14 Mar 2023 Nicola Norman · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure to routinely pass mental-health-related SPA calls to a suitably qualified clinician for mental health assessment and risk assessment View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Nicola Norman · 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
Nicola Norman died on 20 January 2020, aged 42, after being found dead hanging at her mother’s address. Before her death, she contacted the Single Point of Access while highly anxious, reported feeling a burden and later reported an overdose and cutting her wrists. The principal concerns were that these contacts were not routinely discussed with a supervising clinician, passed to a suitably qualified clinician for assessment, or notified to her GP and mental health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to routinely pass mental-health-related SPA calls to a suitably qualified clinician for mental health assessment and risk assessment
Wider context from the report “2. That such calls are not routinely passed on to a suitably qualified clinician able to undertake mental health assessment and assess risk for the patient .
” Source location Nicola Norman · Prevention of Future Deaths report
Open source report
17 Feb 2023 Mr Twm Bryn · Prevention of Future Deaths report North West Wales
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Concerns raised 1
Lack of a standardised LPMHSS referral process for low-risk patients’ interim support View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Twm Bryn · 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 Twm Bryn died on 4 October 2021 in a shipping container near his home after suspending himself by the neck with a ligature. He had experienced mental health difficulties and was awaiting counselling after an assessment that identified a mild risk of suicide. The report raises concerns about delays and lengthy waiting lists for primary mental health support, and the lack of interim contact, monitoring or support for low-risk patients who are waiting for counselling.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a standardised LPMHSS referral process for low-risk patients’ interim support
Wider context from the report “(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services).
” Source location Mr Twm Bryn · Prevention of Future Deaths report
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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 Progress the unallocated-patient waiting-list protocol through consultation, approval, distribution and team launch.
Verbatim wording from the response “Due to the variation in practice across the teams in terms of managing patients on a waiting list, an Unallocated Patient Waiting List Protocol has been developed. This draft protocol ensures that service users referred to the Health Board Community Mental Health Teams and Local Primary Mental Health Support Services are managed efficiently, equitably and consistently. The draft protocol will now progress through consultation, approval and distribution.” Source location Response from Betsi Cadwaladr University Health Board
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29 Sep 2022 Ms Aleksandra Markowska · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of direct access for BPAS patients with pregnancy-related mental health decline to perinatal psychiatry teams View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Ms Aleksandra Markowska · 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 Aleksandra Markowska was found unresponsive on 30 September 2021 after jumping from 21 Gardner Close, and her death was pronounced at the scene. The inquest concluded that she took her own life while suffering from pregnancy-related depression and anxiety, after seeking help but not receiving a review by a perinatal psychiatrist. The principal concern was the lack of direct access for BPAS patients experiencing pregnancy-related mental health decline to perinatal psychiatry teams.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of direct access for BPAS patients with pregnancy-related mental health decline to perinatal psychiatry teams
Wider context from the report “The British Pregnancy Advisory Service (BPAS) is a charity whose services are often commissioned by the NHS. As a charity, BPAS does not have direct access to NHS perinatal psychiatrists. Referrals would have to be made either via the patient's GP or via an unwieldy safeguarding concern (as happened in this case). Referrals via the GP are not possible where the patient does not wish their identity to be revealed.
It is a matter of concern that there is no direct access for BPAS patients who are suffering from pregnancy related mental health decline, to peri-natal psychiatry teams .
Direct and confidential access to peri-natal psychiatry teams may reduce the risk of future deaths.
