PFD report

Dana Louise Baker · Prevention of Future Deaths report

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Issued 29 May 2013•Worcestershire

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
2

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. Inadequate communication between agencies
    Part of recurring concern: Unreliable multi-agency communication procedures
  2. Failure to share interagency serious incident reviews
    Part of recurring concern: Unreliable formal safety-incident management processesPart of recurring concern: Unreliable multi-agency communication procedures
  3. Lack of knowledge and understanding between agencies
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated care
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.2

  1. Action

    Conduct Case Reviews using the Social Care Institute for Excellence and Significant Incident Learning Process models.

    Stated by Worcestershire Safeguarding Children BoardStated completedThe respondent said that this action was complete when they made their response on 29 May 2014.
  2. Action

    Share Individual Management Reviews between participating agencies as part of Serious Case Reviews.

    Stated by Worcestershire Safeguarding Children BoardStated completedThe respondent said that this action was complete when they made their response on 29 May 2014.

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

  1. Position

    Existing guidance and established inter-agency sharing of Individual Management Reviews are considered sufficient to address the concern.

    Stated by Worcestershire Safeguarding Children BoardExisting 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

Inadequate communication between agencies

Wider context from the report

“(1) As outlined in the IMR's, the Serious Case Review and the draft Overview Report there was a lack of knowledge and understanding as between various agencies involved with Dana and inadequate communication between them. ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

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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 share interagency serious incident reviews

Wider context from the report

“(2) The IMR's are kept confidential and not even shared as between Agencies concerned. Some IMR authors indicated that they could not comment on areas of "mutual concern" because they were unaware of the content of other Agency's IMR's. ”

Is this part of a recurring concern?

Yes — Unreliable formal safety-incident management processes; Unreliable multi-agency communication procedures.

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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 knowledge and understanding between agencies

Wider context from the report

“(1) As outlined in the IMR's, the Serious Case Review and the draft Overview Report there was a lack of knowledge and understanding as between various agencies involved with Dana and inadequate communication between them. ”

Is this part of a recurring concern?

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

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 Case Reviews using the Social Care Institute for Excellence and Significant Incident Learning Process models.

Verbatim wording from the response

“In response to this guidance a number of models have been developed nationally, including the Social Care Institute for Excellence (SCIE) and the Significant Incident Learning Process (SILP) models. WSCB has already undertaken Case Reviews using both of these models and the feedback to date has been positive. Whilst the process can be challenging for practitioners and managers, they also welcome the opportunity for closer engagement, reflection and learning.”

Source location

2014-0242-Response-by-Safeguarding-Children-Board
Page 2 · response
Published 29 May 2014

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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

Share Individual Management Reviews between participating agencies as part of Serious Case Reviews.

Verbatim wording from the response

“The sharing of IMRs between agencies on the Panel has always been a key element of the SCR process and the more collaborative 'systems approach'”

Source location

2014-0242-Response-by-Safeguarding-Children-Board
Page 2 · response
Published 29 May 2014

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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

Existing guidance and established inter-agency sharing of Individual Management Reviews are considered sufficient to address the concern.

Verbatim wording from the response

“I would suggest that the current government guidance contained in Working Together to Safeguard Children 2013, together with the knowledge that Worcestershire Safeguarding Children Board has fully embraced this guidance, would help to address the issue of the sharing of IMRs which you have raised in the Regulation Report. Government guidance has been developed in the time since EW's death and WSCB has responded positively to this change.”

Source location

2014-0242-Response-by-Safeguarding-Children-Board
Page 2 · response
Published 29 May 2014

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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

    National safeguarding practice is set by the Department for Education, so the report may have been better directed there.

    Stated by Worcestershire Safeguarding Children BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

National safeguarding practice is set by the Department for Education, so the report may have been better directed there.

Verbatim wording from the response

“I am responding to your Regulation 28 Report to Prevent Future Deaths, dated 29 May 2014. Your letter was also addressed to the Chief Executive of Worcestershire County Council, but I assume it was intended for the Local Safeguarding Children Board. Whilst I set out our response below, I should make the point that Worcestershire Safeguarding Children Board is one of 146 Local Safeguarding Children Boards (LSCBs) in England. We follow, but do not set national practice, and I wonder if your report may have been better directed to the Department for Education.”

Source location

2014-0242-Response-by-Safeguarding-Children-Board
Page 1 · response
Published 29 May 2014

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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