Concerns raised 1
Lack of policy or procedure governing the timing and conduct of appointments View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Lynsey Ellen Dearden · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Lynsey Ellen Dearden was found deceased at her home on 11 March 2025. The inquest concluded with a short-form conclusion of suicide; the stated cause of death was asphyxiation, with anxiety and depression recorded in Part II. Concerns included failures to provide allocated Community Psychiatric Nurse appointments and to complete a standard assessment framework, alongside the absence of policies or guidance governing these processes.
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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.
PFD Monitor interpretation Lack of policy or procedure governing the timing and conduct of appointments
Wider context from the report “1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place;
” Source location Lynsey Ellen Dearden · Prevention of Future Deaths report
Open source report
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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 Issue and operationalize a Practice Note requiring SAF waiting-list contact, key-worker appointment dates, transition timescales, and clarification that SAF is not prerequisite to care.
Verbatim wording from the response “Immediate actions taken:
In response to the PFD and our internal review, we have implemented the following:
A Practice Note issued highlighting the following,” Source location Response from North Staffordshire Combined Healthcare NHS Trust
Open published response
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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 Revise the Trust Care Management Policy to incorporate the new processes, guidance, and audit assurance arrangements.
Verbatim wording from the response “These additional processes and clarifications will be added to the Trust Care Management Policy which is currently under review.” Source location Response from North Staffordshire Combined Healthcare NHS Trust
Open published response
28 May 2025 Julie Sheila Beasley · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure to provide an appropriate urgent psychiatric appointment View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Julie Sheila Beasley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.
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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.
PFD Monitor interpretation Failure to provide an appropriate urgent psychiatric appointment
Wider context from the report “(2) Following this Mrs Beasley contacted crisis mental health explaining that she had vital information that she had not shared following a visit by a psychiatric nurse at her home. Mrs Beasley was not asked what the information was. Mrs Beasley contacted the crisis team again a few days later repeating that she had not shared information and again was not asked what the information was and was not given an appointment . Mrs Beasley’s telephone contacts were noted in her medical record with no details recorded as to what the additional information Mrs Beasley wanted to share. Mrs Beasley did not receive the appropriate psychiatric assessment following her contact with the crisis team.
” Source location Julie Sheila Beasley · Prevention of Future Deaths report
Open source report
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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 Route crisis-team communications and psychiatrist review requests to multidisciplinary team mailboxes.
Verbatim wording from the response “A process has also been initiated whereby communication is not sent to an individual, but will be sent to the MDT. This ensures there are no delays in communication / actions requiring attention.” Source location Response from Essex Partnership University NHS Trust
Open published response
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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 Provide three senior leads to support the crisis team.
Verbatim wording from the response “Psychiatrist review requests are now all sent to an MDT email address rather than to individual psychiatrists, so that this may be actively, and in a timely way attended to by the MDT review. The team is now supported by three senior leads within the team.” Source location Response from Essex Partnership University NHS Trust
Open published response
6 Mar 2025 Andrea Denise MANN · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1
Failure to provide requested psychiatric appointments View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andrea Denise MANN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrea Denise MANN was discovered hanging at her home on 10 February 2024 and died in hospital the following day after invasive medical care was withdrawn and palliative care was provided. The inquest identified concerns about limited Community Mental Health Trust involvement, the absence of a requested psychiatric appointment, delays in psychological therapy, and the lack of an overarching tool to scrutinise and measure the care provided.
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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.
PFD Monitor interpretation Failure to provide requested psychiatric appointments
Wider context from the report “1) That during the period of her involvement with the Community Mental Health Trust between the period 25/04/2023 and 04/12/2023 the care given to the deceased was limited to 2 appointments only within which she was referred back to her GP for medication adjustment which had been seen to be ineffective, and referral to Psychological therapy sessions which had a waiting period of 6 months despite an earlier private consultation having been proved ineffective,
That the frequent requests of the deceased and her family for a Psychiatric appointment had not been provided to her , with the result that the deceased had to seek a private consultation.
” Source location Andrea Denise MANN · Prevention of Future Deaths report
Open source report
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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 Have the administration team book consultant psychiatrist appointments for assessed referrals, using urgent slots when risk-based assessment indicates greater urgency.
