26 Mar 2024 Mark Wolfe Kinzley · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Mark Wolfe Kinzley · 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 Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.
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 refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
Wider context from the report “3. During the same period, Mr Kinzley was not referred for a mental health assessment despite.
a. His history of mental illness.
b. His history of deliberate self-harm.
c. His history of accidental self-harm when agitated.
d. His deteriorating mental state during the month prior to his death.
” Source location Mark Wolfe Kinzley · Prevention of Future Deaths report
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 Deliver targeted provider training on safeguarding, escalation processes and risk identification, including notifying the Local Authority and making safeguarding referrals for identified self-harm or other health risks.
Verbatim wording from the response “The Local Authority will deliver targeted training to care providers regarding safeguarding, escalation processes/and risk identification.” Source location Response from NELFT and Redbridge Council
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 Inform care staff that local mental health teams accept referrals from patients, carers and other medical professionals.
Verbatim wording from the response “Following the inquest, our named clinician, Dr Barker, for the care home has made the care staff aware that the local mental health teams, also accept referrals from patients, carers, and other medical professionals, in addition to referrals from a GP. This may be appropriate for any future cases as it would allow the care home to make a referral without waiting for a GP assessment, such as patients with fluctuating capacity or emergency situations.” Source location Response from Evergreen Surgery
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 A mental-health referral required the consent of a patient assessed as having capacity, and depended on his willingness to consent.
Verbatim wording from the response “Whilst we recognise the importance of mental health assessments and referrals for individuals with a history of mental health issues, we emphasise that any referral to mental health services in this situation would have required Mr. Kinzley's consent. He was deemed to have capacity at the times he was assessed, and therefore any referral would have been contingent upon his willingness to consent to such services.” Source location Response from Evergreen Surgery
Open published response
21 Feb 2024 Mr Oliver Beswetherick · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Lack of contact details for neighbouring psychiatric liaison and crisis mental health teams View source
×
AI-generated summary
Mr Oliver Beswetherick · 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
Mr Oliver Beswetherick, who had a history of depression, bulimia and bipolar affective disorder, was found dead after falling from his flat on 4 September 2020. The report raised concern that mental health crisis teams did not have contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, hindering direct referrals and the sharing of case information.
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 Lack of contact details for neighbouring psychiatric liaison and crisis mental health teams
Wider context from the report “(1) It became evidence during the inquest that CMHT/ Crisis teams do not have contact details of:
(i) Psychiatric liaison nurse services in neighbouring (out of their locality) boroughs based in Accident & Emergency departments, or details of
(ii) CMHT/ crisis teams in neighbouring boroughs.
Such contact could provide for direct referral, contact and passing on of knowledge of cases between neighbouring organisations, especially when individuals have already been assessed and asked to attend for a face-to-face consultation. Otherwise, those individuals who seek help, may have to revisit the same process of being interviewed on multiple occasions with a sense of déjà vu and anxiety that they are not obtaining the urgent assistance and support that they require. That may lead to them not engaging when they had hitherto made every attempt to do so.
To provide those contact details would seem a relatively simple task, so teams could contact each other, and the local psychiatric liaison nurses based within the A&Es.
” Source location Mr Oliver Beswetherick · Prevention of Future Deaths report
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 Existing NHS Service Finder and website directories provide professionals with current neighbouring mental health service contact details and referral information.
Verbatim wording from the response “Your Report raises the concern that Community Mental Health and Crisis Teams do not have the contact details of Psychiatric Liaison, Community Mental Health, and Crisis Teams within neighbouring boroughs.” Source location Response from NHS England
Open published response
Concerns raised 1
Failure to provide sufficient staffing for community mental health team referral screening View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Nicolas Gerasimidis · 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
Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.
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 provide sufficient staffing for community mental health team referral screening
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues ;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Source location Nicolas Gerasimidis · Prevention of Future Deaths report
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 Grow the mental health workforce by an additional 27,000 staff to increase service capacity.
Verbatim wording from the response “You noted that Mr Gerasimidis was on a lengthy waiting-list to access psychological therapy at the time of his death with ensuing concerns that other patients may have to wait significant lengths of time for care. We recognise that the demand on NHS mental health services has risen significantly, and this means that some people may face waiting times that are much longer than we would like. That is why, through the NHS Long Term plan, the Government is providing record levels of investment and increasing the mental health workforce to expand and transform NHS mental health services in England.” Source location Response from DHSC
Open published response
8 Nov 2023 Leva Amra ADRIS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3
Lack of GP awareness that referrals to secondary services may not be considered by secondary services View source Failure to inform referring GPs when referrals to secondary services are rejected View source Failure of secondary services to consider referrals requesting their review and assessment View source
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust NHS Birmingham and Solihull Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Birmingham and Solihull Mental Health NHS Foundation Trust
Amend the GP referral form to clarify that the service will assess referrals and determine where patients’ needs are best met, removing confusing secondary-care terminology.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Continue disseminating the referral and service-model information through GP communications, engagement sessions, meetings and healthcare partnership forums.
