Care risk assessment failures
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
87match
#7 - Inadequate assessment of mental health for children and young people in care.
Young people in care are significantly more likely to have experienced trauma and adverse experiences than their peers, and therefore strong mental health support is crucial. Although local authorities are required to assess the emotional and mental health of children in their care, evidence suggests this does not always happen in practice. Our witnesses were clear that there...
Matched on
terms: assessment, care
Committee recommendation
86match
#10 - 2nd Report - Human Rights of Children in the Social Care System in England
However, conducting assessments of disabled children’s needs only through a child protection lens, rather than a support lens, can lead to the stigmatisation of carers and the failure to provide adequate support to children who might need it. The government must work with local authorities to ensure the single statutory guidance clearly sets out how to effectively conduct...
Matched on
terms: assessment, care, failure
IOPC learning recommendation
86match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police reminds police officers who bring members of the public into custody, custody sergeants and healthcare professionals to be proactive when conducting a risk assessment for a detainee, by reviewing items that belong to the person, whether or not they are still on them or have been seized. When doing so, they...
Matched on
terms: assessment, care
Inquiry recommendation
85match
R101 - Whole-system commissioning with cross-agency risk assessment
Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole system (including primary care, housing, benefits and independent and third sector providers of services). There must be a risk assessment that assesses how the impact of change in one part of the system impacts on another...
Matched on
terms: assessment, care, failure
HSSIB recommendation
82match
Healthcare provision in prisons: needs assessments and disability access
HSSIB recommends that HM Prison and Probation Service reviews and amends its information gathering processes for accommodation requirements for wheelchair users and people with mobility issues, to identify and mitigate risks for people whose accommodation does not meet their needs. This is to enable and support the effective identification of appropriate prison accommodation for these groups.
Matched on
terms: assessment, care
PFD report
81match
May Gibson
The coroner noted failures in obtaining and utilising community care assessments, developing an adequate care plan for Mrs Gibson, and conducting proper risk assessments and reduction plans. Concerns were also raised regarding a lack of cohesive management and insufficient staff training and supervision within the care home.
Matched on
terms: assessment, care, failure
Inquiry recommendation
78match
WATE-(33) - Base care plans on comprehensive assessment, prepared with child consultation
The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Matched on
terms: assessment, care
Inquiry recommendation
78match
WATE-(31) - Require comprehensive child needs assessment before admission to care
Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Matched on
terms: assessment, care
Inquiry recommendation
78match
53 - Timing of first review of assessment
The first review of the initial assessment should take place within one week of the initial assessment, and should take place in every case. It should be a multi-disciplinary review, with representatives from the prisoner’s wing, healthcare and the team responsible for implementing the establishment’s violence reduction strategy all contributing to it. The documents set out in paragraph...
Matched on
terms: assessment, care
HSSIB recommendation
78match
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services...
Providers of inpatient children and young people’s mental health services can improve patient safety by ensuring there is not a blanket approach to safeguarding mitigation measures based on a person’s age, and that mitigation measures are individualised and based on behaviours and risks.
Matched on
terms: care
Inquiry recommendation
77match
6 - Draw up maternity risk assessment protocol
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and...
Matched on
terms: assessment, care
CQC enforcement action
77match
Warning Notice: Oxleas NHS Foundation Trust
The Care Quality Commission (CQC) served Oxleas NHS Foundation Trust with a warning notice, requiring immediate improvements to its mental health wards for older people. An inspection found out-of-date ligature risk assessments, a lack of clear mitigation for high-risk ligature points, and staff not implementing actions from serious incident investigations. Essential information and action plans were not shared...
Matched on
terms: assessment, care
PFD report
73match
Derrick Plater
The coroner raised concerns that care home visits were not standard practice before placing individuals with complex needs, relying instead on the home's assurances. There was also uncertainty regarding guidelines or protocols for undertaking such visits during the assessment and placement process.
Matched on
terms: assessment, care
PFD report
73match
Maureen Flynn
The coroner noted a falls risk assessment for Mrs. Flynn was incomplete, and care staff were unaware. The report identifies a need for a system to alert staff to incomplete assessments, an issue also not identified by the patient safety investigation.
Matched on
terms: assessment, care
PFD report
73match
Etheline De-Gale
The care plan was too vague to guide carers, who also lacked training on how to undertake risk assessments. Insufficient staffing levels compromised resident safety, potentially leading to paramedic recommendations being ignored.
Matched on
terms: assessment, care
PFD report
73match
Lesley Hanson
Care and risk assessments did not fully address risks from doors left open, the type of stair-gate, and the locking mechanism. There was also unclear responsibility for ensuring environmental safety measures at the property.
Matched on
terms: assessment, care
PPO recommendation
73match
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete the medical risk assessment in full, including signing and dating the form.
