Recurring concern

Unreliable community Home Treatment Team care pathways

First to latest report 12 Sep 2013 — 27 May 2026

Reports that mention this concern
29
Times this concern has been raised
39
Stated actions linked to this concern
36

What this concern includes

Includes failures specifically within Home Treatment Team pathways, including referral, urgent assessment, handover, responsibility for initiating contact, treatment transitions, withdrawal or discharge communication and pathway guidance.

What is not included
  • Generic community mental-health coordination with no Home Treatment Team pathway
  • Home Treatment Team staffing or treatment-quality failures after the pathway controls have operated reliably
  • Unrelated mental-health referral, discharge or crisis pathways

Reports and published responses 29 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    MARY NABILIA GWANYAMA · 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

    Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

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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

    Discharge from the Home Treatment team on ineffective medication

    Wider context from the report

    “6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed. ”

    Source location

    MARY NABILIA GWANYAMA · Prevention of Future Deaths report
    Page 5 · 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 coherent community-care planning and care-coordinator involvement at discharge

    Wider context from the report

    “6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed. ”

    Source location

    MARY NABILIA GWANYAMA · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement SBAR in Home Treatment Team practice and update its operational policy to strengthen multidisciplinary medical-review documentation and decision-making.

    Verbatim wording from the response

    “As explained in ████████ letter dated 24th March 2021, consideration is given at the daily HTT handover meetings, where there is a doctor present, as to how to best meet people’s needs within their overall care plan. It should also be noted that in addition to the handover meetings, each HTT holds weekly clinical reviews attended by the full multi-disciplinary team. During this review, each person on the HTT caseload is systematically reviewed to determine the appropriateness of the existing care plan, risk management plans including medical review and discharge plans.”

    Source location

    2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 23 April 2021

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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 CPA and Acute Care Services policies to require a pre-discharge CPA meeting for every homeless inpatient.

    Verbatim wording from the response

    “The Trust accepts that a discharge CPA meeting was not held prior to Ms Gwanyama being discharged from the Abraham Cowley Unit and, given she was homeless at the time and her housing situation was uncertain, such a meeting should have taken place. Accordingly, the Trust’s CPA policy and Acute Care Services Operational Protocol will be updated to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge.”

    Source location

    2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 1 · response
    Published 23 April 2021

    Open published response

  2. East London

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    Steven Paul David Gary Stout · 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

    Steven Paul David Gary Stout was detained under section 136 of the Mental Health Act after cutting both wrists while intoxicated by alcohol, and was later admitted to a mental health ward. He was discharged on 18 October 2019 without a referral to the home treatment team and was found unresponsive, suspended by his neck from a ligature, on 4 November 2019; he could not be resuscitated. The concerns included failures to accurately record and file important medical records and to ensure an effective referral to the home treatment team.

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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 ensure effective referral from the ward to the community home treatment team

    Wider context from the report

    “2. The failure of Turner Ward Goodmayes hospital to ensure the effective referral of a patient from the ward to the home treatment team within the community. ”

    Source location

    Steven Paul David Gary Stout · Prevention of Future Deaths report
    Page 2 · concerns

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    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 HTT Service Operational Procedure to require HTT or ACAT assessment before relevant patient discharges.

    Verbatim wording from the response

    “The Trust has taken into consideration concerns highlighted in the Regulation 28 report and agreed to take a number of actions to address your concerns. This includes:”

    Source location

    2021-0059 Response from North East London NHS Foundation Trust
    Page 1 · response
    Published 8 March 2021

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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 Clinical Handover of Care and Discharge Policy to improve discharge safety and referral completion.

    Verbatim wording from the response

    “The Trust has taken into consideration concerns highlighted in the Regulation 28 report and agreed to take a number of actions to address your concerns. This includes:”

    Source location

    2021-0059 Response from North East London NHS Foundation Trust
    Page 1 · response
    Published 8 March 2021

    Open published response

  3. Lincolnshire

    AI-generated summary

    Toby Peter Edward Nieland · 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

    Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

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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 of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis

    Wider context from the report

    “8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 4 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review Dual Diagnosis pathways across the treatment system jointly with partner organisations and commissioners.

    Verbatim wording from the response

    “I can confirm that we have participated in ‘Planned Dual Diagnosis Work” meetings with LPFT and our respective commissioners. And we have jointly agreed to review Dual Diagnosis pathways across the treatment system.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 1 · response
    Published 26 October 2020

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.