View source
NHS Birmingham and Solihull Integrated Care Board
Establish effective working relationships and clarify referral processes between mental health services and general practice.
View source
NHS Birmingham and Solihull Integrated Care Board
Operate a central general-practice portal for consolidating referral protocols.
View source
NHS Birmingham and Solihull Integrated Care Board
Include mental-health referral protocols in the central general-practice portal.
View source See 2 more actions
×
AI-generated summary
Leva Amra ADRIS · 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
Leva Amra Adris was pronounced deceased on 18 March 2023 after suffering a fitting episode, and post-mortem testing identified toxicity following an overdose of medication used for anxiety. The report raised concerns that a GP referral requesting secondary mental health assessment was not considered by secondary services, that the GP was not informed it had been rejected, and that the significance of worsening mental health symptoms may have been underestimated.
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 Lack of GP awareness that referrals to secondary services may not be considered by secondary services
Wider context from the report “6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected.
” Source location Leva Amra ADRIS · 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 inform referring GPs when referrals to secondary services are rejected
Wider context from the report “6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected .
” Source location Leva Amra ADRIS · 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 of secondary services to consider referrals requesting their review and assessment
Wider context from the report “5. When a GP has referred a patient for review and assessment by secondary services I am concerned that it is not safe that there is no consideration of that referral by secondary services and the GP’s opinion that secondary services need to be involved is unilaterally over-ruled .
” Source location Leva Amra ADRIS · Prevention of Future Deaths report
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 Amend the GP referral form to clarify that the service will assess referrals and determine where patients’ needs are best met, removing confusing secondary-care terminology.
Verbatim wording from the response “We have made alterations to our referral form for those GPs who continue to refer using the attached referral form. We have made it explicitly clear that the Community Mental Health and Wellbeing Service will review the referral and determine where the patients’ needs can be best met. We have also removed reference to referral to ‘secondary care services’ to avoid confusion.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Continue disseminating the referral and service-model information through GP communications, engagement sessions, meetings and healthcare partnership forums.
Verbatim wording from the response “We have now liaised with the staff involved in order to be able to respond to your concerns in relation to the GP referral system to secondary mental health services and communication to GPs in respect of the same. Community Mental Health Services have been undergoing significant transformation since April 2021. In line with the attached national programme of work the government committed significant investment in Community Mental Health Services to integrate the ‘front door’ of Mental Health Services with Primary Care Networks (PCNs), improving access to services, providing a multi-agency approach and reducing unnecessary waits. There has been significant communication around the programme and the changes with our PCN Clinical Directors, leads and GPs.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Establish effective working relationships and clarify referral processes between mental health services and general practice.
Verbatim wording from the response “Firstly, may I apologise for the delay in our response and assure you that our organisation takes the findings seriously. We appreciate the thoroughness of your investigation and the comprehensive matters of concern outlined in your report. We are committed to working with partner to address these concerns and we note the response from Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) dated 15th December 2023. In particular, we will ensure that BSMHFT and General Practice have effective working relationships with clarity of referral processes between the two providers particularly with regards to the transformed Community Mental Health and Wellbeing Service and the associated referral form and processes.” Source location Response from Birmingham and Solihull
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 Operate a central general-practice portal for consolidating referral protocols.
Verbatim wording from the response “The interfaces between primary care and other providers is a particular focus for us and as a system we have several work programmes running in this space. Our new structures ensure that representatives of GP as a whole sector are included in key system work programmes, including Community Mental Health; this allows GP views to be heard and shape service change as well as to provide structured communication routes for escalating concerns and information about change. We also now have a central portal for General Practice which can contain all referral protocols in one place and will ensure that mental health ones are included within this.” Source location Response from Birmingham and Solihull
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 Include mental-health referral protocols in the central general-practice portal.
