updated draft Statutory Guidance for public consultation, this year.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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 commissioning standards to set clear expectations for good social care commissioning.

Verbatim wording from the response

“That is why, in Next steps to put people at the heart of care, we committed to developing commissioning standards: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their skills in future-proofing their care markets and ensuring they have the data they need to shape their markets well.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 19 December 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

Invest in pilot training for senior local authority commissioners to improve care-market planning and data use.

Verbatim wording from the response

“That is why, in Next steps to put people at the heart of care, we committed to developing commissioning standards: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their skills in future-proofing their care markets and ensuring they have the data they need to shape their markets well.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 19 December 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

Monitor implementation of the Building the Right Support Action Plan through the cross-system Delivery Board.

Verbatim wording from the response

“We are determined to reduce the number of people with a learning disability and autistic people in mental health hospitals by supporting people to live well in their communities. The Building the Right Support Action Plan (published July 2022, alongside our response to the Health and Social Care Committee Report ‘The treatment of autistic people and people with learning disabilities’), brings together a wide range of actions we are taking across government and public services to help us drive progress on this. The cross-system Building the Right Support Delivery Board that I chair, monitors implementation of the commitments contained in the Action Plan.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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

Provide £15 million to establish ethical international recruitment support and bolster the adult social care workforce.

Verbatim wording from the response

“• Providing £15m for the 2023/24 financial year to help local areas establish support arrangements for ethical international recruitment and bolster workforce in adult social care.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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

Make care workers eligible for the Health and Care Worker Visa and add them to the Shortage Occupation List.

Verbatim wording from the response

“• Making care workers eligible for the Health and Care Worker Visa and adding them to the Shortage Occupation list (February 2022).”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 19 December 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

Provide additional adult social care funding to increase workforce capacity and retention, reduce waiting times and support provider fee rates.

Verbatim wording from the response

“The government has now made available up to £8.6 billion in additional funding over this financial year and next year to support adult social care and discharge. This includes £500m announced in January which has specifically been made available to support local authorities with the cost of social care in 2024/25.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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

Run the next phase of the national Made with Care recruitment campaign.

Verbatim wording from the response

“This is in addition to the Government’s support to Local Authorities in addressing workforce pressures, including:”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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

Invest up to £700 million in workforce training, recognition and career progression to improve social care quality and outcomes.

Verbatim wording from the response

“social care workforce remains at the heart of our reform plans. We are supporting care workers to develop their skills and their careers, alongside a range of new funded training schemes. In December 2021, we set out our strategy for the social care workforce in our ‘People at The Heart of Care’ white paper and in 2023 we published ‘Next Steps to put People at the Heart of Care’ which set out more detail on the government’s plans for reform. It outlined our plans to invest in better workforce training, recognition, and career progression. The ‘Next Steps to put People at the Heart of Care’ also set out how we are investing up to £700 million over this financial year and next, building on £100 million already invested in 2022/23, to improve the quality of social care provision and care outcomes.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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

Local authorities are responsible for planning and shaping local care markets because they are best placed to understand local population needs.

Verbatim wording from the response

“Under the Care Act (2014), local authorities have the duty to promote the efficient and effective operation of their care market, ensuring local care and support provision meets diverse local needs. They must have regard to current and future demand for care and support services and consider how providers will meet that demand. However, the Government recognises that shaping a care market is incredibly challenging. While local authorities are best placed to understand and plan for the care and support needs of their local population, there are elements of good market shaping practice that can be universally applied, such as involving those who draw upon care and their families in the commissioning process, supporting and investing in community services, and taking a prevention-based approach to shaping their market.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 19 December 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.5

  1. 1

    Launch a national career structure for the adult social care workforce through the Care Workforce Pathway.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  2. 2

    Introduce a digital leadership qualification for social care leaders and managers.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  3. 3

    Fund a new level 2 Care Certificate qualification for up to 37,000 direct-care workers.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  4. 4

    Expand subsidised workforce learning and development through an uplift to the Workforce Development Fund.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  5. 5

    Fund training and supervision for new social work and nursing apprenticeships.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 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

Launch a national career structure for the adult social care workforce through the Care Workforce Pathway.

Verbatim wording from the response

“In addition, we are investing in recruitment and retention through better workforce training, recognition and career progression and on the 10th January 2024 the government announced:”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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

Introduce a digital leadership qualification for social care leaders and managers.

Verbatim wording from the response

“• A new digital leadership qualification: This will help equip social care leaders and managers with the confidence and capability to lead the implementation and use of technology in the delivery of care.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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

Fund a new level 2 Care Certificate qualification for up to 37,000 direct-care workers.

Verbatim wording from the response

“• Over £50 million of funding for a new level 2 Care Certificate qualification: This will support up to 37,000 individuals in direct adult social care roles to enrol on the new qualification between June 2024 and March 2025.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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

Expand subsidised workforce learning and development through an uplift to the Workforce Development Fund.

Verbatim wording from the response

“• Subsidised training places: An uplift to the Workforce Development Fund that will expand access to learning and development, creating opportunities for the workforce to become experts in their field or progress into new roles.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 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

Fund training and supervision for new social work and nursing apprenticeships.

Verbatim wording from the response

“• An investment of over £20 million for apprenticeships: Local authorities and adult social care providers will be able to use the money towards training and supervising hundreds of new social work and nurse apprentices.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 December 2023

Open published response
Back to top

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