    Verbatim wording from the response

    “i. A joint working protocol is in place but has not been widely implemented across all services. The CCG, LPFT, We Are With You and Public Health should work together to review this protocol and implement a more robust”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

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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

    Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.

    Verbatim wording from the response

    “Learning from the death of Mr Nieland, the Trust will strengthen the policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 26 October 2020

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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

    Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.

    Verbatim wording from the response

    “We have summarised below the actions the Trust will take to learn from Mr Nieland’s death and enhance services for patients with a complex dual diagnosis presentation: To review internal policies and protocols as well as work together with “We Are With You” to embed care pathways between the two organisations to address gaps in services. (Leads: Clinical Director for Community Division and Quality Lead for the Community Division)”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 7 · response
    Published 26 October 2020

    Open published response

  4. Inner South London

    AI-generated summary

    Ms Kerry Aldridge · 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

    Ms Kerry Aldridge was a student police officer who died by suicide after jumping into the path of a train at Sydenham Railway Station on 6 April 2019. The report raised concerns about the lack of established links between police Safeguarding Teams and NHS mental health teams, and about the need for further mental health training and access to non-urgent advice for officers.

    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

    Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency

    Wider context from the report

    “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support. It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice. ”

    Source location

    Ms Kerry Aldridge · Prevention of Future Deaths report
    Page 1 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate a 24-hour mental-health advice and support line for the public, police and ambulance service, staffed by mental-health professionals who can initiate rapid joint assessment.

    Verbatim wording from the response

    “South London & Maudsley NHS Trust has, since 2017, worked in partnership with the Metropolitan Police to provide a crisis and assessment service. The service enables mental health staff to work jointly with metropolitan police officers in the provision of early assessment and intervention. ████████, allocates officers to work within the Crisis and Assessment Team. The service also provides a 24 hour advice and support line to the public, 111 service, the police and London Ambulance Service. The advice line is staffed by mental health professionals who will advise officers and instigate rapid joint assessment if required. This joint arrangement between the police and South London & Maudsley NHS Foundation Trust offers a proactive joint response to the concerns that may face police officers who may have limited knowledge in relation to mental illness.”

    Source location

    2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
    Page 2 · response
    Published 18 March 2020

    Open published response

  5. Norfolk

    AI-generated summary

    Peter Frosdick · 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

    Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s 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 offer or explore home treatment

    Wider context from the report

    “(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't. ”

    Source location

    Peter Frosdick · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. West Sussex

    AI-generated summary

    George Edward Rogers · 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

    George Edward Rogers had a diagnosis of body dysmorphic disorder and died on 28 August 2018 after causing a fatal laceration to his chest. Following his transfer between care teams, a Lead Practitioner was not appointed promptly, resulting in a period without treatment or ongoing risk assessment. The principal concern was that such transfer arrangements could delay treatment and leave patients unmonitored.

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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 appoint a Lead Practitioner when transferring patients between the CRHTT and ATS

    Wider context from the report

    “1. When transferring patients between the CRHTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment. ”

    Source location

    George Edward Rogers · Prevention of Future Deaths report
    Page 2 · concerns

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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 transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.

    Verbatim wording from the response

    “The process for allocation of a Lead Practitioner is as follows; the CRHTT attends the weekly Multi-Professional ATS meeting (ATS - sometimes referred to as a Community Mental Health Team) to provide an update on each case and to request allocation, if needed, of a Lead Practitioner.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 1 · response
    Published 27 November 2019

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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 weekly patients transferred between teams who remain without an allocated Lead Practitioner.

    Verbatim wording from the response

    “Any patient not allocated a Lead Practitioner is monitored by the Team Leader on a weekly basis.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 2 · response
    Published 27 November 2019

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.

    Verbatim wording from the response

    “I hope that the content of this letter and its enclosures addresses your concerns and provides you with assurance that there is no delay in a patient receiving access to treatment on transfer between CRHTT and the ATS, that there is a process in place to monitor patients who have been transferred and are receiving support with the Duty Worker whilst a Lead Practitioner is identified. However, if any further clarification is required or I can assist further in any way then please do not hesitate to contact me.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 2 · response
    Published 27 November 2019

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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 monitoring and Duty Worker arrangements are sufficient while a Lead Practitioner is identified after transfer.