Verbatim wording from the response “The interfaces between primary care and other providers is a particular focus for us and as a system we have several work programmes running in this space. Our new structures ensure that representatives of GP as a whole sector are included in key system work programmes, including Community Mental Health; this allows GP views to be heard and shape service change as well as to provide structured communication routes for escalating concerns and information about change. We also now have a central portal for General Practice which can contain all referral protocols in one place and will ensure that mental health ones are included within this.” Source location Response from Birmingham and Solihull
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 referral showed no need for medical input or urgent intervention and was handled within the suggested timeframe.
Verbatim wording from the response “This particular referral was managed by an experienced registered psychiatric nurse with secondary care expertise. Having reviewed the referral form there was no indication of a request specifically for a medical colleague review, neither was there an assessed need for medical input. Should the assessing psychiatric nurse have felt a medically trained colleague needed to review the patient, they would have brought the case to one of the regular Multi-Disciplinary Meetings (MDTs) or would have immediately spoken with a medically trained colleague for support. As stated, this was not indicated in this case.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Established local triage of Community Mental Health and Wellbeing Service referrals is considered sufficient.
Verbatim wording from the response “All referrals coming into our Community Mental Health and Wellbeing Service, will be triaged locally, this has been the process in place for many years and is an already established process. BSMHFT central SPOA function is primarily an administrative function and referrals are sent by SPOA (Single Point of Access) to local services to triage (with the exception of older persons services).” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Specialist mental health services, including PCN mental health professionals, should assess need and determine appropriate service placement rather than individual GPs.
Verbatim wording from the response “The assessment of mental health need should be retained within the specialist community mental health and wellbeing service and should not be for individual GPs to determine. As mentioned above PCNs now have access to experienced Mental Health professionals who are best placed to review need and determine where in the service individuals needs can be met.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
20 Oct 2023 Michael Joseph HINDES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to refer patients to the crisis team during delays in community mental health follow-up 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
South West London and St George'S Mental Health NHS Trust
×
AI-generated summary
Michael Joseph HINDES · 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 Hindes died by suicide after calling 999 because he felt suicidal and being taken to St George’s Hospital for a half-hour mental health assessment before discharge. The principal concerns were that he was not referred to the crisis team despite a likely minimum one-week wait for community mental health follow-up, and that the assessing nurse did not try to persuade him to involve his family, who were unaware of his mental ill health until after his death.
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 refer patients to the crisis team during delays in community mental health follow-up
Wider context from the report “He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen.
In the meantime, it was not thought necessary to refer him to the crisis team.
Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this.
The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services.
Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt.
” Source location Michael Joseph HINDES · Prevention of Future Deaths report
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 Clinical assessment found low self-harm risk, so discharge with routine CMHT referral rather than crisis services was considered appropriate.
Verbatim wording from the response “As you are aware through the Inquest, the clinical risk assessment undertaken at the time by the assessing nurse in the Psychiatric Liaison Team deemed the patient to be of low risk of self-harm and that he was suitable to be discharged home. In addition, with a routine referral to the Community Mental Health Team (CMHT) for ongoing diagnosis/further assessment, as crisis services were not required at that time.” Source location Response from South West London and St George's Mental Health
Open published response
Concerns raised 1
Failure to refer students to NHS mental health services when they are receiving other support View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Alex Dews · 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
Alex Dews went to a bridge at Dearne Valley Country Park on 14 July 2022, fell into shallow water, and died at Sheffield Children’s Hospital on 18 July 2022. The report raises concerns about school documentation and assessment processes, barriers to referral to NHS mental health services, unclear allocation of school-procured psychology support, and inadequate communication with the support provider.
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 refer students to NHS mental health services when they are receiving other support
Wider context from the report “1. Alex was not referred by school to NHS mental health services as a result of their experience that if Alex was in receipt of any other support he would not be accepted onto the waiting list (which would be in excess of 10 months to be seen).
” Source location Alex Dews · Prevention of Future Deaths report
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 Establish an I-Space discharge process providing the academy with reports on continuing support and potential re-referral.
Verbatim wording from the response “The academy has worked with I-space to review processes around how a young person is discharged when their allocated sessions come to an end. This review had already taken place prior to the inquest and has now been in place for over a year. A copy of the discharge form (Appendix D) shows that the service now provides a discharge report to the inclusion team in school. This details how the school could support further and would be used to detail how any further re-referral to the service would best be considered. In any event, a pupil who has received support from the I-Space service would remain on the academy’s vulnerable register and, therefore, be triaged weekly as to whether any re-referral or referral to an escalated service might be deemed necessary.” Source location Response from Outwood Grange Academies Trust
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 Decisions about appropriate school support services are delegated to school leaders rather than prescribed by the Department.
