27 Jun 2018 Dudley Vincent Brown · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Delays in AMHPS referral and assessment across weekends and bank holidays View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Dudley Vincent Brown · 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
Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.
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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 Delays in AMHPS referral and assessment across weekends and bank holidays
Wider context from the report “(4) Mr Brown’s referral to the AMHPS and subsequent assessment was delayed due to intervening weekends (including a 3 day bank holiday weekend).
” Source location Dudley Vincent Brown · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve staff and manager fluency in routes and response expectations for general mental health and Mental Health Act assessments.
Verbatim wording from the response “This is a joint response between the Council and East London Foundation Trust. We acknowledge and accept your recommendations in this case, and have worked together to address the concerns, by way of formulating and implementing a multi-agency action plan which is attached for your reference.” Source location 2018-0211-Response-by-Hackney-Borough-Council
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10 Apr 2018 Andrew Reid · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Unavailability of out-of-hours GP referral routes for emergency mental health care in Trafford View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Matt Colledge NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS Greater Manchester Integrated Care Board
Maintain reciprocal commissioning arrangements so patients can access mental health services across Manchester and Trafford borders.
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NHS Greater Manchester Integrated Care Board
Align Manchester and Trafford mental health service specifications and agree clear cross-border arrangements with other Greater Manchester commissioners and trusts.
View source
NHS Greater Manchester Integrated Care Board
Escalate disputed referrals promptly to service managers for timely resolution and use the Cross Border Matrix to clarify registration and residency responsibilities.
View source
Matt Colledge
Maintain reciprocal additional funding for cross-boundary specialist mental health services, including crisis out-of-hours support.
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AI-generated summary
Andrew Reid · 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
Andrew Reid was found suspended from a ligature at Longford Park on 17 October 2017. The inquest concluded that his death was suicide and recorded the medical cause of death as hanging. Concerns related to differences in mental-health service provision and referral routes for residents of Manchester and Trafford, including the lack of out-of-hours emergency GP referrals in Trafford and the requirement for patients to attend A&E.
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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 Unavailability of out-of-hours GP referral routes for emergency mental health care in Trafford
Wider context from the report “1. The inquest heard that when Mr Reid went to see his GP she was very concerned about the risk he posed to himself and wanted him to be seen urgently by the Home Based Treatment Team (HBTT). The initial call was to the Manchester team -because the GP practice was within the City Of Manchester-who accept referrals from GPs. The Manchester HBTT are commissioned to provide a 24/7 Urgent Assessment Team that GPs can refer into. However, as Mr Reid was a Trafford resident the referral was not accepted and the GP called the Trafford HBTT. Under the terms of their commissioned service they cannot accept referrals from GPs and contact is via the RAID team in A and E. In this case that meant Mr Reid was told he would have to go to A and E. The inquest was told that the differences in level of provision for those with mental health are based on the decisions made by each commissioning authority. As a result residents of GM with mental health issues have a different level of support and route to access services.
2. In Trafford the outcome of the commissioning is that there are no emergency GP referrals dealt with OOH. They can only be dealt with Monday to Friday by the CMHT. GPs outside these times dealing with emergency mental health issues for Trafford residents have to ask patients to make their way to A and E for assessment. If they are concerned that a patient may not make it to A and E then they have to ask the Police to check with A and E -as happened in the case of Mr Reid
” Source location Andrew Reid · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain reciprocal commissioning arrangements so patients can access mental health services across Manchester and Trafford borders.
Verbatim wording from the response “The deceased was a registered patient with a Manchester GP at Chorlton Health Centre and he lived in Stretford in the borough of Trafford. This is important as NHS services are commissioned on the basis of GP registration (so Manchester in this case). Importantly, commissioners across both Manchester and Trafford CCGs have put in place reciprocal arrangements to cover mental health patients needing support but who are registered in separate areas to where they reside. In this case, therefore the GP should have been able to refer to either the Manchester service or the Trafford service.” Source location Andrew-REID-Response2
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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 Align Manchester and Trafford mental health service specifications and agree clear cross-border arrangements with other Greater Manchester commissioners and trusts.
Verbatim wording from the response “An arrangement does exist between all GM mental health Trusts, which operates to ensure the most appropriate service for a patient resident or registered on or near the border of another service. This incident has highlighted the need to revisit this arrangement to reduce unnecessary variation in service commissioning and ensure that all providers are clear on service arrangements. Service provision must be based on a flexible, common-sense” Source location Andrew-REID-Response2
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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 Escalate disputed referrals promptly to service managers for timely resolution and use the Cross Border Matrix to clarify registration and residency responsibilities.
