Unsupervised High-Risk Residents
High-risk residents being left unsupervised, potentially due to insufficient staffing or inadequate alert systems, increasing the risk of harm.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
77match
John Wherlock
The coroner noted insufficient ward cover due to staff taking breaks simultaneously, leaving the deceased unsupervised before a fall. The report also highlights that this practice continued despite being identified in a serious incident report.
Matched on
terms: high, unsupervised
PFD report
77match
Edith Alden
Concerns include inconsistent falls prevention care plans and risk assessments, staff being unclear on mitigation, and insufficient supervision for high-risk residents in communal areas and bedrooms. The coroner also noted potential inadequacy of staffing levels.
Matched on
terms: high, resident
PFD report
73match
Doris Douthwaite
The coroner noted that vulnerable residents were left unsupervised in communal areas, with no clear policy for monitoring. Concerns were also raised about an unclear falls risk assessment tool and a lack of investigation into a resident's multiple falls.
Matched on
terms: resident, unsupervised
PFD report
73match
Janet Smith
The coroner noted concerns regarding insufficient staffing levels at the care home, where two carers for 17 residents meant individuals were left unmonitored, potentially contributing to a resident's fall.
Matched on
terms: resident
PFD report
69match
Ruth Gregory
The coroner noted that residents were regularly unsupervised in communal care home areas, creating a risk of resident-on-resident incidents leading to trauma. Information on risk management and supervision arrangements was absent.
Matched on
terms: resident, unsupervised
PFD report
65match
Alois Piska
The coroner identified inadequate staffing levels at Harry Sotnick House, which meant residents in communal areas were not supervised at all times.
Matched on
terms: resident
PFD report
65match
Tarik Drakes
Insufficient staffing and monitoring at Dorset Lodge permits unmonitored entry by non-residents and drug use within the premises. Additional concerns include agency staff not conducting key worker sessions and a non-functional out-of-hours emergency contact.
Matched on
terms: resident
PFD report
61match
Lee Rigby
The coroner noted support workers lacked keys to premises, potentially leaving residents unobserved when admitting other staff, and raised concerns regarding the adequacy of staff numbers, risk management procedures, and staff training related to care plans.
Matched on
terms: resident
PFD report
61match
Christine Neild
Concerns were raised regarding easily accessible non-food items for a resident lacking insight, an unescalated prior incident of ingesting non-food items without risk assessment, and the absence of sensors to alert night staff to residents wandering.
Matched on
terms: resident
PFD report
61match
Stephen Verrall
The coroner noted the Care Quality Commission does not routinely check window restrictors during inspections. Concerns were also raised about St John's Nursing Home, where residents without capacity could leave unaccompanied due to unstaffed reception areas on weekends.
Matched on
terms: resident
PFD report
57match
Marion Glover
The care home design allows residents with cognitive illnesses to freely leave the building unnoticed, as the main exit is unlocked during the day and there is no observation of the foyer area. This raises concerns about the suitability of the accommodation for individuals with such conditions.
Matched on
terms: resident
PFD report
57match
Philip Ellis
The deceased was able to leave the service premises unsupervised and obtain drugs, breaching the service's own rules. Additionally, a serious incident review into the supervision failures had not been undertaken by Free the Way.
Matched on
terms: unsupervised
PFD report
57match
Thomas Smith
The coroner identified insufficient staff knowledge and training on synthetic cannabinoid dangers in mental health settings. Additionally, the system for assessing risks during s.17 leave was inadequate, as escorting staff lacked access to vital patient information.
Matched on
classifier match
PFD report
57match
Diane Poole
The report highlights concerns regarding a faulty emergency exit door and a lack of staff awareness about its operation, prompting a request for confirmation that corrective actions are ongoing.
Matched on
terms: high
PFD report
57match
Paul Reeves
Concerns were raised about the supported accommodation's unclear role in medication supervision and a significant lack of communication between its staff and the mental health unit regarding changes in a resident's mental state and the escalation of deterioration.