    Verbatim wording from the response

    “If the patient is already known to the team, the Lead Practitioner (ATS) will remain involved and work with the CRHTT throughout the episode of care. If the person is unknown to the ATS, the CRHTT and ATS will work together to plan onward care and support. Where a Lead Practitioner cannot be provided immediately by the ATS, an initial appointment will be offered within 7 days of transfer from the CRHTT and follow-up plans will be agreed. This may include care and support being offered by the ATS Duty Worker (a senior registered professional) who the patient will be able to contact for support. This support includes face to face contact on the same day if necessary and attendance at the ATS if”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 1 · response
    Published 27 November 2019

    Open published response

  7. Birmingham and Solihull

    AI-generated summary

    Nigel Byron Abbott · 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

    On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.

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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

    Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community

    Wider context from the report

    “Summary of Concerns In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them. The five generic on-going matters of concern: (1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments. (2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds. (3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT. (4) Whilst section 4 is available to be used, it is not used. (5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed. ”

    Source location

    Nigel Byron Abbott · Prevention of Future Deaths report
    Page 10 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise, approve and cascade the Home Treatment Team operational procedure to align safeguards with the Bed Management Policy.

    Verbatim wording from the response

    “15 The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 7 · response
    Published 18 October 2019

    Open published response

  8. Birmingham and Solihull

    AI-generated summary

    David Jonathon Jukes · 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

    David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.

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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 attempt timely assessment after a high-risk patient re-establishes contact

    Wider context from the report

    “6. On the 9th October 2018 an HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018. By this time he was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact. The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk. No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues. ”

    Source location

    David Jonathon Jukes · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Increase Home Treatment Team workforce capacity through additional managers, practitioners, medical staff, psychologists and administrative staff.

    Verbatim wording from the response

    “We are conscious that our Home Treatment Teams have been operating within an environment of high demand and acuity and that may at times compromise their ability to consistently meet the important standards that we expect of staff. We are investing a significant amount of new financial resource into our Home Treatment Team to increase workforce capacity. This includes:”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 5 · response
    Published 26 July 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Home Treatment Team operating protocol to strengthen nurse-led triage, assessment screening and escalation to consultant psychiatrists.

    Verbatim wording from the response

    “In direct response to this matter of concern we are now reviewing our Home Treatment Team Operating Protocol to strengthen the requirement for nurse led triage and assessment screening and appropriate clinical escalation to a Consultant Psychiatrist. Consultant Psychiatrist overview and scrutiny of each case would either be through direct clinical assessment or review or through input and direction within the multi-disciplinary team or through formal or informal supervision of doctors and other home treatment staff. We note the view of the team that they felt they acted appropriately and are therefore also using this very sad incident as a Case Study in our new Clinical Risk Assessment and Management Training so that staff are fully alert to accumulative risk factors. This training is mandatory for all clinical staff in the Trust irrelevant of clinical profession or team.”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 4 · response
    Published 26 July 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Care and treatment concerns are largely for provider organisations to resolve.

    Verbatim wording from the response

    “2.8 These issues are largely within the remit of the provider organisations to resolve, and the CCG confirms that an appropriate action plan has been drawn up and completed by BSMHFT.”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · response
    Published 26 July 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local NHS agencies are expected to address the report’s local concerns.

    Verbatim wording from the response

    “Please note this response will address the matters of concern from a national level and we would expect the local NHS agencies, which I note are copied in to the letter, to address the local concerns raised.”

    Source location

    2019-0220-Response-by-NHS-England
    Page 1 · response
    Published 26 July 2019

    Open published response

  9. Inner South London

    AI-generated summary

    Michael Vukovic · 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

    Michael Vukovic, who was suffering psychosis, jumped from a second- or third-floor balcony on 8 July 2017 and sustained an L1 vertebral fracture. He suffered a cardiac arrest and hypoxic brain damage after admission to hospital, and died on 11 July 2017. The principal concerns were that he was not seen by the Home Treatment Team, that follow-up with a drug and alcohol service was not checked, and that he was discharged without follow-up.