Verbatim wording from the response “7. For those referrals that have been assessed as requiring an appointment with a consultant psychiatrist, this will be booked by the admin team. At present, routine appointments are being booked 4-6 weeks in advance however the urgency of the appointment is based on the formulation of risk based on the assessment findings and a Multi-Disciplinary Team discussion. If it is felt that the individual needs to be seen more urgently, medics have urgent appointment slots for this purpose.” Source location Response from Bradford District Care NHS Trust
Open published response
25 Sep 2023 Robert Leigh · Prevention of Future Deaths report Manchester West
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Concerns raised 2
Failure to provide planned Care Coordinator or Community Psychiatric Nurse visits View source Failure to assign Duty officer responsibility for reviewing planned appointments and arranging Community Psychiatric Nurse attendance View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Greater Manchester Mental Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Greater Manchester Mental Health NHS Foundation Trust
Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
View source
Greater Manchester Mental Health NHS Foundation Trust
Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
View source
Greater Manchester Mental Health NHS Foundation Trust
Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
View source
Greater Manchester Mental Health NHS Foundation Trust
Audit the absence-cover process after three months to verify that it is embedded and being followed.
View source See 1 more action
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AI-generated summary
Robert Leigh · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.
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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.
PFD Monitor interpretation Failure to provide planned Care Coordinator or Community Psychiatric Nurse visits
Wider context from the report “1. During the Inquest evidence was heard that: -
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed .
ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences.
” Source location Robert Leigh · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assign Duty officer responsibility for reviewing planned appointments and arranging Community Psychiatric Nurse attendance
Wider context from the report “1. During the Inquest evidence was heard that: -
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed.
ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences.
” Source location Robert Leigh · Prevention of Future Deaths report
Open source report
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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 Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
Verbatim wording from the response “Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is completed by the Care Coordinator prior to any planned absence, such as annual leave or a planned medical intervention. This ensures the Care Coordinator has considered any follow up for service users that is required during their period of absence and identifies who will carry out any planned interventions such as administration of depot medications, undertaking face to face visits, and making telephone contacts. If specific follow up is not required during the period of planned absence, the service user, and their families or carers will be provided with the contact details for the team, should they require additional support. The Team Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions required are undertaken by the team.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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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 Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
Verbatim wording from the response “For unplanned absences such as sickness, it is expected that the Care Coordinator, at the point of contacting the Team Manager or Senior Practitioner to advise of their absence, will provide a detailed handover of any work that is required to be covered.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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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 Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
Verbatim wording from the response “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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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 Audit the absence-cover process after three months to verify that it is embedded and being followed.
Verbatim wording from the response “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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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 Team Managers or Senior Practitioners, rather than duty officers, are responsible for reviewing appointments and determining required follow-up during Care Coordinator absences.
Verbatim wording from the response “As noted above, it is the Team Manager’s or Senior Practitioner responsibility to review alongside the Care Coordinator when reporting their absence, where possible, and collaboratively agreeing the course of action required. The duty officer will then, at the request of the Team Manager or Senior Practitioner, contact the service user, either by telephone or a face-to-face visit, as clinically indicated.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
1 Jul 2022 Dominic Robert Noble · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Delays in providing psychiatrist appointments after assessment referrals View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Dominic Robert Noble · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged referrals.
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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.
PFD Monitor interpretation Delays in providing psychiatrist appointments after assessment referrals
Wider context from the report “(1) Evidence was taken at the inquest that:
(i) HMP Leeds has only 3 days per week of a psychiatrist's time available
(ii) HMP Leeds has some 5000 prisoners arriving each year.
(iii) A large proportion of the prisoners arriving have mental health issues
(iv) The mental health team is mainly a nurse-led service
(v) The division of labour between mental health nurses and psychiatrists is that a doctor is responsible for the diagnosis of mental illness, prescribing medication such as anti-psychic drugs and seeing prisoners/patients with severe or complex conditions. Mental health nurses make initial assessments and provide ongoing care.
(vi) Concern was expressed about the adequacy of the psychiatric doctor provision to provide psychiatric treatment for a large population which includes men with significant mental health issues.
(vii) Mr Noble was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given.
(viii) A mental health nurse working on behalf of PPG on 10 July 2020 identified the “possibility of emerging psychotic features” and noted the sentiment that engaging in treatment as soon as possible mitigated in favour of a better outcome. Where such a suspicion was raised it would have been advantageous to obtain a second opinion from a psychiatrist swiftly (particularly after his mother contacted the prison to report his paranoid and bizarre conversation regarding a gun, a secret room in the prison and some unknown person trying to kill him.)