” Source location Ms Aleksandra Markowska · Prevention of Future Deaths report
Open source report
10 Aug 2022 Allan Michael WADDUP · Prevention of Future Deaths report North Northumberland
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Concerns raised 2
Failure to triage mental health self-referrals within 24 hours View source Lack of weekend triage for mental health referrals View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Allan Michael WADDUP · 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
Allan Michael WADDUP died in prison on 13 December 2019 after seeking mental health support. He had been referred and later self-referred, but was discharged without an assessment, was not assessed before his death, and concerns were raised about appointment notification, the Did Not Attend process, delays in triage, and the absence of weekend triage or urgent-assistance guidance on the prison kiosk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to triage mental health self-referrals within 24 hours
Wider context from the report “(2) Mr Waddup was referred to mental health on 30 October 2019. Attempts were made to assess him in his cell over the telephone on 14, 19 and 21 November 2019. He was discharged from mental health on 2 December 2019 without an assessment being undertaken. There was no in person contact to explore the reasons he did not attend those appointments prior to discharge. It could not be confirmed he was personally aware of those appointments. He self-referred on 5 December 2019 and was not triaged within 24 hours or assessed prior to his death. An immediate review of the Did Not Attend (DNA) policy for the mental health services to include an in person contact is being undertaken prior to discharge but has not been completed.
” Source location Allan Michael WADDUP · 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 Lack of weekend triage for mental health referrals
Wider context from the report “(3) Mr Waddup self-referred via the kiosk system. There is no triaging of referrals on a weekend. A disclaimer or warning directing inmates to how to seek urgent assistance is not currently displayed on the kiosk.
” Source location Allan Michael WADDUP · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request electronic kiosk referrals with referral-processing timeframes and urgent-contact information from the prison provider.
Verbatim wording from the response “The prison service provider at HMP Northumberland has granted the request to remove the ability to refer to mental health services via kiosk. Due to the restrictions on the prison kiosk system, men are unable to give any detailed rationale for the appointment request making triage processes difficult for the team upon receipt of the request. A request has been made to the prison provider at HMP Northumberland as to whether an electronic referral can be uploaded to the kiosk system, as well as a notification advising patients of timeframes for referrals to be processed and who to contact, and how, in an urgent situation.” Source location Response from NHS Tees, Esk and Wear Valleys
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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 Provide self-referral forms, including easy-read versions, with questions enabling triage by service need and urgency.
Verbatim wording from the response “Self-referrals, including easy read versions, are available to all men on wing locations. The referral asks specific questions which allow the team to triage the referral appropriately in relation to service required, as well as urgency.” Source location Response from NHS Tees, Esk and Wear Valleys
Open published response
Concerns raised 1
Lack of a route back into the Mental Health Service after CRHT discharge View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kieran Joseph Kevan CRIMMINS · 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
Kieran Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a route back into the Mental Health Service after CRHT discharge
Wider context from the report “(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies.
My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy.
” Source location Kieran Joseph Kevan CRIMMINS · Prevention of Future Deaths report
Open source report
1 Jul 2022 Dominic Robert Noble · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to make psychiatric referrals because of unavailable responding resources View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Dominic Robert Noble · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged referrals.
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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 psychiatric referrals because of unavailable responding resources
Wider context from the report “(3) Concern was expressed in the course of the inquest that the meagre provision of psychiatric consultant availability might deter mental health nurses from making referrals . This concern was not accepted on behalf of PPG. Despite this the concern remains that a self-fulfilling prophecy has inadvertently been created in which referrals are not made because there is no resource to respond to any which may be made .
(4) The concerns raised mirrored issues raised in an inquest which concluded on 1 June 2022 relating to the death of Mohammed Irfaan Afzal in HMP Prison Leeds on 4 August 2019. In a narrative conclusion the jury concluded that despite an urgent referral to a psychiatrist on 15 July 2019, no appointment had been provided before his death on 4 August 2019, “it is possible that the delays in providing treatment contributed more than minimally to Mr Afzal’s death”.
” Source location Dominic Robert Noble · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Approach NHS England and discuss seeking additional psychology and psychiatry resource for HMP Leeds.