Verbatim wording from the response “The Department for Education is not prescriptive in what support services schools can use – that authority is delegated to school leaders to ensure that the support is tailored for children by those who know them best. Schools have delegated budgets to make those decisions and should escalate cases to children’s social care or to child and adolescent mental health services when there is cause for concern over and above the support that a school puts in place.” Source location Response from Department for Education
Open published response
31 Aug 2023 Donna Levy · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to make formal mental health referrals for reluctance to accept offered care View source
This report raised 4 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.
×
AI-generated summary
Donna Levy · 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
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.
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 make formal mental health referrals for reluctance to accept offered care
Wider context from the report “5. No formal referral was made to mental health services regarding Ms Levy’s reluctance to take advantage of offered care .
” Source location Donna Levy · Prevention of Future Deaths report
Open source report
1 Aug 2023 Edward England Rhodes · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3
Breakdown in communication about the steps and responsibilities for Mental Health referral View source Failure to send a letter confirming the respective responsibilities of the doctor and patient View source Absence of an automatic Mental Health referral pathway after 90 days of sobriety View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Edward England Rhodes · 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
Edward England Rhodes, who had a history of alcohol misuse, relapsed after a period of abstinence and was found unresponsive on 17 November 2022. Toxicology revealed methadone at a level consistent with severe, possibly fatal toxicity, and the inquest recorded a drug-related death. Concerns included a possible breakdown or misunderstanding between Mr Rhodes and his GP about the steps required for a mental health referral, and the absence of clear written confirmation of respective responsibilities.
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 Breakdown in communication about the steps and responsibilities for Mental Health referral
Wider context from the report “2. I have concerns with regard to the following:
i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral.
ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict.
iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient.
iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient.
” Source location Edward England Rhodes · 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 send a letter confirming the respective responsibilities of the doctor and patient
Wider context from the report “2. I have concerns with regard to the following:
i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral.
ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict.
iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient.
iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient.
” Source location Edward England Rhodes · 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 Absence of an automatic Mental Health referral pathway after 90 days of sobriety
Wider context from the report “2. I have concerns with regard to the following:
i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral.
ii. Reliance appears to have been placed on verbal discussions during consultation and in circumstances where the patent is an addict.
iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient .
iv. There does not appear to be a letter sent by the surgery confirming the respective responsibilities of the doctor and patient.
” Source location Edward England Rhodes · Prevention of Future Deaths report
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 Obtained current CMHT referral pathways, Pan Dorset guidance and integrated community mental-health procedures.
Verbatim wording from the response “9.2. The Practice have sought and obtained copies of the CMHT referral pathways from the Integrated Service Manager for Bournemouth East CMHT, the “Pan Dorset Guidance/Process” and “Integrated Community Mental Health Team Procedures” copies of which are attached. These had not previously been provided to the Practice. These were requested on 9 August 2023 and obtained on 10 August 2023. The CMHT’s referral criteria does not specify a requirement for 90 days’ abstinence.” Source location Response from Beaufort Road Surgery
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 Met system patient-safety and mental-health representatives to discuss referral matters and criteria.
Verbatim wording from the response “9.8. By way of follow up meeting on 25 September 2023 ████████ (Practice Manager) and ████████ attended a meeting with ████████████████████ (Patient Safety at Dorchester Hospital and University Hospitals Dorset) ████████ (ICB Transformation Lead), ████████ (Secondary Care Mental Health Service Lead), ████████ (ICB Patient Safety Lead) to discuss matters arising and referral criteria to CMHT. The pertinent discussion points of relevance were:” Source location Response from Beaufort Road Surgery
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 Practice disputes that communication broke down or that it miscommunicated the steps required for a mental health referral.
Verbatim wording from the response “i. There appears to be an apparent breakdown in communication or a misunderstanding between GP and patient as to what steps needed to be taken and by whom in order for there to a Mental Health referral.” Source location Response from Beaufort Road Surgery
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 Practice considers the hepatologist’s written communication to the patient sufficient and will not routinely send reminder letters about requesting referrals.
Verbatim wording from the response “The “discussion” was between the Deceased and his liver specialist and was followed up in writing, by letter dated 18 August 2022 marked as copied to the Deceased. See Response 2. a. above which is reiterated.” Source location Response from Beaufort Road Surgery
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 Practice considers automatic referral after abstinence inappropriate and unworkable because relapse or changed mental health needs require review before referral.
