Recurring concern

Unreliable communication within and between community mental-health teams

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First reported 17 Dec 2013•Latest report 16 Jan 2026

Definition

What this concern includes

Includes failures in communication of clinically or safety-relevant patient information within or between community mental-health teams and closely connected community mental-health teams, including unclear internal communication, ineffective team-to-team communication and failures that leave responsibilities, treatment plans or risks misunderstood.

Not included

  • Excludes generic communication failures without an explicit community mental-health team context.
  • Excludes communication between community mental-health teams and unrelated services unless the assertion also directly concerns the community mental-health team communication process.
  • Excludes failures in the quality of clinical assessment, treatment or care after relevant information has been communicated reliably.
  • Excludes generic staffing, training, documentation or governance deficiencies unless they directly cause unreliable communication within or between community mental-health teams.
  • Excludes neutral descriptions of multidisciplinary or inter-team working without an asserted unsafe communication condition.
Reports
9

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
NHS England2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Coventry and Warwickshire Partnership NHS Trust1
Devon Partnership NHS Trust1
Dorset Healthcare University NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Herefordshire and Worcestershire Health and Care NHS Trust1
Leeds and York Partnership NHS Foundation Trust1
Medicines and Healthcare products Regulatory Agency1
NHS Birmingham and Solihull Integrated Care Board1
NHS Devon Integrated Care Board1
NHS Humber and North Yorkshire Integrated Care Board1
Tees, Esk and Wear Valleys NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Coventry

    AI-generated summary

    Wayne Pierce Walton · 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

    Wayne Pierce Walton was discharged from the Caludon Centre on 21 June 2024 after taking an overdose with the intention of ending his life. He failed to engage consistently with the Home Treatment Team and died by asphyxiation on 29 June 2024. Concerns included inadequate completion and transfer of risk assessment and safety plan information, and a lack of guidance on potential conflicts of interest involving staff who recognised a patient outside the circumstances covered by an existing policy.

    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 pass important risk information to the Home Treatment Team

    Wider context from the report

    “(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. ”

    Source location

    Wayne Pierce Walton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.

    Verbatim wording from the response

    “Our investigatory work from the Patient Safety Incident Investigation (PSII) report PSII2172, focused on learning and improvement, ensuring staff are supported to understand the processes to embed effective documentation of a person’s risk, as well as Trust processes to support safe discharge and/or transition between services. We are revising our Standard Operating Procedure (SOP) for Internal Transfers within Adult and Older Adults Mental Health Services (version 5), to reflect the function and structure of the new Electronic Patient Record (EPR) system (SystemOne), and provide clearer guidance on the agreed date of handover of care, the continuation and ownership of care packages during transfer, and the requirement for a joint handover meeting between teams, with an agreed date understood by all.”

    Source location

    2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
    Page 1 · response
    Published 21 January 2026

    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

    Audit internal transfers after SOP ratification to assess compliance and identify further improvement opportunities.

    Verbatim wording from the response

    “Once ratified, we shall audit our internal transfers between teams to assess compliance, as well as any further opportunities to gain experience, on an ongoing basis.”

    Source location

    2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
    Page 2 · response
    Published 21 January 2026

    Open published response

  2. Devon, Plymouth and Torbay

    AI-generated summary

    William Antony Northcott · 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

    William Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.

    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 achieve clear communication of key information within community mental health teams

    Wider context from the report

    “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been. I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team, and when dealing with its other agencies involved in a patient's care. ”

    Source location

    William Antony Northcott · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Adopt SystmOne electronic patient records to enable consent-based information sharing between primary and secondary mental health services.

    Verbatim wording from the response

    “There are a number of steps that Devon Partnership NHS Trust has adopted to ensure effective information sharing between those involved in the care of the patients.”

    Source location

    Response from Devon Partnership NHS Trust
    Page 4 · response
    Published 7 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and implement a process for sharing annual clozapine health-check outcomes with mental health services.

    Verbatim wording from the response

    “The practice would be happy to communicate the findings and results of the annual health checks with the Mental Health Services, providing that the patient has consented to this. We had considered involvement of the ICB and LMC to facilitate a streamlined approach. However, we have established that there is a Local Enhanced Service in place which we are currently reviewing and implementing a process to be able to share the outcomes and results from the annual review with Mental Health Services.”

