PFD report

Samuel Robert Pearson · Prevention of Future Deaths report

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Issued 10 Nov 2022•South London

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
6

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 of authorities to maintain partnership working during emergency decants
  2. Failure of authorities to share information during emergency decants
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated care
  3. Delays in screening referrals by the ADAPT service
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.6

  1. Action

    Request a meeting with Bromley Federation of Housing Associations members to discuss notifying the Local Authority about relevant emergency decants.

    Stated by London Borough of BromleyStated completedThe respondent said that this action was complete when they made their response on 11 November 2022.
  2. Action

    Notify relevant Local Authority personnel promptly when future emergency decants involve vulnerable people receiving social care support.

    Stated by London Borough of BromleyStated plannedThe respondent said that this action was planned when they made their response on 11 November 2022.
  3. Action

    Provide Clarion with contact details for vulnerable adults’ services, children’s services and Local Authority housing contacts for emergency-decant notifications.

    Stated by London Borough of BromleyStated completedThe respondent said that this action was complete when they made their response on 11 November 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Housing associations are responsible for handling emergency decants and developing notification protocols because they know their processes best.

    Stated by London Borough of BromleyRedirects 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

Failure of authorities to maintain partnership working during emergency decants

Wider context from the report

“(1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants. ”

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 authorities to share information during emergency decants

Wider context from the report

“(1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care.

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

Delays in screening referrals by the ADAPT service

Wider context from the report

“(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations. ”

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 inform referrers when referral services cannot meet usual service expectations

Wider context from the report

“(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations. ”

Is this part of a recurring concern?

Yes — Unreliable communication to referrers about referral service access and expectations.

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

Request a meeting with Bromley Federation of Housing Associations members to discuss notifying the Local Authority about relevant emergency decants.

Verbatim wording from the response

“3. Additionally, senior management in the LA Housing department have contacted Bromley Federation of Housing Associations to request that a meeting is convened to discuss this topic with their members, to ensure that they have due regard to arrangements for notifying LBB of emergency decants where there is a vulnerable household member.”

Source location

Response London Borough of Bromley Council
Page 2 · response
Published 11 November 2022

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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

Notify relevant Local Authority personnel promptly when future emergency decants involve vulnerable people receiving social care support.

Verbatim wording from the response

“1. In respect to the Coroner’s concern (1), emergency decants are dealt with by Housing Associations in the London Borough of Bromley. The Local Authority’s OT (Occupational Therapy) service were not made aware of the emergency move/decant of Mr Pearson at the time it took place. When made aware the OT service raised their concern by email to the relevant personnel regarding the temporary accommodation provided. Arising from this there is the need for the relevant Local Authority personnel to be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement (e.g adult social care/OT) is moved.”

Source location

Response London Borough of Bromley Council
Page 2 · response
Published 11 November 2022

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 Clarion with contact details for vulnerable adults’ services, children’s services and Local Authority housing contacts for emergency-decant notifications.

Verbatim wording from the response

“2. In respect of London Borough of Bromley’s largest provider Clarion, Senior Management in the Housing Department (LA) made contact with a Clarion Manager on the 14/12/22 and 29/12/22, raising the need to review their Emergency Decant Policy around notification of emergency decants to LBB where there is a vulnerable household member. Clarion have been asked to set out a notification protocol within this policy so that this can be agreed with the Local Authority. It is appropriate for the Housing Association to do this as they know their processes best. The Local Authority have already provided contact details to Clarion for vulnerable adults and children’s services as well as an LA housing contact, so that emergency decants can be notified as soon as the need is identified.”

Source location

Response London Borough of Bromley Council
Page 2 · response
Published 11 November 2022

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

Review alternative accommodation and assessment processes, including how interagency working can be embedded to improve future provision.

Verbatim wording from the response

“Review Since the inquest CHG have been reviewing its alternative accommodation and related assessment process to see what more if anything can reasonably be done to improve the system.”

Source location

Response from Clarion Housing Group
Page 2 · response
Published 11 November 2022

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

Complete the ADAPT Operational Policy to define waiting-time information provided to service users and referrers after referral receipt.

Verbatim wording from the response

“At the inquest we confirmed that we had been reviewing our ADAPT Operational Policy, however, it had not concluded in terms of how we would inform referrers about service expectations. Our new policy is now complete, and it now clearly sets out the expectations of what information services users and the referrer will receive once the Team receive the referral in terms of waiting times. A copy of the new Operational Policy incorporating this new process is enclosed with this response.”

Source location

Response from Oxleas NHS Foundation Trust
Page 1 · response
Published 11 November 2022

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

Generate automated referral acknowledgements and send service users and referrers letters stating current waiting times and escalation advice for urgent referrals.

Verbatim wording from the response

“An automated email will be generated and sent to the referrer:”

Source location

Response from Oxleas NHS Foundation Trust
Page 1 · response
Published 11 November 2022

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

Housing associations are responsible for handling emergency decants and developing notification protocols because they know their processes best.

Verbatim wording from the response

“1. In respect to the Coroner’s concern (1), emergency decants are dealt with by Housing Associations in the London Borough of Bromley. The Local Authority’s OT (Occupational Therapy) service were not made aware of the emergency move/decant of Mr Pearson at the time it took place. When made aware the OT service raised their concern by email to the relevant personnel regarding the temporary accommodation provided. Arising from this there is the need for the relevant Local Authority personnel to be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement (e.g adult social care/OT) is moved.”

Source location

Response London Borough of Bromley Council
Page 2 · response
Published 11 November 2022

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

At the time of the emergency relocation, direct assessment did not indicate that immediate involvement of another agency was needed.

Verbatim wording from the response

“This notwithstanding CHG instigated an urgent assessment of need with Samuel and his mum and through a separate and specialist property search agency, located properties capable of meeting his needs, which was primarily for wheelchair access. At the time of the accident CHG assessed Samuel’s needs with his mum and were not given to think (having asked a direct question) that any other agency or professional needed to be immediately involved at that stage, noting that as part of the process CHG keep matters under close review.”

Source location

Response from Clarion Housing Group
Page 1 · response
Published 11 November 2022

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