” Source location Dominic Robert Noble · Prevention of Future Deaths report
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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 Approach NHS England and discuss seeking additional psychology and psychiatry resource for HMP Leeds.
Verbatim wording from the response “Intended Changes
Following the Learned Coroner’s comments during the inquest into the death of Mr Afzal, ████████, Practice Plus Group’s Regional Director North – Health in Justice, began discussions with Commissioners at NHS England. Whilst Practice Plus Group maintains that the level of psychiatry provision is at least equivalent to that offered in the community, we also recognise that there are significant levels of mental health morbidity in prisons, particularly in a local remand setting such as HMP Leeds. The Learned Coroner’s comments and subsequent report have highlighted a potential need and we have therefore approached our Commissioners for additional resource.” Source location 2022-0204 - Response from Practice Plus Group
Open published response
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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 Submit a business case to Commissioners for increased psychology and psychiatry provision at HMP Leeds.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
Open published response
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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 Existing stepped-care provision and multidisciplinary referral arrangements are considered sufficient to meet patients’ psychiatric needs at current levels.
Verbatim wording from the response “As in the community, Practice Plus Group delivers a stepped care model, which focuses on providing the most appropriate care for the concerns a patient may have. By adopting this model most people with mental health problems do not need to see a consultant psychiatrist. The stepped care model of mental health focuses on providing people with the right level of support from the right clinician at the right time. For example, people experiencing mild to moderate depression and anxiety would see a primary care mental health clinician in the community, alongside the GP, which is step 2/3.” Source location 2022-0204 - Response from Practice Plus Group
Open published response
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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 Even if additional funding is approved, recruitment difficulties may prevent immediate increases in psychiatric provision.
Verbatim wording from the response “HMP Leeds is a high demand remand site and we are seeking additional resource with the aim to improve the number of clinical sessions from 6 to 8 per week. In effect this means that HMP Leeds will need the equivalent of a half-time psychiatrist in addition to what is currently in place in order to achieve the additional clinical sessions. This is due to the non-patient facing time that all directly employed consultant psychiatrists working for Mental Health Trusts have in their contract. These activities include clinical administration tasks (e.g. letters and referrals), service development and training/development.” Source location 2022-0204 - Response from Practice Plus Group
Open published response
5 May 2021 Hannah Bampfylde · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Unclear responsibility for re-booking appointments after non-attendance View source Failure to ensure re-booking of appointments after non-attendance for newly referred patients View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Hannah Bampfylde · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Bampfylde was found hanging in the garage of her mother’s home, where she had been staying, and the inquest determined that she took her own life. She had been referred to HATS for mental health input after an overdose, but missed or could not attend assessment appointments and was discharged without being assessed. The report identified unclear responsibility for rebooking missed appointments and a lack of routine notification to GPs when newly referred patients did not engage with the service.
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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.
PFD Monitor interpretation Unclear responsibility for re-booking appointments after non-attendance
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA , or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Hannah Bampfylde · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure re-booking of appointments after non-attendance for newly referred patients
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Hannah Bampfylde · Prevention of Future Deaths report
Open source report
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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 Assign the Referral Co-ordinator responsibility for booking further initial assessment appointments after non-attendance.
Verbatim wording from the response “Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. This measure reduces the risk of a patient not being followed up as highlighted the North West Sussex Referral, Triage, Assessment and Allocation Process Map attached.” Source location 2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Open published response
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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 Audit compliance with the strengthened referral follow-up arrangements over the forthcoming months.
Verbatim wording from the response “The safety of patients referred to us is of paramount importance to the Trust. Our service cannot coerce engagement as the desire to engage must come from the patient themselves, particularly when they are capacious, like Hannah was. However, it is important for our systems to be effective and to ensure that no patient “falls” between services. I trust this letter demonstrates to you and Hannah’s family the action we took to strengthen our systems. I will ensure we audit compliance with this over forthcoming months.” Source location 2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Open published response
22 Nov 2018 Matthew Gerard Craven · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of agreed target timescales for routine psychiatric appointments View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Matthew Gerard Craven · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Gerard Craven was found dead at home on 19 April 2018 after consuming pregabalin in excess of his prescribed amount; toxicology showed a fatal dose of pregabalin. Concerns included repeated rejected referrals for psychiatric assessment, the absence of a challenge or escalation process, no agreed timescales for routine appointments, limited documentation of referral decisions, and inadequate sharing and review of mental health information.