    Source location

    Response from The Pembroke Medical Practice
    Page 1 · response
    Published 7 February 2025

    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

    Clinical discussions with prescribers and care delivered by the Trust fall outside the regulator’s remit, so it cannot directly address them.

    Verbatim wording from the response

    “We have considered the evidence provided and the circumstances leading to Mr Northcott’s death and acknowledge that most of your concerns relate to clinical discussions between a patient and their prescriber or via the clinical care delivered by the Trust. Unfortunately, the MHRA cannot directly address these points, as it is not within our remit to comment on the clinical care in specific cases.”

    Source location

    Response from Medicines and Healthcare Projects Regulation Authority
    Page 2 · response
    Published 7 February 2025

    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

    Devon Partnership NHS Trust is responsible for improving internal and cross-agency communication, so no direct response is provided.

    Verbatim wording from the response

    “Concern 3: Patients with treatment-resistant schizophrenia typically receive support from multiple teams and agencies. During the inquest, it became apparent that communication between professionals was, at times, suboptimal. The Coroner seeks assurance that Devon Partnership NHS Trust is working to improve internal and cross-agency communication.”

    Source location

    Response from Devon ICB
    Page 2 · response
    Published 7 February 2025

    Open published response

  3. West London

    AI-generated summary

    Tom Sweeting · 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

    Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.

    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

    Ineffective communication between community teams

    Wider context from the report

    “2. No letter of discharge was sent at the time Tom was seen by the liaison psychiatry team, and a letter was only generated in response to investigations taking place after the death. The team acknowledged that there were “problems” with sending out letters at the time, and no evidence was brought before the court that this issue has now been resolved. Letters should be dispatched within 24 hours of attendance. Communication between the various community teams and setting out the treatment plan to the patient are important factors that were not effective during Tom’s care and remain a concerning omission where there may be a simple and effective remedy. ”

    Source location

    Tom Sweeting · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Birmingham and Solihull

    AI-generated summary

    PETER MARTIN AARON FLEMING · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.

    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

    Ineffective communication between specialist mental health teams

    Wider context from the report

    “2. BSMHFT utilizes self-contained specialist teams. The deceased was treated by (a) crisis team/home treatment team, (b) community mental health team, and (b) psychiatric liaison team. The evidence demonstrated communication between the specialist teams was not effective and this caused delays. For example, the psychiatric liaison team nurse that reviewed the deceased updated the community mental health team. However, the GP could not prescribe the deceased’s medication in October 2022 because it had not been approved by the community mental health team consultant via an ESCA and the deceased went without his medication. The deceased’s GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse’s involvement. The deceased cited this delay as making his mental health worse shortly before his death. My concern is communication between the specialist teams is not effective enough. BSMHFT’s RCA action plan is to seek assurance from the CCG/ICB that communication between the specialist teams is being strengthened. My concern is that this does not go far enough and there should be consideration of a formal process or policy. ”

    Source location

    PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the Dialog Plus care-planning tool across the transition to the Community Mental Health Framework.

    Verbatim wording from the response

    “The use of a Dialog Plus Care Planning tool will be the foundational component of the framework to ensure the holistic identification of needs with allocation of the appropriate clinician within teams to support those needs to be met, to liaise with other professionals who need to input into care and to ensure the Action Plan is reviewed in a timely manner.”

    Source location

    Response from Birmingham and Solihull Mental Health Foundation Trust
    Page 2 · response
    Published 18 July 2023

    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

    Integrate serious mental illness services and expand community mental health services through integrated care systems.

    Verbatim wording from the response

    “A concern was also raised regarding a lack of communication between different health organisations. We are working towards better integration of services though the role of integrated care systems. As part of this, we are integrating services for serious mental illness, expanding community mental health services to reduce reliance on inpatient treatment, so that”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 18 July 2023

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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

    Many concerns, particularly those relating to the mental health trust, fall outside the respondent’s remit.

    Verbatim wording from the response

    “This letter responds to the concerns raised in your report relevant to NHS England. It is not within NHS England’s remit to respond to many of the concerns raised, particularly relating to Birmingham and Solihull Mental Health Trust (BSMHFT). NHS England has asked to be sighted on the responses from BSMHFT and Birmingham and Solihull Integrated Care Board (ICB) and will give due consideration to their responses.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Local areas are responsible for establishing policies, training, and processes supporting appropriate responses from mental health services.