Verbatim wording from the response “Intended Changes
Following the Learned Coroner’s comments during the inquest into the death of Mr Afzal, ████████, Practice Plus Group’s Regional Director North – Health in Justice, began discussions with Commissioners at NHS England. Whilst Practice Plus Group maintains that the level of psychiatry provision is at least equivalent to that offered in the community, we also recognise that there are significant levels of mental health morbidity in prisons, particularly in a local remand setting such as HMP Leeds. The Learned Coroner’s comments and subsequent report have highlighted a potential need and we have therefore approached our Commissioners for additional resource.” Source location 2022-0204 - Response from Practice Plus Group
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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 Submit a business case to Commissioners for increased psychology and psychiatry provision at HMP Leeds.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
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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 Existing stepped-care provision and multidisciplinary referral arrangements are considered sufficient to meet patients’ psychiatric needs at current levels.
Verbatim wording from the response “As in the community, Practice Plus Group delivers a stepped care model, which focuses on providing the most appropriate care for the concerns a patient may have. By adopting this model most people with mental health problems do not need to see a consultant psychiatrist. The stepped care model of mental health focuses on providing people with the right level of support from the right clinician at the right time. For example, people experiencing mild to moderate depression and anxiety would see a primary care mental health clinician in the community, alongside the GP, which is step 2/3.” Source location 2022-0204 - Response from Practice Plus Group
Open published response
18 May 2022 Matthew John Evans · Prevention of Future Deaths report Surrey
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Concerns raised 1
Lack of guidance on thresholds for referral to secondary mental health services View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Farnham Park Health Group General Medical Council Recipient name withheld
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AI-generated summary
Matthew John Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of guidance on thresholds for referral to secondary mental health services
Wider context from the report “3. The actions of TalkPlus
There does not appear to be robust guidance or a policy as to the threshold necessary to refer a patient to secondary mental health services in Matthew’s circumstances where his mental health had deteriorated as the sessions progressed and he had began to indicate suicidal ideation and self-harm on a background of no previous mental health difficulties.
” Source location Matthew John Evans · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Verbatim wording from the response “We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where” Source location Response from Care Quality Commisson
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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 No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Verbatim wording from the response “We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where” Source location Response from Care Quality Commisson
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
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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 No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The response disputes that secondary mental health referral was indicated, stating that the patient did not meet referral criteria and remained low risk.
Verbatim wording from the response “10. The Deceased did not come close to a referral to the urgent assessment unit.” Source location Response from Farnham Practice
Open published response
31 Jan 2022 OSKAR MILES NASH · Prevention of Future Deaths report Surrey
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Concerns raised 3
Failure to establish changed child mental health triage practices in written guidance View source Inappropriate closure or referral of child mental health referrals View source Automatic categorisation of routine referrals as low risk View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
OSKAR MILES NASH · 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
Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish changed child mental health triage practices in written guidance
Wider context from the report “I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance .
” Source location OSKAR MILES NASH · 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 Inappropriate closure or referral of child mental health referrals
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies . In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” Source location OSKAR MILES NASH · 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 Automatic categorisation of routine referrals as low risk
Wider context from the report “The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk” . I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.
” Source location OSKAR MILES NASH · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and approve the Standard Operating Procedure manual to reflect new referral triage practices.
Verbatim wording from the response “Concern 4
I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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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 Apply harm reviews to routine referrals waiting over four weeks and review continuing waits every four weeks until triage.
Verbatim wording from the response “If a routine referral has been waiting for over four weeks to be triaged, then it is now subject to a harm review. The child/young person and/or their family will be contacted as part of this, and there will be a conversation about what the current situation is and whether there are any increased risks. Following this review, the referral will either be categorised as being suitable and safe to remain in the routine referral waiting list, with safety netting advice being provided. Alternatively, if the risks have escalated, the referral will be triaged immediately and then referred on to an appropriate service.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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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 Require exceptional referral closure safeguards, including GP and family notification, continued-access information and consideration of safeguarding referral.
Verbatim wording from the response “Referrals will only be closed to the AAT without providing an onward referral in exceptional circumstances. This would typically be where the parent or carer does not engage in the triage process. Before a referral is closed a letter is sent to the parent / carer and the child / young person’s GP, this provides the number to call should they wish to continue with the triage process, or if their circumstances change. Therefore, no referral is closed without the Trust having engaged with the GP and providing the parent / carer with information on how to get support if their circumstances change. Where there is no engagement from the parent or carer, a safeguarding referral must be considered.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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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 closure safeguards require engagement with the GP, information for families, and consideration of safeguarding before referrals are closed.