Matched on
terms: resident
PFD report
57match
Evelyn Chancellor
The coroner noted concerns regarding the sufficiency of staff to ensure resident safety, particularly when staff members are engaged in activities that may divert their attention from residents.
Matched on
terms: resident
PFD report
57match
Francis Leech
Care and behavioural support plans for a resident with escalating aggressive behaviour were not updated, reflecting staff's lack of understanding and management's absence of a system for updates. The internal investigation also did not identify these plan deficiencies.
Matched on
terms: resident
PFD report
53match
John Follon
The coroner noted concerns that the alarm system allows staff to silence alarms before checking patients during night shifts, leaving patients potentially unmonitored. Infrequent monitor checks further increase the risk of patients remaining unmonitored for significant periods.
Matched on
classifier match
Committee recommendation
52match
#41 - Fourth Report: Home Office preparedness for COVID-19 (Coronavirus): institutional accommodation
It is troubling that nearly 40% of those remaining in immigration detention should have been categorised as meeting Levels 2 or 3 of the Adults at Risk policy indicating significant vulnerability and, potentially, that they are at high risk from Covid-19. Government guidance on the operation of the adults at risk policy indicates that evidence meeting the standard...
Matched on
terms: high
PFD report
49match
Jane Dyson Gabbitas
The SHARE accommodation unit lacked a clear system to record and monitor patient absences. This raised concerns that future deaths could occur if action is not taken to track and appropriately respond to prolonged or inappropriate absences.
Matched on
classifier match
PFD report
49match
Amar Majid
Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.
Matched on
classifier match
PFD report
49match
Jane Bell
The coroner identifies insufficient arrangements for constant poolside supervision at the hotel, noting concerns that reliance on CCTV monitored by reception staff with other duties and infrequent patrols may not ensure adequate visibility of the pool.
Matched on
classifier match
Committee recommendation
48match
#1 - Third Report - Exempt Accommodation
An unknown but significant number of residents’ experiences of exempt accommodation are beyond disgraceful. Taxpayers’ money is being spent on uncapped housing benefit on the understanding that residents, who are usually vulnerable, receive some care, support, or supervision—yet it is clear that some people’s situations actually deteriorate as a result of the shocking conditions in which they live....
Matched on
terms: resident
PFD report
45match
Ryan Williams
The coroner noted a lack of supervision for members of the public at station premises, raising concerns about the absence of oversight at unmanned stations, especially for vulnerable individuals.
Matched on
classifier match
PFD report
45match
Susan Perry
The coroner identified that keys to locked medication cupboards were kept in easily accessible, unlocked locations, risking service users accessing medication. There was no evidence that this practice had been changed or addressed across other similar accommodations.
Matched on
classifier match
Inquiry recommendation
45match
MAI-55 - Risk-based visitor restrictions for radicalising prisoners
I recommend that the Home Office consider introducing a system based on a robust assessment of the risk a prisoner poses for radicalisation of others. This system should allow for proportionate restrictions to be applied to visitors to that person. Controls such as prohibiting vulnerable visitors where justified or ensuring conversations are supervised should be among the options...
Matched on
classifier match
CQC action
45match
Clatterbridge Hospital
The diagnostic imaging services should ensure that appropriate changing facilities are in place so that patients are not left alone in controlled areas when not undergoing a scan.
Matched on
classifier match
NCEPOD recommendation
41match
Treat as One
Matched on
classifier match
CQC action
41match
Stamford & Rutland Hospital
The service must ensure the ward areas are secured and monitor people leaving the area.
Matched on
classifier match
HSSIB recommendation
40match
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation identify and code patients – who may be more vulnerable to harm from insulin due to their circumstances – for increased monitoring? This may include patients who have their medications delivered to their home, who do not have family nearby, or who are housebound.