Verbatim wording from the response “In Greater Manchester, required adherence with Responsible Commissioner principles has been communicated across all the GM MH Commissioners and Trusts. This included summary Cross Border Matrix tables to resolve any issues involving the service users registered and residency status shared with all specialist mental health out-of-hours and inpatient services.” Source location Andrew-REID-Response2
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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 Maintain reciprocal additional funding for cross-boundary specialist mental health services, including crisis out-of-hours support.
Verbatim wording from the response “Manchester GPs might be resident in Trafford. On recognition of this, there was also a need to invest additional funding to ensure timely access to local specialist mental health services in Trafford (and vice versa). This was put in place with Manchester commissioners providing specific additional funding for mental health services in Trafford (including crisis out-of-hours support) so that any such patients were supported rapidly with the minimum possibility of confusion related to Responsible Commissioner considerations. The same reciprocal model was enacted by Trafford commissioners providing specific additional funding for mental health services in Manchester (including crisis out-of-hours support).” Source location Andrew-REID-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 breakdown was not due to inappropriate differential commissioning models between Trafford CCG and Manchester commissioners.
Verbatim wording from the response “We appreciate that as the Coroner in this case you have noted concerns that despite this a difference in commissioning arrangements between Manchester and Trafford may have been contributory in the GPs experience of being passed between Trafford HBTT and Manchester UCAT – and then resulting in the service user needing to go to A&E for an assessment. We also note that it is this which prompted the Regulation 28 being issued.” Source location Andrew-REID-Response2
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4 Oct 2017 Sofia Ann Legg · Prevention of Future Deaths report Somerset
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Concerns raised 1
Failure to obtain urgent psychiatric input View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Somerset Clinical Commissioning Group Somerset NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Somerset NHS Foundation Trust
Restructure initial-assessment clinics to support staff decision-making and involve psychiatrists and senior clinicians earlier.
View source
Somerset NHS Foundation Trust
Hold weekly multidisciplinary meetings with psychiatrists to guide complex case discussions and identify cases requiring psychiatric input.
View source
Somerset NHS Foundation Trust
Provide psychiatric liaison nurses at Somerset acute hospitals to assess self-harm and suicidal presentations and coordinate follow-up or paediatric admission.
View source
NHS Somerset Clinical Commissioning Group
Operate a jointly funded CAMHS Enhanced Outreach Service providing multidisciplinary support seven days a week, including psychiatric support.
View source
NHS Somerset Clinical Commissioning Group
Provide practitioners with open access to a multidisciplinary team including a psychiatrist through the Single Point of Access.
View source
NHS Somerset Clinical Commissioning Group
Operate an out-of-hours CAMHS Enhanced Outreach Team to accept urgent referrals and provide intensive home support.
View source
NHS Somerset Clinical Commissioning Group
Distribute the on-call psychiatrist rota electronically across the service.
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AI-generated summary
Sofia Ann Legg · 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
Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI 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 Failure to obtain urgent psychiatric input
Wider context from the report “3. Sofia’s care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance .
” Source location Sofia Ann Legg · 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 Restructure initial-assessment clinics to support staff decision-making and involve psychiatrists and senior clinicians earlier.
Verbatim wording from the response “2.3 During 2017 the way initial assessments are performed has also changed. This includes the re-structuring of clinics to better support all staff in their decision making and to include psychiatrists and senior clinicians at an earlier stage. Weekly multi-disciplinary meetings with psychiatrists in attendance have been implemented to guide staff through complex case discussions and identify those cases which may need their input.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
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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 weekly multidisciplinary meetings with psychiatrists to guide complex case discussions and identify cases requiring psychiatric input.
Verbatim wording from the response “2.3 During 2017 the way initial assessments are performed has also changed. This includes the re-structuring of clinics to better support all staff in their decision making and to include psychiatrists and senior clinicians at an earlier stage. Weekly multi-disciplinary meetings with psychiatrists in attendance have been implemented to guide staff through complex case discussions and identify those cases which may need their input.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide psychiatric liaison nurses at Somerset acute hospitals to assess self-harm and suicidal presentations and coordinate follow-up or paediatric admission.
Verbatim wording from the response “3.4 In addition the Trust now has a team of highly experienced psychiatric liaison nurses based at both acute hospitals in Somerset, these nurses assess young people who self-harm or experience suicidal thoughts on presentation to an emergency department. If the child/young person is discharged and they require further CAMHS input this information is communicated to the relevant local team for follow up. This team can also admit to the paediatric ward if they need to keep a young person safe and this would prevent a delay in care if the young person could only be seen by a psychiatrist to undertake these assessments.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
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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 Operate a jointly funded CAMHS Enhanced Outreach Service providing multidisciplinary support seven days a week, including psychiatric support.
