Unsupervised High-Risk Residents
High-risk residents being left unsupervised, potentially due to insufficient staffing or inadequate alert systems, increasing the risk of harm.
Source spread
Where this theme appears
This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
23 PFD reports
3 committee recs
1 HSSIB rec
3 CQC actions
1 DHR rec
2 PHSO decisions
8 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
MAI-55 — Risk-based visitor restrictions for radicalising prisoners
Recommendation: 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. …
Gov response: Accepted in full
Accepted
1 — CCTV and monitoring
Recommendation: 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, …
Gov response: On safety and reassurance for parents, Lady Justice Thirlwall recommends the introduction of video baby monitors for neonatal units. I agree. I have asked my officials to urgently develop plans for cot cams, which can …
Accepted
Prevention of Future Deaths reports(23)
Jane Dyson Gabbitas
Concerns: 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.
Overdue
Amar Majid
Concerns: Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.
Overdue
Alois Piska
Concerns: The coroner identified inadequate staffing levels at Harry Sotnick House, which meant residents in communal areas were not supervised at all times.
Response (Care Uk): • Care UK stated that staffing levels on the day of the incident were appropriate and exceeded industry averages. • Care UK confirmed that staff are deployed based on identified … (AI summary)
Overdue
Lee Rigby
Concerns: 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.
Overdue
Jane Bell
Concerns: 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.
Response (Jane Bell): • The hotel implemented constant poolside supervision, with trained staff patrolling the poolside and another trained staff member monitoring CCTV from reception. • The pool's depth was reduced to 1.4m, … (AI summary)
Responded
John Wherlock
Concerns: 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.
Overdue
Doris Douthwaite
Concerns: 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.
Overdue
Ryan Williams
Concerns: 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.
Overdue
Ruth Gregory
Concerns: 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.
Response (Borough Care): • The organisation increased staffing levels across its homes in January 2018. • Day shifts now include eight staff, comprising a deputy manager and senior carer. • Night shifts now … (AI summary)
Responded
Christine Neild
Concerns: 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.
Response (Meade Close Care Home): • Enhanced one-to-one supervision was undertaken with the support worker involved in the incident, and all staff are required to retake a reporting and recording e-learning module. • Resident-specific risk … (AI summary)
Response (Responses from Trafford Council and CQC): • The council provided and reiterated guidance to providers on the safe usage and disposal of PPE, and plans to conduct bi-annual audits to monitor adherence. • The council reiterated … (AI summary)
Responded
Marion Glover
Concerns: 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.
Response (Able Care and Support Services Ltd): • The organisation confirmed the implementation of enhanced pre-admission risk assessments for new tenants, including those with cognitive illnesses and confusion. • It stated that scheduled annual reviews of resident … (AI summary)
Responded
Stephen Verrall
Concerns: 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.
Response (St Johns Nursing Home Ltd): • The home stated that measures are in place, including staff accompanying visitors, staff awareness of door security, and window restrictors fitted to all windows. • Newly introduced measures include … (AI summary)
Response (CQC): • CQC conducted a targeted inspection of St John’s Nursing Home, identified continued breaches of regulations, and is progressing regulatory action against the provider. • CQC will check at its … (AI summary)
Responded
Philip Ellis
Concerns: 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.
Response (Free the Way): • Clients re-entering treatment will be escorted to their homes if required, and their property will be searched by a member of staff. • Clients entering treatment will not be … (AI summary)
Responded
Thomas Smith
Concerns: 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.
Response (Responses from NHS England): • NHS England reported that East London NHS Foundation Trust (ELFT) delivered training to staff on "Spice" awareness and engaged local drug and alcohol service providers. • NHS England stated … (AI summary)
Overdue
Susan Perry
Concerns: 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.
Response (MIRUS): • MIRUS reviewed and updated its medication policy, procedures, and practice regarding key handling, specifying that keys must be kept on the nominated medication key holder's person. • The content … (AI summary)
Responded
Tarik Drakes
Concerns: 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.
Response (BCHA): • BCHA has implemented additional Night Response Team presence at Dorset Lodge and plans to enhance evening presence across sites. • BCHA, in collaboration with partners, is reviewing multi-agency 'Link … (AI summary)
Responded
Janet Smith
Concerns: 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.