Verbatim wording from the response “iii. There does not appear to be a system where there would be an automatic referral by the GP to the Mental Health team after a 90 day period of sobriety unless the patient “opted out” or where following an automatic referral it is left to the Mental Health team to seek the co operation of the patient.” Source location Response from Beaufort Road Surgery
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 Practice disputes that 90 days’ sobriety was a formal mental health referral rule, describing it as a historic misunderstanding.
Verbatim wording from the response “9.7. Contacted and met with ICB Patient Safety Services on 30 August 2023. Established there is a review underway of the service provision for patients with alcohol dependency but that is still at the fact finding stage and the timeframe for completion is realistically not until the middle of 2024.” Source location Response from Beaufort Road Surgery
Open published response
5 Jun 2023 Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Nottinghamshire Healthcare 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
Nottinghamshire Healthcare NHS Foundation Trust
Distribute veteran-service leaflets, posters and QR-linked intranet information to mental-health practitioners and Trust services.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Scope mandatory veteran-status recording, service hyperlinks and referral-support prompts in RiO.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Include self-referral support and veteran referral requirements in the updated LMHT Standard Operating Procedure and distribute it to staff.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Share the Veteran folder across Mental Health Services after suitability review.
View source See 1 more action
×
AI-generated summary
Jonathan “Jonny” Philip Cole [JC] · 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
Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.
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 Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners ;
b) a lack of understanding as to services available for Veterans;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
” Source location Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report
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 Distribute veteran-service leaflets, posters and QR-linked intranet information to mental-health practitioners and Trust services.
Verbatim wording from the response “The Trust has taken action to gain knowledge of appropriate Veteran services which are available, and we are able to make referrals to. As a result of this, we have looked to update our mental health practitioners with regards to this information. All this information has been collated from Nottinghamshire Healthcare culture and staff engagement facilitators, who are part of the Veterans’ Network. Leaflets and posters have been provided and are being distributed throughout the Mental Health Care Group and shared with the wider Trust for review and distribution. As part of the information provided is a card that has a QR code on it, practitioners can scan this code and it takes them to the Veteran information pages on the Nottinghamshire Healthcare Trust intranet site ‘Connect.’” Source location Response from Nottinghamshire Healthcare
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 Scope mandatory veteran-status recording, service hyperlinks and referral-support prompts in RiO.
Verbatim wording from the response “The Patient Medical records (RiO) now request that a section to be completed which seeks to ask if they are a veteran. We are in the process of scoping if this can be a mandated question and to also add a hyperlink which will guide the practitioner to the services available. We also plan to add a prompt about ensuring that the patient is supported with the referral if required. This functionality will be audited in 6 months’ time to review accessibility and whether this can be used more widely.” Source location Response from Nottinghamshire Healthcare
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 Include self-referral support and veteran referral requirements in the updated LMHT Standard Operating Procedure and distribute it to staff.
Verbatim wording from the response “In addition, guidance has been written for staff to demonstrate professional curiosity in relation to a service users’ motivation or ability to complete self-referrals. This identifies those who need support to self-refer and clinicians will complete this with the individual or for them if appropriate. This guidance will be included in the updated version of the Local Mental Health Team (LMHT) Standard Operating Procedure (SOP), which will be provided for reference once completed by the end of August 2023. This SOP will incorporate the need to refer Veterans to OpCourage rather than rely on self-referral due to the known difficulty our Veterans have in seeking support. All LMHT staff will be provided with a copy via email and this section will be highlighted in the business meetings.” Source location Response from Nottinghamshire Healthcare
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 Share the Veteran folder across Mental Health Services after suitability review.
Verbatim wording from the response “A Veteran folder (Appendix 4) has been developed to help and support referrals for Veterans, this has been shared throughout the Adult Mental Health services And is currently being reviewed by our Mental Health Services for Older Peoples leads and Specialist Services leads to check suitability for patient group and will be shared across Mental Health Services by 18 August 2023.” Source location Response from Nottinghamshire Healthcare
Open published response
Concerns raised 1
Delays and failures in referral to the Community Treatment Team View source
This report raised 12 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.
×
AI-generated summary
Odessa Carey · 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
Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.
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 and failures in referral to the Community Treatment Team
Wider context from the report “8. Contact with IRT and referral to Community Treatment Team
The service user contacted the service on a number of occasions and sought self-referral to the Crisis team on 19 September 2018 who assessed her as requiring a re-referral to the community team. No referral was made.
I am concerned that there was a delay in the referral to the Community Treatment Team and there is no audit system to ensure referrals are made and in a timely fashion.
” Source location Odessa Carey · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.