Verbatim wording from the response “1.3 Somerset CCG and NHS England Specialised Commissioning are jointly funding a CAMHS Enhanced Outreach Service which is now fully operational to support young people and families in similar situations. This service is available 7 days a week from 8.00am to 8.00pm and is a Multi-disciplinary Team, which includes a Psychiatrist.” Source location 2017-0293-Response-by-Somerset-NHS-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide practitioners with open access to a multidisciplinary team including a psychiatrist through the Single Point of Access.
Verbatim wording from the response “3.2 Since the implementation of the Single Point of Access Programme (SPA), practitioners have open access to the Multi-disciplinary Team (including a Psychiatrist). The enhanced Outreach Team (out of hours CAMHS Team) is also now established and working 8.00am- 8.00pm Monday to Sunday and will take urgent referrals and offer intensive home support as needed. Additionally, the process around availability of the on-call psychiatrist has been strengthened by ensuring the rota is distributed electronically to the whole service.” Source location 2017-0293-Response-by-Somerset-NHS-CCG
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 Operate an out-of-hours CAMHS Enhanced Outreach Team to accept urgent referrals and provide intensive home support.
Verbatim wording from the response “3.2 Since the implementation of the Single Point of Access Programme (SPA), practitioners have open access to the Multi-disciplinary Team (including a Psychiatrist). The enhanced Outreach Team (out of hours CAMHS Team) is also now established and working 8.00am- 8.00pm Monday to Sunday and will take urgent referrals and offer intensive home support as needed. Additionally, the process around availability of the on-call psychiatrist has been strengthened by ensuring the rota is distributed electronically to the whole service.” Source location 2017-0293-Response-by-Somerset-NHS-CCG
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 Distribute the on-call psychiatrist rota electronically across the service.
Verbatim wording from the response “3.2 Since the implementation of the Single Point of Access Programme (SPA), practitioners have open access to the Multi-disciplinary Team (including a Psychiatrist). The enhanced Outreach Team (out of hours CAMHS Team) is also now established and working 8.00am- 8.00pm Monday to Sunday and will take urgent referrals and offer intensive home support as needed. Additionally, the process around availability of the on-call psychiatrist has been strengthened by ensuring the rota is distributed electronically to the whole service.” Source location 2017-0293-Response-by-Somerset-NHS-CCG
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 Limited psychiatrist numbers mean psychiatrists cannot see every case involving suicidal ideation; experienced senior clinicians therefore assess and manage many cases.
Verbatim wording from the response “3. Sofia’s care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
28 Sep 2017 GILLIAN O’KEEFFE · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 1
Lack of a procedure for following up urgent GP concerns or referrals View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
GILLIAN O’KEEFFE · 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
Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or 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 Lack of a procedure for following up urgent GP concerns or referrals
Wider context from the report “(4) Evidence was given at the inquest that there was no procedure or policy in place at the Trust to follow up GP concerns or referrals particularly where there was likely to be a degree of urgency .
” Source location GILLIAN O’KEEFFE · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formalise guidance for GPs on raising urgent concerns and referrals with lead CCG involvement.
Verbatim wording from the response “The referral was never sent by the GP but this concern highlights the need for some clear guidance for GPs regarding concerns they may have. The Trust is in the process of formalising this with the lead CCG GP involvement. It will be shared with GP colleagues once it has been signed off.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
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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 Share the formalised GP concerns and referrals guidance with GP colleagues after sign-off.
Verbatim wording from the response “The referral was never sent by the GP but this concern highlights the need for some clear guidance for GPs regarding concerns they may have. The Trust is in the process of formalising this with the lead CCG GP involvement. It will be shared with GP colleagues once it has been signed off.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Open published response
20 Apr 2017 Charlotte Anne Agnew · Prevention of Future Deaths report City of London
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Concerns raised 1
Delays in granting urgent psychiatric assessments View source
This report raised 7 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
Charlotte Anne Agnew · 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
Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.
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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 Delays in granting urgent psychiatric assessments
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness.
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” Source location Charlotte Anne Agnew · Prevention of Future Deaths report
Open source report
8 Dec 2016 Sandra Brotherton · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in obtaining urgent Consultant Psychiatrist assessment for a person with a dual diagnosis View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Sandra Brotherton · 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
Sandra Brotherton was killed at her home on 31 December 2014, shortly after returning from hospital. The inquest heard that she had been the predominant and effectively sole carer for a person with a dual diagnosis of paranoid schizophrenia and Asperger’s Syndrome, who had been alone at home during her hospital stay. Concerns included the lack of a clearly discussed contingency plan, inadequate documentation and sharing of care-plan information with the Personal Assistant, difficulty obtaining an urgent psychiatric appointment, and insufficient follow-up after Sandra requested that he be rehoused immediately.
