PFD report

Margaret Emily Flemming · Prevention of Future Deaths report

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Issued 29 Jan 2015•Bedfordshire and Luton

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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

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Concerns raised2

  1. Failure to arrange urgent assessment of confused people
  2. Delays in completing Best Interests Assessments following urgent Deprivation of Liberty Safeguarding Authorisation requests
    Part of recurring concern: Inadequate deprivation of liberty safeguarding for people lacking capacity
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.5

  1. Action

    Recruit temporary qualified staff to address increased DoLS assessment activity.

    Stated by the CouncilStated completedThe respondent said that this action was complete when they made their response on 29 January 2015.
  2. Action

    Train additional staff to perform the Best Interests Assessor function.

    Stated by the CouncilStated completedThe respondent said that this action was complete when they made their response on 29 January 2015.
  3. Action

    Apply a risk-based approach and waiting list to prioritise DoLS assessments.

    Stated by the CouncilStated completedThe respondent said that this action was complete when they made their response on 29 January 2015.

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

  1. Position

    The Council considered the care provided during the delayed DoLS assessment appropriate and in the deceased’s best interests.

    Stated by the 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 arrange urgent assessment of confused people

Wider context from the report

“2. The Local Authority were aware for a long period of time that the deceased had become confused and required urgent assessment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Delays in completing Best Interests Assessments following urgent Deprivation of Liberty Safeguarding Authorisation requests

Wider context from the report

“1. An urgent Request for a Deprivation of Liberty Safeguarding Authorisation was placed with Central Bedfordshire Council on 8th October 2014 and yet the Best Interests Assessment did not take place until 7th January 2015. The deceased remained vulnerable throughout this period. ”

Is this part of a recurring concern?

Yes — Inadequate deprivation of liberty safeguarding for people lacking capacity.

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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

Recruit temporary qualified staff to address increased DoLS assessment activity.

Verbatim wording from the response

“The Council has adopted the prioritisation approach and waiting list as a temporary measure, in order to be able to respond to the ten fold increase in DoLS activity. Part of the strategy to respond to this increase has been to recruit temporary qualified staff, and train additional staff to perform the Best Interests Assessor function. The Council is maintaining its investment in these staff to deal with the increase in activity.”

Source location

2015-0029-Response-by-Central-Bedfordshire-Council
Page 2 · response
Published 29 January 2015

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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

Train additional staff to perform the Best Interests Assessor function.

Verbatim wording from the response

“The Council has adopted the prioritisation approach and waiting list as a temporary measure, in order to be able to respond to the ten fold increase in DoLS activity. Part of the strategy to respond to this increase has been to recruit temporary qualified staff, and train additional staff to perform the Best Interests Assessor function. The Council is maintaining its investment in these staff to deal with the increase in activity.”

Source location

2015-0029-Response-by-Central-Bedfordshire-Council
Page 2 · response
Published 29 January 2015

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 a risk-based approach and waiting list to prioritise DoLS assessments.

Verbatim wording from the response

“Since March 2014, the Council has adopted a risk based approach, prioritising DoLS assessments on the basis of risk of harm to the person concerned, and using a waiting list for those assessed as low risk. As there was no indication of concerning with Mrs Flemming’s care package, no concerns raised by her family, and no indication of undue or excessive physical or medical restraint being used, the request relating to Mrs Flemming was assessed as low risk. Because of this, it meant that Mrs Flemming’s Best Interests Assessment did not take place until 9th January 2015. The outcome of this was that restrictions amounting to continuous supervision and control had been in place for frequent and prolonged period since Mrs Flemming’s admission on 22nd May 2009, she was not free to leave, and the placement was in her best interests.”

Source location

2015-0029-Response-by-Central-Bedfordshire-Council
Page 1 · response
Published 29 January 2015

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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

Maintain investment in temporary and additional assessment staff to address increased DoLS activity.

Verbatim wording from the response

“The Council has adopted the prioritisation approach and waiting list as a temporary measure, in order to be able to respond to the ten fold increase in DoLS activity. Part of the strategy to respond to this increase has been to recruit temporary qualified staff, and train additional staff to perform the Best Interests Assessor function. The Council is maintaining its investment in these staff to deal with the increase in activity.”

Source location

2015-0029-Response-by-Central-Bedfordshire-Council
Page 2 · response
Published 29 January 2015

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

Procure external specialist support to undertake assessments on the DoLS waiting list.

Verbatim wording from the response

“Whilst the waiting list is reducing (from 237 in January to 209 in February) this is not a position the Council wishes to maintain. We are currently in the process of procuring external specialist support to undertake all of the assessments on the waiting list.”

Source location

2015-0029-Response-by-Central-Bedfordshire-Council
Page 2 · response
Published 29 January 2015

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

The Council considered the care provided during the delayed DoLS assessment appropriate and in the deceased’s best interests.

Verbatim wording from the response

“Since March 2014, the Council has adopted a risk based approach, prioritising DoLS assessments on the basis of risk of harm to the person concerned, and using a waiting list for those assessed as low risk. As there was no indication of concerning with Mrs Flemming’s care package, no concerns raised by her family, and no indication of undue or excessive physical or medical restraint being used, the request relating to Mrs Flemming was assessed as low risk. Because of this, it meant that Mrs Flemming’s Best Interests Assessment did not take place until 9th January 2015. The outcome of this was that restrictions amounting to continuous supervision and control had been in place for frequent and prolonged period since Mrs Flemming’s admission on 22nd May 2009, she was not free to leave, and the placement was in her best interests.”

Source location

2015-0029-Response-by-Central-Bedfordshire-Council
Page 1 · response
Published 29 January 2015

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