PFD report

Asher Blackman · Prevention of Future Deaths report

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Issued 6 Mar 2026•North 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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised3

  1. Failure to record next of kin details in the initial assessment
    Part of recurring concern: Failure to maintain accurate next-of-kin information in healthcare records
  2. Failure to record what to do when the district nurse cannot gain access
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure of the no-access policy to include police involvement where the patient's life may be at risk
    Part of recurring concern: Failure to escalate welfare concerns after unsuccessful contact
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.4

  1. Action

    Conduct Trust-wide engagement events to review no-access clinical practice and reinforce comprehensive records and emergency-contact documentation.

    Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 March 2026.
  2. Action

    Update electronic patient records with prompts and alerts supporting completion and verification of next-of-kin and emergency-contact information.

    Stated by Central London Community Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2026.
  3. Action

    Undertake a comprehensive review to strengthen the no-access policy’s emphasis on immediate escalation for patients at significant clinical risk.

    Stated by Central London Community Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2026.

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

  1. Position

    Implemented improvements to no-access arrangements and the proportionate PSIRF response directly address the reported concerns and strengthen patient safeguards.

    Stated by Central London Community Healthcare NHS TrustExisting 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 record next of kin details in the initial assessment

Wider context from the report

“That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access. The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access. ”

Is this part of a recurring concern?

Yes — Failure to maintain accurate next-of-kin information in healthcare records.

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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 record what to do when the district nurse cannot gain access

Wider context from the report

“That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access. The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 the no-access policy to include police involvement where the patient's life may be at risk

Wider context from the report

“That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access. The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access. ”

Is this part of a recurring concern?

Yes — Failure to escalate welfare concerns after unsuccessful contact.

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

Conduct Trust-wide engagement events to review no-access clinical practice and reinforce comprehensive records and emergency-contact documentation.

Verbatim wording from the response

“On behalf of Central London Community Healthcare NHS Trust (CLCH), I would like to express again our sincere condolences to Mr Blackman’s family. The Trust has carefully reviewed the matters raised in your report and, to ensure that we fully reflect on and learn from the events leading to the death of Mr Blackman, has undertaken a programme of Trust-wide engagement events. These sessions have been designed to review clinical practice and the application of the ‘No Access: Not Seen: Disengagement Policy’, ensuring that current approaches to managing situations where clinical staff are unable to gain access to a patient appropriately identify and assess all potential risks, and that proportionate mitigations are implemented to meet individual patient need.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 1 · response
Published 10 March 2026

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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

Update electronic patient records with prompts and alerts supporting completion and verification of next-of-kin and emergency-contact information.

Verbatim wording from the response

“In addition, the Trust has a long-term plan to improve visibility of this information on the system, and we are working with the Information Management Team to update the electronic patient record system to include prompts and alerts to support completion and verification of this information.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 10 March 2026

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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 comprehensive review to strengthen the no-access policy’s emphasis on immediate escalation for patients at significant clinical risk.

Verbatim wording from the response

“Notwithstanding the existence of this Trust policy, the Trust is currently undertaking a comprehensive review informed by recent staff engagement activities. This review is intended to strengthen the policy by placing greater emphasis on the immediate escalation of a “no access” visit where a patient is assessed as being at significant clinical risk, including cases requiring critical interventions such as blood glucose monitoring and insulin administration.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 10 March 2026

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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 District Nursing referral forms, initial assessment documentation, and clinical-system configurations for contact-information capture and visibility.

Verbatim wording from the response

“The Trust has undertaken a review of District Nursing referral forms, initial assessment documentation, and clinical system configurations to ensure that:”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 10 March 2026

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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

Implemented improvements to no-access arrangements and the proportionate PSIRF response directly address the reported concerns and strengthen patient safeguards.

Verbatim wording from the response

“Central London Community Healthcare NHS Trust has formally reviewed the incident in accordance with its Patient Safety Incident Response Framework (PSIRF) and has identified opportunities to enhance existing processes. The Trust is assured that the actions implemented to embed improvements within the No Access: Not Seen: Disengagement arrangements, together with the proportionate PSIRF response, directly address the concerns raised in your report and significantly strengthen safeguards for patients receiving community nursing services.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 3 · response
Published 10 March 2026

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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

The existing policy already provides for police involvement where non-access creates immediate, escalating or significant risks to patient safety or life.

Verbatim wording from the response

“The No Access: Not Seen: Disengagement Policy states that, while police involvement is not routine, it is both justified and expected where a failure to gain access gives rise to immediate or escalating concerns regarding patient safety or risk to life. The policy further provides for escalation to emergency services, including the police, where urgent visual confirmation of a patient’s wellbeing is required; where access is obstructed by others and there are genuine concerns regarding safety; or where non-access indicates a risk of significant harm or death.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 10 March 2026

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.2

  1. 1

    Provide patients with additional information about support available when staff cannot gain access.

    Stated by Central London Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 March 2026.
  2. 2

    Refresh staff knowledge on responding safely and appropriately to no-access situations.

    Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 March 2026.

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 patients with additional information about support available when staff cannot gain access.

Verbatim wording from the response

“The Trust will also be providing patients with additional information about how it will support them in circumstances where there is no access.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 10 March 2026

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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

Refresh staff knowledge on responding safely and appropriately to no-access situations.

Verbatim wording from the response

“In addition to the engagement events, the Trust has taken steps to refresh staff knowledge on how to respond safely and appropriately to instances of no access, aligned with the concerns you have raised.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 3 · response
Published 10 March 2026

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