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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 Delays in obtaining urgent Consultant Psychiatrist assessment for a person with a dual diagnosis
Wider context from the report “3) It was concerning that the Care Co-Ordinator who visited ████████ in August 2014 was not able to obtain an urgent appointment with a Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with a dual diagnosis was required . Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014
” Source location Sandra Brotherton · Prevention of Future Deaths report
Open source report
17 Feb 2016 Vanessa Christine DADSWELL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Lack of an intermediate urgent mental health referral timeframe View source
Linked response
Sussex Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Sussex Partnership NHS Foundation Trust
Enable Triage Team Leaders to book priority appointments directly.
View source
Sussex Partnership NHS Foundation Trust
Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.
View source
Sussex Partnership NHS Foundation Trust
Fast-track referrals to the first available appointment based on risk assessment.
View source
Sussex Partnership NHS Foundation Trust
Develop a Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.
View source
Sussex Partnership NHS Foundation Trust
Meet West Sussex mental health commissioners to jointly review the urgent care pathway in light of the improvements and current practice.
View source See 2 more actions
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AI-generated summary
Vanessa Christine DADSWELL · 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
Vanessa Dadswell died from injuries after placing herself in the path of an oncoming train at Whitley Railway Station on 2 April 2015. She had been urgently referred to Mental Health Services by her GP, requesting that she be seen within 24 hours, but she was not seen before her death. The principal concern was the lack of an intermediate referral option between four hours and within five days, and the absence of contact within the requested 24-hour period.
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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 an intermediate urgent mental health referral timeframe
Wider context from the report “During the course of the inquest the evidence revealed that any urgent referral by a GP would be categorised by West Sussex Community Mental Health as either as a ‘4 hour’ referral or as a ‘within 5 day’ referral . A ‘4 hour’ referral would involve the service user having to attend A&E urgently for an assessment within 4 hours. A ‘within 5 day referral’ was exactly as described, an appointment within 5 days. The issue arose where a referring GP did not consider it necessary nor appropriate for a 4 hour referral and yet believed a 24 hour visit was necessary as 5 days would be too long . The deceased was not seen within 24 hours and committed suicide 3 days after the referral with no direct contact having been made. Evidence given by the Service manager for the Trust agreed that an intermediate option for referral would not be unreasonable .
Consideration should be given to an alternative, intermediate referral time between the current ‘4 hour’ and ‘within 5 day’ periods for referrals together with effective management thereof.
” Source location Vanessa Christine DADSWELL · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable Triage Team Leaders to book priority appointments directly.
Verbatim wording from the response “• Triage Team Leaders now have direct bookable Priority Appointment slots and do not need to pass priority referrals to the Assessment & Treatment Duty Worker for booking.” Source location Vanessa-DADSWELL-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 Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.
Verbatim wording from the response “• Every morning the Triage Team Leader assesses all incoming referrals received out of hours and, if the referrer has requested the service user to be seen within 24 hours but did not consider a 4 hour response was clinically required, appointments within 24 hours are arranged.” Source location Vanessa-DADSWELL-Response
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 Fast-track referrals to the first available appointment based on risk assessment.
Verbatim wording from the response “• Referrals can be fast track allocated by the Triage Team Leader so they do not wait up to 5 days for a slot; they are given the first available appointment, dependent on assessment of risk, often within 2–3 days.” Source location Vanessa-DADSWELL-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.
Verbatim wording from the response “Penny Fenton, General Manager Coastal West Sussex Care Delivery Service (CDS), Nadia Anderson, Service Manager Western, Working Age Mental Health Services, Coastal West Sussex Care Delivery Service (CDS) and Liam Rudden, Service Manager for Adur, Arun & Worthing Assessment and Treatment Service are currently drafting a protocol encompassing the improved system throughout Coastal West Sussex CDS. The checklist and flowchart developed and exhibited at the inquest will be appended so there is a clear user friendly guide for staff. Dr Brian Solts, Divisional Clinical Director – Coastal West Sussex Care Delivery Service (CDS) has confirmed he will present the protocol, together with the learning from Mrs Dadswell’s inquest, to the Adult Management Board to maximize learning and embed the improvements introduced.” Source location Vanessa-DADSWELL-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 Meet West Sussex mental health commissioners to jointly review the urgent care pathway in light of the improvements and current practice.