Matched on
classifier match
LGO / SPSO decision
39match
22-005-424 - Norfolk County Council
Mr B complained a care home allowed his mother’s husband to take her out unsupervised ignoring a best interest decision and putting her at risk. The Council arranged Mrs C’s placement at the care home. We have discontinued our investigation because there are ongoing court proceedings.
Matched on
terms: unsupervised
Committee recommendation
36match
#195 - Manage key OCG operators under enhanced security, segregating them from general prison population
Individuals identified as key OCG operators must be managed under enhanced security protocols and, where possible, segregated from the general prison population to prevent them from exploiting vulnerable prisoners and staff to maintain their “clean profile”. The practice of merely transferring these individuals between prisons, which leads to spikes in violence and drug use in the prison to...
Matched on
classifier match
LGO / SPSO decision
35match
20-007-142 - Durham County Council
Summary: The Council failed to offer an appropriate remedy for the identified failings in the care provided to Mr Y at a residential care home.
Matched on
terms: resident
Inquiry recommendation
32match
1 - CCTV and monitoring
All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. The funding for this should be centrally managed and ring-fenced, to ensure consistency and implementation across all neonatal units at speed. By 31 March 2027, NHS England should...
Matched on
classifier match
CQC action
32match
Kettering General Hospital
The servicemust ensure the paediatric emergency department is safely managed. This includes but is not limited to ensuring waiting areas are safe and risks are assessed and mitigated; ensuring there is appropriate visual supervision of patients at all times.
Matched on
classifier match
PHSO casework decision
27match
P-001389 - A nursing home in the Lincolnshire area
Mrs U complained the nursing home failed to safeguard her stepfather, leading to him leaving unattended twice and suffering falls, one causing a fractured hip, and inappropriately shaving his hair.
Matched on
classifier match
PHSO casework decision
27match
P-003086 - Chesterfield Royal Hospital NHS Foundation Trust
Staff left her father alone when at risk of falling, leading to falls and a brain bleed. His CT scan was overlooked, delaying diagnosis before his death.
Matched on
classifier match
LGO / SPSO decision
26match
24-007-965 - Reading Borough Council
Summary: We will not investigate this complaint about the Council’s school transport policy, allegations of sub-contracting, and issues with the taxi-driver leaving her child unsupervised and leaving her before she was received into the care of an adult. We consider further investigation will not add to that carried out by the Council. Nor would it lead to a...
Matched on
terms: unsupervised
LGO / SPSO decision
23match
21-003-429 - London Borough of Southwark
Summary: Miss X complained about the Council commissioned care provider’s actions when her mother went missing at the care home. The Council and care provider investigated the concerns, identified faults and put actions in place to prevent the faults recurring. The Council has already apologised to Miss X. In addition, it has agreed to make a payment to...
Matched on
classifier match
LGO / SPSO decision
23match
23-018-594 - Cheshire East Council
Summary: We will not investigate this complaint about the Council disallowing the complainant’s mother to leave her care own against her wishes. This is because the complaint is late and there are no good reasons to exercise our discretion. We cannot investigate the complainant’s other concerns about alleged defamatory statements made against him during legal proceedings. This is...
Matched on
classifier match
LGO / SPSO decision
22match
201800052 - Trust Housing Association Ltd
Mrs C complained that the housing association unreasonably failed to inform her of future service change when they offered her a tenancy. Mrs C signed a tenancy agreement for sheltered accommodation run by the association. Shortly after moving into the accommodation she was advised that the service provision was likely to change due to changes to funding provided...
Matched on
classifier match
LGO / SPSO decision
18match
201705622 - Dumfries and Galloway Council
Mrs C complained to the council about social work involvement in the care her late mother received whilst in a care home. Mrs C considered that the way the council handled her complaint was unreasonable and that the action plan they created as a result of the complaints investigation did not adequately address the failings identified. We upheld...
Matched on
classifier match
LGO / SPSO decision
9match
24-020-664 - Rochdale Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint the Council failed to safeguard him from abuse. There is not enough evidence of fault to justify our involvement.
Matched on
classifier match