Verbatim wording from the response “Referrals will only be closed to the AAT without providing an onward referral in exceptional circumstances. This would typically be where the parent or carer does not engage in the triage process. Before a referral is closed a letter is sent to the parent / carer and the child / young person’s GP, this provides the number to call should they wish to continue with the triage process, or if their circumstances change. Therefore, no referral is closed without the Trust having engaged with the GP and providing the parent / carer with information on how to get support if their circumstances change. Where there is no engagement from the parent or carer, a safeguarding referral must be considered.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine referrals are not automatically treated as low risk; they are screened as low risk only after assessment and confirmation of protective factors.
Verbatim wording from the response “I have been told that the routine referrals are automatically categorised as “low risk”. … It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
Open published response
17 Dec 2021 Nichola Jane Lomax · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3
Failures and delays in maintaining and re-referring patients on the Priory waiting list View source Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Greater Manchester Mental Health NHS Foundation Trust NHS Bury Clinical Commissioning Group NHS Greater Manchester Integrated Care Board Priory Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.
View source
NHS Greater Manchester Integrated Care Board
Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.
View source
NHS Greater Manchester Integrated Care Board
Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.
View source
Priory Group
Share and consider revised Priory referral criteria with relevant stakeholders.
View source
Greater Manchester Mental Health NHS Foundation Trust
Develop a community eating disorder medical-monitoring pathway and accept medically stable patients based on clinical assessment rather than BMI alone.
View source
NHS Bury Clinical Commissioning Group
Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.
View source See 3 more actions
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AI-generated summary
Nichola Jane Lomax · 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
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failures and delays in maintaining and re-referring patients on the Priory waiting list
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list . This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS.
” Source location Nichola Jane Lomax · 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 Unclear Priory referral and admission criteria for medically stable patients with low BMI
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13 . The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding . Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Source location Nichola Jane Lomax · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14 . The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Source location Nichola Jane Lomax · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.
Verbatim wording from the response “The traffic light system in MEED has been endorsed by NHSE/I and is being rolled out across the system in Greater Manchester and nationally now so that, like NEWS 2, we can see significant improvement in risk assessment and triage. There will also be a requirement for all ICSs to have a formally established whole-system MEED group, which we have started for young people and are now starting for adults, with a link across the two to ensure the transitions are also addressed. Greater Manchester have also accelerated the review of the whole adult eating disorders pathway, including revised protocols with our independent sector providers and greater collaboration with the voluntary, community and social enterprise sector providing both prevention and recovery support as well as carer support.” Source location 2021-0433 - Response regarding Nichola Lomax
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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 Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.
Verbatim wording from the response “In advance of this, GMHSCP MH Programme Team are working with partners to ensure the Children and Young Person’s Eating Disorders working group that is already in place is broadened to become an all-age group. This will address wider transition issues between Children’s and Adult Eating Disorder services - an area of particular concern for this patient group. Actions to ensure connectivity of evidence-based pathways that apply consistent referral criteria will be a key part of the work of this group. It will involve clinicians, commissioners, service providers and service users. This is something that has already been encouraged over the past year in the” Source location 2021-0433 - Response regarding Nichola Lomax
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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 Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.
Verbatim wording from the response “GMHSCP also acknowledges that the commissioned adult eating disorders service in Bury (like many areas of the country) was insufficient to meet local need. Since then, funding has now also been confirmed between Bury CCG and GMHSCP to implement the GMMH Adult Eating Disorders Business Case.” Source location 2021-0433 - Response regarding Nichola Lomax
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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 Share and consider revised Priory referral criteria with relevant stakeholders.
