PFD report

June Mavis Winterbottom · Prevention of Future Deaths report

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Issued 24 Sep 2020•West Yorkshire Eastern

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 raised4

  1. Failure to identify urgent cases that drift outside normal hours
    Part of recurring concern: Failure of case monitoring to identify cases requiring follow-up
  2. Lack of an ambulance escalation safety net when Adult Social Care cannot respond promptly
    Part of recurring concern: Failure to call an ambulance promptly when emergency assistance is requiredPart of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Failure to take timely escalation action when safety thresholds are breached
  3. Failure of urgent referrals to receive a timely response
    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.9

  1. Action

    Embed a referral-transfer process requiring dashboard entry and direct confirmation with the worker on shift.

    Stated by Wakefield City CouncilStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  2. Action

    Enable all Adult Triage workers to view both East and West Urgent Response Dashboards and monitor submitted referrals.

    Stated by Wakefield City CouncilStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  3. Action

    Establish an on-call rota identifying a manager responsible for out-of-hours periods.

    Stated by Wakefield City CouncilStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.

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

  1. Position

    Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.

    Stated by Wakefield City CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 urgent cases that drift outside normal hours

Wider context from the report

“(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance (2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20. (3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient. (4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager. (5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up.

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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

Lack of an ambulance escalation safety net when Adult Social Care cannot respond promptly

Wider context from the report

“(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance (2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20. (3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient. (4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager. (5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required; Failure to seek medical attention when a person's condition warrants it; Failure to take timely escalation action when safety thresholds are breached.

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 urgent referrals to receive a timely response

Wider context from the report

“(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance (2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20. (3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient. (4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager. (5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason. ”

Is this part of a recurring concern?

Yes — Unreliable social care referral pathways.

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 establish accountability with an identified manager

Wider context from the report

“(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance (2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20. (3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient. (4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager. (5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Embed a referral-transfer process requiring dashboard entry and direct confirmation with the worker on shift.

Verbatim wording from the response

“Further work was then undertaken over the next four weeks to ensure that the referral transfer process was robust, with the following specific actions being implemented:”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 3 · response
Published 19 November 2020

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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

Enable all Adult Triage workers to view both East and West Urgent Response Dashboards and monitor submitted referrals.

Verbatim wording from the response

“• We have ensured that all Adult Triage workers in Social Care Direct can view the Urgent Response Dashboards for both East and West to check the progress of any referrals they sent through.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Establish an on-call rota identifying a manager responsible for out-of-hours periods.

Verbatim wording from the response

“• A Team Managers on call rota was set up, to ensure that there was always a clearly identified manager responsible for out of hours, whether evenings or weekends.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Revise and simplify the rota, adding contact numbers for workers, managers and teams.

Verbatim wording from the response

“• The rota format was revised and simplified so that it is clearer to identify who is working.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Distribute weekly rota emails with working arrangements and out-of-hours shift guidance, including instructions to check both Urgent Response Dashboards.

Verbatim wording from the response

“• A weekly email is distributed across the Adult Social Care service, containing the rota which in turn contains clear working arrangement guidance. It makes it clear who is working and when, and in what role.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 3 · response
Published 19 November 2020

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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

Require core-hours Urgent Response workers to communicate follow-up requirements directly to extended-hours workers.

Verbatim wording from the response

“• The Urgent Response workers covering core hours will directly communicate with the extended hours workers regarding anything which needs following up from the day.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 3 · response
Published 19 November 2020

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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 dedicated out-of-hours workforce system for handling referrals.

Verbatim wording from the response

“At this time, WMDC Adult Social Care had realigned its workforce in order to support the Covid response as directed by the Department for Health and Social Care. In particular, the national guidance required Adult Social Care to facilitate urgent hospital discharges between 8am and 8pm, to ease the mounting pressure on overburdened hospitals. WMDC Adult Social Care had implemented a new system of workers covering referrals outside of usual working hours in the weeks prior to this referral being received. There were also further changes to usual working practices in that significant numbers of staff were working remotely from home due to the Covid situation. Nevertheless, action should have resulted from the referral during the evening of 2nd June 2020 and I offer my sincere apologies to Mrs Winterbottom’s family.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 2 · response
Published 19 November 2020

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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

Instruct out-of-hours Approved Mental Health Professionals to check the Urgent Response Dashboard when starting evening duty.

Verbatim wording from the response

“• Additionally, the Social Care Direct Manager has instructed the Out of Hours Approved Mental Health Professionals (“AMHP”) to check the Urgent Response dashboard when they come on duty in the evening (although it is recognised that they will always have to prioritise Mental Health Act assessments over other work).”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Give Social Care Direct access to extended-hours rotas, staff mobile numbers and a manager escalation contact for urgent referrals.

Verbatim wording from the response

“On the 3rd June 2020, senior managers worked immediately to improve the system.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 2 · response
Published 19 November 2020

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

Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.

Verbatim wording from the response

“I trust that the above information addresses the matters of concern you raise, and provides sufficient reassurance that Adult Social Care in Wakefield have already appropriately reviewed our systems following the death of Mrs Winterbottom, and taken action to ensure the robustness of our systems. As a consequence, Adult Social Care do not feel that there are any additional actions which need to be taken resulting from your issuance of the Regulation 28 Report.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 4 · response
Published 19 November 2020

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

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

  1. 1

    It is speculative that medical assistance or a different outcome would have resulted from a social care practitioner’s attendance on 2 June 2020.

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

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

It is speculative that medical assistance or a different outcome would have resulted from a social care practitioner’s attendance on 2 June 2020.

Verbatim wording from the response

“It is also noted that you raise as a matter of concern that Mrs Winterbottom “was left alone without the medical assistance which would probably have been called in had she been seen.” Of course, Mrs Winterbottom was seen by her grandson that evening, who did not feel that medical assistance was required. Social workers are not trained medical professionals. Nor do Social Care Direct operate an emergency service. The response was being coordinated at a time when there was rapid community transmission of Coronavirus and consideration was therefore required around the risks of introducing new people into the household of a vulnerable adult. It is speculative that any different course of action would have been taken had a social care practitioner attended on the evening of 2nd June 2020.”

Source location

2020-0183-Response-from-Wakefield-Council_Redacted.pdf
Page 4 · response
Published 19 November 2020

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