Response (Pine View Care Homes LTD): • The care home has employed a third member of staff during the day to ensure continuous monitoring in the lounge area. • Sensor mats have been installed in bedrooms … (AI summary)
Responded
Edith Alden
Concerns: 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.
Response (The Limes Care Home): • The care home reviewed and revised care plans and risk assessments, implementing a person-focused approach with enhanced risk management and introducing pre-admission falls risk assessments. • A 'Falls Champion' … (AI summary)
Responded
John Follon
Concerns: 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.
Response (Cardiff and Vale University Health Board): • The alarm system was updated to include a 2-minute re-alarm setting for unresolved conditions and reclassified 'leads off' alarms as yellow priority. • Monitor configurations in Cardiothoracic areas are … (AI summary)
Responded
Diane Poole
Concerns: 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.
Response (Victoria Residential Home): • The home implemented daily rigorous inspections of all emergency exit alarms, made the conservatory door permanently inaccessible, and secured the outside front door with an electronic fob and self-closer. … (AI summary)
Responded
Paul Reeves
Concerns: 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.
Response (The Riverside Group Limited): • The organisation completed mandatory refresher training for staff on medication procedures and implemented a three-month improvement plan to strengthen communication and medication handling. • The national Support Planning Procedure … (AI summary)
Responded
Evelyn Chancellor
Concerns: 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.
Response (Ashton Lodge Care Home): • The care home reinforced staff awareness on maintaining visual oversight and adjusted staff routines to enhance monitoring in communal areas. • A formal protocol for staff supervision in communal … (AI summary)
Responded
Francis Leech
Concerns: 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.
Response (Adept Care Homes Bowood Court): • Monthly audits of care plans and behavioural support plans by the Care Manager have been introduced. • Further instruction was issued to management reaffirming expectations for reviewing and amending … (AI summary)
Responded
Select committee recommendations(3)
#195 — Manage key OCG operators under enhanced security, segregating them from general prison population
Recommendation: 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 …
Response attribution not verified
#41 —
Recommendation: 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 …
Response attribution not verified
#1 —
Recommendation: 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 …
Response attribution not verified
NCEPOD recommendations(1)
CQC inspection actions(3)
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.
Should Do
Stamford & Rutland Hospital
The service must ensure the ward areas are secured and monitor people leaving the area.
Must Do
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.
Must Do
Health investigations(6)
Independent investigation: Alexander Cusworth, HMP Dartmoor (2015) — Rec 2
The Governor should ensure that prisoners are adequately supervised in high risk work areas.
south_west
Independent investigation into the care and treatment of Ms A — Rec 8
The Trust should review the Practice of discharging conditionally discharged patients to low supported accommodation which does not have staffing over a 24 hour period.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Harry … — Rec 4
We recommend that LTHT conduct a review of the case mix and safety of patients on J19 given the severity of violent incidents. This review should be conducted by security management specialists in conjunction with acute nursing staff on the ward and mental health specialists.
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Harry … — Rec 3
We recommend that LTHT issue guidance to staff on general acute wards regarding the criteria to request one-to-one support for patients who are a risk to themselves or others.
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Harry … — Rec 12
We recommend that LTHT conduct a risk assessment when vulnerable patients may be in a bay with patients who are aggressive or agitated. We further recommend that LTHT take steps to ensure that where patients are inappropriately placed together that additional staffing is secured to maintain their safety.
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of patient M … — Rec 91
If the person fails to respond, or their condition is deteriorating, they will need to be in an environment where their safety can be maintained. On assessment, this may be a place with heightened levels of observation within the prison, or transfer to hospital may be necessary.
east_of_england
PHSO casework decisions(2)
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.
NHS in England
May 2022
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.
NHS in England
Oct 2024
LGO / SPSO decisions(8)
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.
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
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, …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
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.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
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 …
LGO (Local Government & …
Adult Care Services
Apr 2024
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 …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2018
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 …
LGO (Local Government & …
Education
Nov 2024
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 …
SPSO (Scottish Public Se…
Local Government
Upheld
Dec 2018
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.
LGO (Local Government & …
Adult Care Services
Apr 2025