Verbatim wording from the response “2. Referral criteria for the Priory
We have identified referral criteria that we have concluded are accurate for the adult inpatient eating disorder services that Priory Hospital Cheadle Royal provides. It should be noted however that there is always a requirement for some flexibility and proportionality around the criteria given the particular circumstances of each individual patient for example their history, current presentation and any particular current risks that may impact upon their care and treatment. The inclusion and exclusion criteria are as follows:” Source location 2021-0433 - Response regarding Nichola Lomax
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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 Develop a community eating disorder medical-monitoring pathway and accept medically stable patients based on clinical assessment rather than BMI alone.
Verbatim wording from the response “Greater Manchester Mental Health NHS Foundation Trust (GMMH) welcomes the recent investment by Bury Clinical Commissioning Group (CCG) in the new GMMH clinical model for adult eating disorders which is compliant with national commissioning guidance. This funding commitment will enable the provision of more comprehensive care and treatment to adults with eating disorders under GMMH. This will enable GMMH Community Eating Disorder Services (CEDS) to build on previous advice provided regarding MARSIPAN and dietetic advice for Fairfield General Hospital (FGH) and other acute hospitals across Greater Manchester and to work closely with partner organisations to develop robust pathways to ensure access to specialist advice.” Source location 2021-0433 - Response regarding Nichola Lomax
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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 Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.
Verbatim wording from the response “A business case to expand the service in line with national standards and Greater Manchester and local priorities has been agreed between the CCG and GMMH, and was formally approved by the CCG board on 22 December 2021. I understand that the court was provided with a copy of this business case by GMMH during the course of the inquest; a further copy can be provided if needed. The new model as agreed includes the addition of psychiatry/ medical input to the service (a Consultant Psychiatrist and a Physical Health Practitioner) which will allow patients with a BMI of less than 14 to be accepted by the service and monitored medically by a clinician who has experience and knowledge of eating disorders. In addition it will include:” Source location 2021-0433 - Response regarding Nichola Lomax
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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 Responsibility for addressing Priory referral criteria rests with other organisations.
Verbatim wording from the response “The referral criteria for the Priory is best addressed by other organisations but we understand from recent GM meetings that BMI should not be used as a threshold for determining admission as a matter of policy and it is not now relevant in referrals to the CEDS or from there to the Priory.” Source location 2021-0433 - Response regarding Nichola Lomax
Open published response
15 Oct 2021 Darren John Lawrence · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1
Failure to consider referral back to HBTT when circumstances change View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Darren John Lawrence · 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
Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider referral back to HBTT when circumstances change
Wider context from the report “c. There was no consideration of referral back to the HBTT by the CMHT when the deceased may have benefited from it when circumstances changed . There was disengagement from services after the end of February 2020 as well as evidence of noncompliance with medication.
” Source location Darren John Lawrence · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold daily CMHT multidisciplinary zoning meetings with HBTT participation twice weekly to review crisis support and transfers of care.
Verbatim wording from the response “The Trust has implemented daily multi-disciplinary zoning meetings in CMHT to review individuals who may be in crisis and require additional support. These daily meetings are now attended by staff from HBTT twice per week allowing for better communication between the teams and the ability for both teams to communicate with each other in respect of” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
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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 Use an HBTT discharge checklist, including joint CMHT visits, to support transfers into CMHT.
Verbatim wording from the response “HBTT have also introduced a discharge checklist that includes joint visits with CMHT staff when discharging to CMHT which has had an audit undertaken to ensure this is embedded. Going forward the HBTT Team Manager will carry out a quarterly audit of discharges from HBTT to ensure that individuals are being stepped down from HBTT to CMHT in line with both services operational policies and receiving the support they require. The first one of these will be completed by 31st March 2022.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly audits of HBTT discharges to check policy-compliant step-downs and adequate support.
Verbatim wording from the response “HBTT have also introduced a discharge checklist that includes joint visits with CMHT staff when discharging to CMHT which has had an audit undertaken to ensure this is embedded. Going forward the HBTT Team Manager will carry out a quarterly audit of discharges from HBTT to ensure that individuals are being stepped down from HBTT to CMHT in line with both services operational policies and receiving the support they require. The first one of these will be completed by 31st March 2022.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.