Matched on
terms: assessment, care
Committee recommendation
73match
#26 - Fourth Report: Home Office preparedness for COVID-19 (Coronavirus): institutional accommodation
Asylum seekers should not have been moved to new accommodation during the pandemic without justified and urgent reasons for doing so or without a vulnerability assessment demonstrating that the move could be made safely. This must happen Home Office preparedness for COVID-19 (Coronavirus): institutional accommodation 57 in future. If, following such an assessment, a move is found to...
Matched on
terms: assessment, care
CQC enforcement action
73match
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an inspection of their community-based mental health services for people of working age in October. Inspectors found safety concerns still needed addressing across the service, including understaffing, postponed routine appointments, and issues with care plans, risk assessments, and medication storage....
Matched on
terms: assessment, care
Inquiry recommendation
73match
SP22 - LCC online harms risk assessment review
Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms to children. This review should ensure that all frontline staff have a consistent and up-to-date understanding of online risks, and that they have access to effective tools and...
Matched on
terms: assessment, care
PFD report
69match
Ross Boyd
The coroner noted an inadequate needs assessment for Ross Boyd prior to his admission to The Willows, which resulted in an inappropriate placement for his care needs.
Matched on
terms: assessment, care
PFD report
69match
Harold de Mello
The coroner identified inadequate good practice guidelines for assessments, resulting in incomplete and inconsistent evaluations of care needs. Concerns were raised about assessments failing to consider referrer reports or historical records, and insufficient investigation into available care.
Matched on
terms: assessment, care
PFD report
69match
Maria Silkin
The care home's "Falls Risk Assessment" document incorrectly recorded no previous falls, despite evidence of multiple falls, which contributed to a delay in the person being taken to hospital.
Matched on
terms: assessment, care
PFD report
69match
Peter Furness
The care home lacks a documented process for escalating incidents or concerns to trigger multi-disciplinary team meetings that review risk assessments and care plans for vulnerable residents.
Matched on
terms: assessment, care
PFD report
69match
Alan Ludlow
The coroner raises concerns about insufficient information exchange during assessments for residential and nursing placements, noting a new care home was not provided with critical past incident details about a resident.
Matched on
terms: assessment, care
PFD report
69match
Joanna Bowring
The patient and carer left an initial assessment without a clear understanding of the service or a care plan. Carers were not routinely included in risk assessments, their views were not actively sought, and they were not advised about behaviours indicating an increased risk of suicide.
Matched on
terms: assessment, care
PFD report
69match
Freda Cordy
The coroner noted Mrs Cordy was placed in a care home with 2-hourly checks despite needing constant supervision. No specific falls risk assessment was undertaken despite a falls history, and only a floor mattress was provided for prevention.
Matched on
terms: assessment, care
PFD report
69match
Dorethea Parr
The coroner noted a lack of notification to family and carers regarding new equipment delivery, preventing training and risk assessment for a high-risk patient. There were no formal protocols for informing District Nurses about new equipment or changes in patient fall risk.
Matched on
terms: assessment, care
PFD report
69match
Raymond Shepherd
The coroner noted poor record-keeping and a lack of updates to customer files in home care. Concerns included no action being taken after multiple reported falls or deterioration in condition, and the absence of a mental capacity assessment.
Matched on
terms: assessment, care
PFD report
69match
David Sketchley
The report identifies concerns regarding the quality of the BUPA investigation, which did not conclude on supervision levels or commode suitability. It also notes an absence of evidence that BUPA's practice reflects care service standards for commode assessments.
Matched on
terms: assessment, care
PFD report
69match
Stanley Langdon
The Haven Day Care Centre began providing services without an adequate care plan or needs assessment from Durham County Council. The council's systems to prevent this were not consistently applied, and the care plan eventually implemented was incomplete and not discussed with the family.
Matched on
terms: assessment, care
LGO / SPSO decision
69match
25-000-452 - Berkley Care Blenheim Limited
Summary: There was fault in the quality of care provided to Mr X’s late grandfather Mr Y by the care home. It failed to carry out a thorough pre-assessment, delayed taking action when Mr Y’s food and fluid intake reduced and failed to properly assess and respond to Mr Y’s risk of falls. It also delayed billing Mr...
Matched on
terms: assessment, care
Committee recommendation
69match
#9 - 79th Report - Supporting people with frailty outside hospitals
In 2024–25, 32 of 106 local NHS areas (known as sub-ICBs) assessed less than 10% of their registered patients aged 65 or over. However, nine of 106 local areas assessed 90% or more of this group of people, suggesting that good performance is possible within existing resources.18 The National Institute for Health and Care Excellence (NICE) guidelines specify...
Matched on
terms: assessment, care
Committee recommendation
69match
#7 - 79th Report - Supporting people with frailty outside hospitals
For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having an enriched summary care record that provides healthcare professionals with access to core details about the patient (medications,...