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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.
PFD Monitor interpretation Lack of agreed target timescales for routine psychiatric appointments
Wider context from the report “A routine psychiatric out patient was offered after his mother indicated she would make a formal complaint. The inquest heard that there were no agreed target timescales for the offering of routine appointments .
” Source location Matthew Gerard Craven · Prevention of Future Deaths report
Open source report
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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 Set a 12-week target for offering routine appointments following review with the Lead Consultant Psychiatrist.
Verbatim wording from the response “Following review with the Lead Consultant Psychiatrist the agreed target timescales for routine appointments is 12 weeks. Clear communication of the target timescales will form part of the action above.” Source location 2018-0365-Response-by-Pennine-Care-NHS-Trust
Open published response
Concerns raised 2
Delays in offering psychiatric follow-up appointments View source Insufficient resourcing of the psychiatric unit View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Leicester City Council Leicestershire Partnership NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Leicestershire Partnership NHS Trust
Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.
View source
Leicestershire Partnership NHS Trust
Develop a partial-booking system for outpatient appointments.
View source
Leicestershire Partnership NHS Trust
Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.
View source
Leicester City Council
Fill vacancies and improve staffing capacity to reduce assessment waiting times.
View source See 1 more action
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AI-generated summary
Barry Thraves · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barry Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and GP.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in offering psychiatric follow-up appointments
Wider context from the report “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months ; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time.
” Source location Barry Thraves · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient resourcing of the psychiatric unit
Wider context from the report “3. The expectation of the Local Authority is that appointments should take place within 28 days, but the unit is significantly under-resourced and delays are common and appear to be tolerated, and have been for some time. Earlier, timely appointments could assist in identifying and intervening with relapsing patients. This opportunity was lost.
” Source location Barry Thraves · Prevention of Future Deaths report
Open source report
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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 Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.
Verbatim wording from the response “In the period between completion of the investigation and leading up to the Coroner’s inquest LPT has been undertaking a programme of specific work to ensure that the maximum use of clinical appointment slots are available in the Adult Mental Health Outpatients department thereby increasing the availability of appointments to our patients. This will reduce the numbers of people who are not attending appointments.” Source location 2015-0443-Response2
Open published response
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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 Develop a partial-booking system for outpatient appointments.
Verbatim wording from the response “LPT is also working towards a ‘partial booking’ system for outpatient appointments whereby appointments are booked much closer to the scheduled date to be seen allowing for a more flexible use of available appointments and a reduction in cancelled clinics. Cancelling of clinics is sometimes unavoidable but it is subject to Clinical Director approval and an action plan to monitor compliance and improvement is scrutinized for assurance at the LPT Quality Assurance Committee.” Source location 2015-0443-Response2
Open published response
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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 Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.
Verbatim wording from the response “Since the beginning of November 2015 what are known as ‘open contacts’ on the patient electronic record (RiO) are being monitored on a weekly basis. This is where a patient has had an appointment date that has passed but the episode of care has not been closed on the record, either by a record of the appointment having taken place or evidence of a further appointment offered. These will be drawn to the” Source location 2015-0443-Response2
Open published response
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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 Fill vacancies and improve staffing capacity to reduce assessment waiting times.
Verbatim wording from the response “Unfortunately at this time the team was under particular pressure due to long term sickness and vacancies, subsequently resulting in individuals waiting a long period of time for assessments. It is most unfortunate that this consequently impacted upon Mr Thraves and also other people awaiting assessment at that time. Fortunately, the staffing situation has now improved, vacancies are filled, and waiting times for assessment have reduced.” Source location 2015-0443-Response
Open published response
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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 concern about psychiatric follow-up falls to Leicestershire Partnership Trust, which will respond separately.
Verbatim wording from the response “This concern relates to Leicestershire Partnership Trust’s involvement with Mr Thraves and I am aware that the Trust will be responding to you on this point.” Source location 2015-0443-Response
Open published response
16 Jan 2015 Mark Robert Anstice · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to communicate scheduled psychiatric appointments across the care team View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mark Robert Anstice · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate scheduled psychiatric appointments across the care team
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team , despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014 .
” Source location Mark Robert Anstice · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.