PFD report

Stella Ann JAMES · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 4 Jul 2023•South Wales Central

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of a mechanism for Social Services to become aware of adults at risk of neglect
    Part of recurring concern: Safeguarding systems failing to identify and respond to neglectPart of recurring concern: Unreliable social care referral pathways
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.1

  1. Action

    Review current multi-agency referral and monitoring arrangements for vulnerable adults.

    Stated by Cardiff CouncilStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.

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

  1. Position

    A separate vulnerable-adults register was considered unnecessary because existing multi-agency monitoring and referral arrangements were sufficient and clearer.

    Stated by Cardiff 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

Lack of a mechanism for Social Services to become aware of adults at risk of neglect

Wider context from the report

“(1) Stella appeared to meet the criteria as an ‘adult at risk of neglect’ due to her food avoidance and very low body weight, yet there was no apparent mechanism for Social Services to be aware of Stella’s status. Stella was very secretive and formally had capacity when assessed months before her death, although it is noted that this can fluctuate. (2) Could there be a register to include a person in Stella’s position, whereby unannounced house visits from a social worker can be an option? Perhaps involving a mechanism for anonymous referral? ”

Is this part of a recurring concern?

Yes — Safeguarding systems failing to identify and respond to neglect; Unreliable social care referral pathways.

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

Review current multi-agency referral and monitoring arrangements for vulnerable adults.

Verbatim wording from the response

“In this case the decision not to refer for social worker involvement was the correct one and, having reviewed current arrangements, all partners are confident that should such a referral be assessed as needed in a future case then the process is clear and unambiguous. There is also the potential that the creation of a much wider vulnerable adults list would give the misguided impression to someone referring an individual onto the register, that the individual would be safeguarded.”

Source location

Response from Cardiff Council
Page 3 · response
Published 2 July 2026

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

A separate vulnerable-adults register was considered unnecessary because existing multi-agency monitoring and referral arrangements were sufficient and clearer.

Verbatim wording from the response

“In terms of holding a register of vulnerable adults more generally, we think that this could potentially negatively impact on the existing arrangements in place for appropriate multi agency involvement in future complex cases.”

Source location

Response from Cardiff Council
Page 3 · response
Published 2 July 2026

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 decision not to refer for social work involvement was considered correct because existing referral processes were clear and appropriate.

Verbatim wording from the response

“In this case the decision not to refer for social worker involvement was the correct one and, having reviewed current arrangements, all partners are confident that should such a referral be assessed as needed in a future case then the process is clear and unambiguous. There is also the potential that the creation of a much wider vulnerable adults list would give the misguided impression to someone referring an individual onto the register, that the individual would be safeguarded.”

Source location

Response from Cardiff Council
Page 3 · response
Published 2 July 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

    Ensure learning from the case informs Council practice going forward.

    Stated by Cardiff CouncilStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2026.
  2. 2

    Review learning from the internal review to identify implications for Council practice.

    Stated by Cardiff CouncilStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Ongoing review arrangements and decisions about unannounced visits should be managed by the Health Board because the cases require clinical expertise.

    Stated by Cardiff CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Ensure learning from the case informs Council practice going forward.

Verbatim wording from the response

“I would like to assure you that the Council has fully considered the concerns set out in the Regulation 28 report and whilst we have concluded that it would not be appropriate for the Council to operate a separate register for vulnerable adults in similar circumstances, please be assured that we have reviewed the learning from the internal review carried out by Cardiff and Vale UHB and have appropriately reflected on the points raised. We are committed to ensure that the learning from this case informs practice going forward.”

Source location

Response from Cardiff Council
Page 4 · response
Published 2 July 2026

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 learning from the internal review to identify implications for Council practice.

Verbatim wording from the response

“While the findings in this case applied to the Cardiff and Vale UHB rather than the local authority, we have reviewed these to ensure that we are also learning from the outcome of this very tragic case.”

Source location

Response from Cardiff Council
Page 3 · response
Published 2 July 2026

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

Ongoing review arrangements and decisions about unannounced visits should be managed by the Health Board because the cases require clinical expertise.

Verbatim wording from the response

“In terms of holding a register of adults with similar needs to Ms James, as her needs required clinical expertise, it would be more appropriate that any ongoing review arrangements were carried out by Cardiff and Vale UHB.”

Source location

Response from Cardiff Council
Page 3 · response
Published 2 July 2026

Open published response
Back to top

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