    Verbatim wording from the response

    “A number of the concerns you have raised in this report relate to policies and training requirements at a local level. It is for these local areas to ensure they have the processes in place to support mental health services, so that people with suspected mental health problems receive the appropriate response at all times.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 18 July 2023

    Open published response

  5. North Yorkshire and York including North Yorkshire Western District

    AI-generated summary

    Zoe Emma ZAREMBA · 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

    Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of communication and shared information across autism and mental health teams

    Wider context from the report

    “The evidence indicated: 1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that. 2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”). 3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship. 4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood. 5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe. 6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:- A no multidisciplinary clinical assessment and formulation addressed her autism; B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all; C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians. D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences; E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts; F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide; G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services; H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations; Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs. ”

    Source location

    Zoe Emma ZAREMBA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with TEWV to resolve internal and external communication issues affecting patient care.

    Verbatim wording from the response

    “The CCG/ICB are aware; from reviewing the evidence from the inquest and from discussions with TEWV that there are communication issues internally and externally which need to be resolved for the benefit of the patient. This appears to go beyond incompatibility of IT systems (for example within the inquest there is reference to the autism service provided to other geographical parts of TEWV but not being available within the North Yorkshire part of the organisation). Both TEWV and the ICB are committed to working closely to resolve this. It is anticipated that ultimately the establishment and development of Provider Collaboratives within the ICB will support with these type of issues in the future.”

    Source location

    Response from Humber and North Yorkshire Health Care Partnership
    Page 4 · response
    Published 27 April 2022

    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

    Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.

    Verbatim wording from the response

    “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).”

    Source location

    Response from TEWV
    Page 3 · response
    Published 27 April 2022

    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

    Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.

    Verbatim wording from the response

    “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).”

    Source location

    Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
    Page 3 · response
    Published 27 April 2022

    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

    Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.

    Verbatim wording from the response

    “Our new patient recording information system (CITO) will not only allow a greater clarity around active and discounted diagnoses but will importantly also support patient access to their own records improving mutual understanding and effective”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
    Page 2 · response
    Published 27 April 2022

    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 learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.

    Verbatim wording from the response

    “We have learned from Zoe’s sad death and shared with our clinical teams the importance of communication with our partners, to ensure that patients’ needs are addressed in a more cohesive and person-centred manner.”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
    Page 6 · response
    Published 27 April 2022

    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

    TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.

    Verbatim wording from the response

    “This is therapy which is beyond that which TEWV can provide as the primary mental health provider. That does not change the expectation that TEWV be in a position to make appropriate adjustments to their mental health support for those with any neuro development diagnosis. By this we mean that we would expect TEWV to be in a position to support those with a mental health condition even where they have a diagnosis of autism spectrum disorder however it is recognised by the CCG/ICB that there may be cases where there is additional specialist input required. This is when IFR requests are made. The CCG/ICB accepts that this is becoming more frequent and the reasons for this are not clear but are sufficient for the CCG/ICB to be considering the commissioning pathway for this type of therapy.”

    Source location

    Response from Humber and North Yorkshire Health Care Partnership
    Page 2 · response
    Published 27 April 2022

    Open published response

  6. Essex

    AI-generated summary

    THOMAS JEFFERY KING · 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

    Thomas Jeffery King was found hanging at his home on 28 April 2020, and his death was confirmed at the scene. The inquest concluded that he had intentionally ended his own life while experiencing very low mood and a history of poor mental health. The principal concern was that the Health and Justice Team used software that could not be accessed by other relevant mental health teams, meaning important information about crises and risks could be unavailable when assessing and managing a person.

