PFD report

Rebecca Hayward · Prevention of Future Deaths report

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Issued 13 Oct 2022•Nottinghamshire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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.

Report evidence summary

Concerns raised2

  1. Failure to extend Care Act assessments to changed care needs when people move accommodation
    Part of recurring concern: Untimely or incomplete community care assessments
  2. Lack of specialist expertise in assessments of persons with severe and multiple disadvantage
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

Failure to extend Care Act assessments to changed care needs when people move accommodation

Wider context from the report

“(2) Where a person is about to move to a different type of accommodation, Care Act assessments are only extended to include consideration of the individual’s changed care needs in their new environment if the early assessment work identifies eligible care needs in their current circumstances, with the social care provision subsequently being dependant on a re-referral and where such re-referrals are resisted; ”

Is this part of a recurring concern?

Yes — Untimely or incomplete community care assessments.

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 specialist expertise in assessments of persons with severe and multiple disadvantage

Wider context from the report

“(1) Assessments of persons with severe and multiple disadvantage are undertaken by persons with little or no experience or specialist training in homelessness and substance misuse, resulting in inaccurate assessment and plans; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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.4

  1. 1

    Develop an overarching action plan addressing the identified safeguarding and quality-assurance concerns.

    Stated by Nottingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 20 October 2022.
  2. 2

    Incorporate reports, revised policies, data reporting and qualitative measures into revised policies and training programmes.

    Stated by Nottingham City CouncilStated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.
  3. 3

    Review the action plan monthly under Senior Leadership Team governance.

    Stated by Nottingham City CouncilStated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.
  4. 4

    Apply the same governance arrangements to other concerns identified in the Adult Social Care Case and Quality Assurance Review.

    Stated by Nottingham City CouncilStated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.

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 an overarching action plan addressing the identified safeguarding and quality-assurance concerns.

Verbatim wording from the response

“The matters of concern have been reviewed and addressed by the Nottingham City Council Adult Social Care Senior Safeguarding Team, and Principal Social Workers. We have developed an overarching action plan which provides a comprehensive response to these matters. The plan will be reviewed on a monthly basis, and will be governed by the Senior Leadership Team. Progression of the plan will be evidenced through review of all reports and revised policies, data reporting and qualitative measures which will be incorporated into all revised policies and training programmes.”

Source location

Response from Nottingham Council
Page 1 · response
Published 20 October 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

Incorporate reports, revised policies, data reporting and qualitative measures into revised policies and training programmes.

Verbatim wording from the response

“The matters of concern have been reviewed and addressed by the Nottingham City Council Adult Social Care Senior Safeguarding Team, and Principal Social Workers. We have developed an overarching action plan which provides a comprehensive response to these matters. The plan will be reviewed on a monthly basis, and will be governed by the Senior Leadership Team. Progression of the plan will be evidenced through review of all reports and revised policies, data reporting and qualitative measures which will be incorporated into all revised policies and training programmes.”

Source location

Response from Nottingham Council
Page 1 · response
Published 20 October 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 the action plan monthly under Senior Leadership Team governance.

Verbatim wording from the response

“The matters of concern have been reviewed and addressed by the Nottingham City Council Adult Social Care Senior Safeguarding Team, and Principal Social Workers. We have developed an overarching action plan which provides a comprehensive response to these matters. The plan will be reviewed on a monthly basis, and will be governed by the Senior Leadership Team. Progression of the plan will be evidenced through review of all reports and revised policies, data reporting and qualitative measures which will be incorporated into all revised policies and training programmes.”

Source location

Response from Nottingham Council
Page 1 · response
Published 20 October 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

Apply the same governance arrangements to other concerns identified in the Adult Social Care Case and Quality Assurance Review.

Verbatim wording from the response

“The other areas of concern identified in the Case and Quality Assurance Review submitted by Nottingham City Council in evidence to assist the Inquest will adhere to the same governance arrangements as noted above.”

Source location

Response from Nottingham Council
Page 1 · response
Published 20 October 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

Official responses located
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Data last updated 7 September 2026