Matched on
terms: assessment, care
Committee recommendation
69match
#3 - 79th Report - Supporting people with frailty outside hospitals
NHS England’s existing oversight arrangements are not improving GPs’ assessment and support of people with frailty. It is not clear exactly who is responsible for improving performance. NHSE considers that ICBs are responsible for commissioning services to meet the needs of their population; and that the service providers must ensure that the services they are commissioned to provide...
Matched on
terms: assessment, care
HSSIB recommendation
69match
Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke
There is no validated venous thromboembolism (VTE) risk assessment tool in the UK that produces a stratified risk for predicting a patient’s likelihood of developing a deep vein thromboembolism or pulmonary embolism. If it is not possible to produce a stratified VTE risk assessment, it may be beneficial to consider amending the title of the published VTE risk...
Matched on
terms: assessment, care
CQC action
69match
The York Hospital
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Matched on
terms: assessment, care
Scottish FAI
69match
James Hutchison
(5) Recommendations I make the following recommendations (where I refer to a nursing home it should be understood that I am referring to a nursing home for elderly and mentally infirm persons, an EMI home) :- (a) When any elderly and mentally infirm person (probably therefore a person suffering from dementia) is to be admitted to a nursing...
Matched on
terms: assessment, care
CQC enforcement action
69match
Warning Notice: Wye Valley NHS Trust
The Care Quality Commission issued Wye Valley NHS Trust with a warning notice following an inspection in September and October 2015. The warning required the trust to make significant improvements to its systems for assessing, monitoring, and mitigating risks to patient health, safety, and welfare. Inspectors found that systems to protect patients from abuse and avoidable harm were...
Matched on
terms: care
Inquiry recommendation
68match
R28 - Nutritional screening
Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool. Where nutritional problems are identified further assessment should be undertaken to determine an individual care plan. Appropriate and timely referrals should be made to dieticians for patients identified as being in need of specialist nutritional...
Matched on
terms: assessment, care
LGO / SPSO decision
68match
23-008-538 - Oxfordshire County Council
Summary: Ms X complained about Oxfordshire County Council, Oxford Health NHS Foundation Trust, and NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. She complained about faults relating to aftercare under section 117 of the Mental Health Act 1983. We have upheld Ms X’s complaints about discharge, assessment, care planning and personal health budgets. We did not uphold...
Matched on
terms: assessment, care
Article 2 learning point
68match
CR — HMP Swansea - LP Healthcare 1
A range of information including that from assessment during custody and from court proceedings should be considered along with the presenting risk factors when undertaking an initial assessment of an individual’s risk of suicide/self-harm and the opening of a potential ACCT.
Matched on
terms: assessment, care
LGO / SPSO decision
68match
24-022-503 - Derby City Council
Ms X complained the Council failed to respond to complaints, failed to adhere to her agreed reasonable adjustments and failed to carry out a suitable care needs assessment. She also queried its actions about Direct Payments. We found no fault in the Council’s complaint responses. We found there was some failure to adhere to agreed Reasonable Adjustments and...
Matched on
terms: assessment, care, failure
LGO / SPSO decision
68match
20-014-489 - Hertfordshire County Council
Summary: Ms C complains the Council failed to properly safeguard her mother or provide satisfactory information about funding for care homes. The Council is at fault for failing to carry out safeguarding, assessment, and complaint handling procedures correctly. It is also at fault for failing to properly advise Ms C about funding for care home placements. These failures...
Matched on
terms: assessment, care, failure
LGO / SPSO decision
68match
21-007-208 - Hertfordshire County Council
Summary: The Council’s failure to consider the needs and practicalities of the wider family before agreeing that a proposal by the Borough Council would meet Miss X’s disabled child’s needs was fault. The Council has agreed to complete a new assessment.
Matched on
terms: assessment, care, failure
Inquiry recommendation
66match
74 - Mental health assessments to address risk
When prisoners are referred for a mental health assessment, the assessment should address the risk which they pose to staff and other inmates.
Matched on
terms: assessment
Inquiry recommendation
66match
R68 - Cumulative risk assessment across protection plans
Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable adults within a single unit, cumulative risks arising from those individual protection plans across all residents must also be evaluated.
Matched on
terms: assessment
Inquiry recommendation
66match
R25 - Pressure damage risk assessment
Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score in accordance with best practice guidance. Where patients are identified as at risk they must be reassessed at the frequency identified by the risk scoring system employed. Compliance should be monitored...
Matched on
terms: assessment
HSSIB recommendation
66match
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?
Matched on
terms: care
HSSIB recommendation
66match
Assessment of risk during the maternity pathway
a pregnant woman/person’s individual risks
Matched on
terms: assessment