    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 enable relevant mental health teams to access and share important information

    Wider context from the report

    “(1) It was the evidence of the author of the EPUT Root Cause Analysis Investigation Report, ████████, that whilst all the other EPUT teams that came into contact with Mr King, such as the Mental Health Liaison Team and the Street Triage Team, used the same software called Mobius with which to record, access and share important information and developments regarding Mr King, one Team, namely the Health and Justice Team did not use this software and instead used software that was incapable of being accessed by the other teams. A consequence of this was that the other teams were wholly unaware of crises and other important information regarding Mr King’s mental health that were known to the Health and Justice Team. (2) Whilst it was the view of the RCA author that in Mr King’s case such an obstacle to the sharing / accessing of important information did not have a direct bearing on the outcome for Mr King, she did expressly state, and I share this concern, that there is the potential for the wellbeing and lives of other individuals to be jeopardised where important information and / or crises are known to and recorded by the Health and Justice Team but unknown to all the other relevant Teams. There is the potential for the risk of harm to self and others, including death, to be inaccurately assessed and managed where the assessor does not have access to the full picture. (3) The RCA author was not aware as to why the Health and Justice Team had different software to Mobius or why it was not capable of integration with Mobius, but she felt, and I agree, that action should be taken, if it has not already happened, to explore this issue and to implement a solution. ”

    Source location

    THOMAS JEFFERY KING · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement an interoperable health information exchange providing clinicians access to patient data across recording systems.

    Verbatim wording from the response

    “The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.”

    Source location

    2020-0207-Response-from-EPUT_Redacted.pdf
    Page 1 · response
    Published 3 December 2020

    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

    Use the health information exchange to share information across organisations through the shared care record for Essex STPs.

    Verbatim wording from the response

    “The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE.”

    Source location

    2020-0207-Response-from-EPUT_Redacted.pdf
    Page 1 · response
    Published 3 December 2020

    Open published response

  7. Dorset

    AI-generated summary

    Joanne Elizabeth Richardson · 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

    Joanne Elizabeth Richardson was found suspended by a ligature at her home on 26 September 2017 and the inquest concluded that her death was suicide. Concerns were raised about inadequate communication and lack of joined-up working between mental health teams, which meant important risk information was not shared and could lead to inaccurate risk assessments and a future 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

    Lack of communication between mental-health care teams about patients' care

    Wider context from the report

    “iv. The details of that assessment were never referred to the CMHT. They were therefore not aware of how she presented or the risk assessment made by the Steps to Wellbeing Service. This information could have been very valuable to those in the CMHT who assessed her on the 23rd August and 19th September. v. Evidence was given that some of the Steps to Wellbeing Service have access to DHUFT records, namely RIO records, but not all of them do. Evidence was further given that they do not write entries in these records. Those carrying out assessments therefore are not likely to have access to all information available to DHUFT in relation to the patient. vi. Further on the 28th August 2017, Mrs Richardson contacted the Crisis Team within DHUFT stating that she had suicidal thoughts of ending her life by hanging. A call was made from the Crisis Team to the CMHT and a Community Psychiatric Nurse was spoken to. There was however no follow up after this, or any written communication with anyone involved in her care. vii. Valuable information therefore, in relation to a patient, is not being communicated to those involved in the care. There does not appear to be joined up working between the different teams within the Trust. This could therefore lead to inaccurate risk assessments and a future death. 2. I have concerns with regard to the following: i. That there is a lack of communication between the different teams in DHUFT in respect of a patient's care and as a result there could be the death of a person in the future. ”

    Source location

    Joanne Elizabeth Richardson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. West Yorkshire (East)

    AI-generated summary

    Michaela Louise Thompson · 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

    Michaela Louise Thompson, who had a history of depression and regular suicidal thoughts, died by self-suspension at home on 1 December 2015. Concerns included inadequate documentation of multidisciplinary team meetings and the failure to record and promptly communicate a distressing telephone call to mental health services on the morning of her 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 immediately communicate service calls to the involved Community Mental Health Nurse

    Wider context from the report

    “(2) On the morning that Michaela Thompson died, she had telephoned Aire Court in the presence of a friend who noticed that she became anxious and upset during that brief call. There was no record kept as to the nature of the call or any information or advice given, nor was the fact of the call immediately communicated to the Community Mental Health Nurse involved. Calls to the Service should therefore be recorded, to ensure that details of the nature of the call; its urgency; and the action taken by a named individual or individuals can be clearly ascertained. ”

    Source location

    Michaela Louise Thompson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Worcestershire

    AI-generated summary

    Sean Christopher Seabourne · 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

    Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of effective communication of patient risk between mental health teams

    Wider context from the report

    “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”

    Source location

    Sean Christopher Seabourne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to define and communicate mental health teams' roles and responsibilities for onward care

    Wider context from the report

    “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”

    Source location

    Sean Christopher Seabourne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026