    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 of the Home Treatment Team to see referred patients

    Wider context from the report

    “My specific concerns are as follows: (1) ████████ evidence that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team. (2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the HTT he would have been encouraged to engage with Lifeline. (3) The result was that Mr Vukovic was discharged from hospital without follow up. ”

    Source location

    Michael Vukovic · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 patient was not referred to the Home Treatment Team, so the concern that he was referred but not seen is factually incorrect.

    Verbatim wording from the response

    “(1) Dr Apio’s evidence was that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team.”

    Source location

    Michael-Vukovic-Response
    Page 1 · response
    Published 8 June 2018

    Open published response

  10. Inner South London

    AI-generated summary

    Anne Morris · 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

    Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.

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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 of the HTT to obtain a written discharge plan from the hospital

    Wider context from the report

    “(4) The Oxleas HTT do not appear to have proactively contacted the Priory Hospital for a written discharge plan prior to, or at the time, of the home visit on the 25/6/17. Had the HTT made contact with the Priory Hospital it would still have been possible to formulate a plan (including the availability of collateral assistance from Messrs ████████). ”

    Source location

    Anne Morris · Prevention of Future Deaths report
    Page 2 · concerns

    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 liaise with the HTT before discharge

    Wider context from the report

    “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge. ”

    Source location

    Anne Morris · Prevention of Future Deaths report
    Page 2 · concerns

    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 formulate a written discharge plan identifying the responsible community HTT

    Wider context from the report

    “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues. ”

    Source location

    Anne Morris · Prevention of Future Deaths report
    Page 2 · concerns

    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 identify a responsible HTT for the discharge address

    Wider context from the report

    “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge. ”

    Source location

    Anne Morris · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the transfer-of-care protocol to address obtaining missing information from referring or receiving services.

    Verbatim wording from the response

    “• Our ‘Transfer of Care within Oxleas and externally’ protocol has been reviewed by the Medical Director, because it only described the information which should be provided to other units not what services should do in order to obtain information when a patient is referred / transferred. This will ensure standardisation in all Oxleas services in addition to the Home Treatment Team and this will then be disseminated through our clinical effectiveness governance process. This action is complete.”

    Source location

    2017-0383-Response-by-Oxleas-NHS-Trust_Redacted
    Page 1 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Disseminate the reviewed transfer-of-care protocol through the clinical effectiveness governance process.

    Verbatim wording from the response

    “• Our ‘Transfer of Care within Oxleas and externally’ protocol has been reviewed by the Medical Director, because it only described the information which should be provided to other units not what services should do in order to obtain information when a patient is referred / transferred. This will ensure standardisation in all Oxleas services in addition to the Home Treatment Team and this will then be disseminated through our clinical effectiveness governance process. This action is complete.”

    Source location

    2017-0383-Response-by-Oxleas-NHS-Trust_Redacted
    Page 1 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and relaunch the discharge policy, strengthening family involvement, care-plan circulation, service identification and written acceptance of follow-up responsibility.

    Verbatim wording from the response

    “Please note that we have reviewed and re-launched Priory Healthcare Policy H02: Admission, Transfer and Discharge and made reference to the involvement of family, friends and carers in the discharge planning process (paragraph 5.1e). A rolling programme of training webinars which detail policy and practice in relation to discharge planning will feature as part of these webinars. Please be assured that the point that you have made in respect of communicating with family and friends prior to discharge will be highlighted as part of these webinars.”

    Source location

    2017-0383-Response-by-Priory-Group
    Page 1 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver a rolling webinar training programme highlighting discharge-planning policy, family communication, care-plan circulation and follow-up service responsibilities.

    Verbatim wording from the response

    “Please note that we have reviewed and re-launched Priory Healthcare Policy H02: Admission, Transfer and Discharge and made reference to the involvement of family, friends and carers in the discharge planning process (paragraph 5.1e). A rolling programme of training webinars which detail policy and practice in relation to discharge planning will feature as part of these webinars. Please be assured that the point that you have made in respect of communicating with family and friends prior to discharge will be highlighted as part of these webinars.”

    Source location

    2017-0383-Response-by-Priory-Group
    Page 1 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The fourth and fifth concerns relate to Oxleas Mental Health NHS Trust rather than Priory Group.

    Verbatim wording from the response

    “We note that the fourth and fifth matters of concern relate to Oxleas Mental Health NHS Trust rather than to Priory Group.”

    Source location

    2017-0383-Response-by-Priory-Group
    Page 2 · response
    Published 12 February 2018

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026