Verbatim wording from the response “The Service Specification for the Urgent Care Pathway detailing the 4 hour and 5 day referral options was developed in partnership with our West Sussex Commissioners and is due for renewal. Dr Solts has requested a meeting to be arranged with the West Sussex Mental Health commissioners to review the pathway jointly with us, in light of the improvements we have made, and the greater flexibility we have introduced, so it reflects current practice.” Source location Vanessa-DADSWELL-Response
Open published response
24 Jun 2015 Alice MEAD · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Delays in responding to urgent concerns about known vulnerable patients View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Alice MEAD · 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
Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.
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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 Delays in responding to urgent concerns about known vulnerable patients
Wider context from the report “(3) Action, if it can be described as action, was only taken when Alice’s young son’s Heath Visitor wrote of her urgent concerns about Alice in good detailed e-mails sent to Alice’s GP and to the Community Mental Health Team on the evening of the 15ᵗʰ January. It was clear that the Mental Health Team should react . Their response was to phone Alice on the 16ᵗʰ and make an appointment to see her on the 28ᵗʰ January .
This “hands off” approach to a known vulnerable patient is unacceptable. The patient should be at the heart of Care Programme Approach care (indeed any care).
” Source location Alice MEAD · 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 Co-locate urgent-response and assessment teams and establish an information-sharing protocol and shared communication tools.
Verbatim wording from the response “In relation to the calls Ms Mead made and communication with staff, Brighton Urgent Response Service, now called Mental Health Rapid Response Service (MHRRS), and the Assessment and Treatment Service (ATS) Duty Team are now co-located in the same working space. They have agreed a protocol for information sharing. This allows for improved communication between the teams and for vital information on service users to be shared with staff and fed back to service users. There is a communication book in place and a whiteboard to keep key pieces of information and service user contacts prominent within the team. In addition, to aid improved communication, there is now a Duty Lead working every day. The Duty Lead working that day prioritises the incoming work and supports the decisions made by the call takers. They review and update the communication book and whiteboard.” Source location 2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
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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 a daily Duty Lead to prioritise incoming work, support call-taker decisions, and maintain team communication records.
Verbatim wording from the response “In relation to the calls Ms Mead made and communication with staff, Brighton Urgent Response Service, now called Mental Health Rapid Response Service (MHRRS), and the Assessment and Treatment Service (ATS) Duty Team are now co-located in the same working space. They have agreed a protocol for information sharing. This allows for improved communication between the teams and for vital information on service users to be shared with staff and fed back to service users. There is a communication book in place and a whiteboard to keep key pieces of information and service user contacts prominent within the team. In addition, to aid improved communication, there is now a Duty Lead working every day. The Duty Lead working that day prioritises the incoming work and supports the decisions made by the call takers. They review and update the communication book and whiteboard.” Source location 2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
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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 Introduce face-to-face assessment for East ATS service users making three calls within two weeks, subject to senior clinical review and documented rationale for exceptions.
Verbatim wording from the response “Following Ms Mead’s request, a new approach to calls is underway in East ATS. If a service user calls 3 times in a 2 week period in need of mental health input, they will be seen face to face. The only exceptions will be in circumstances when the case is reviewed by a senior member of the team and a face to face appointment is not deemed in the best interests of the service user or appropriate; in these cases a detailed record will be kept documenting the decision rationale.” Source location 2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
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23 Mar 2015 Barbara Mary Anne Mayer · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Unavailability of timely urgent mental health assessment during increased demand 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
Barbara Mary Anne Mayer · 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
Barbara Mary Anne Mayer had a history of depression and was found drowned in a nearby pond on 16 November 2014 after leaving her house during the early hours. Concerns included carer fatigue not being followed up, lack of continuity in her care, treatments not being adequately discussed with her, and no urgent mental health assessment being available when she needed help on 14 November 2014.
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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 Unavailability of timely urgent mental health assessment during increased demand
Wider context from the report “(4) Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014 . It is understood Doctors are now called out and on Call Manager can be contacted in such situations.
” Source location Barbara Mary Anne Mayer · 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 Review locality escalation plans for Crisis Resolution and Home Treatment and Dementia Intensive Support Team services to strengthen capacity escalation and contingency responses.
Verbatim wording from the response “The Trust is experiencing increasing demands for all of its services at a time of being challenged to make savings. It is recognised that when services such as the CRHT team reach levels of capacity there has to be robust mechanisms for escalation and contingency. To this end the localities across the Trust are reviewing their escalation plans for services such as CRHT and the Dementia Intensive Support Teams, both of which are required to respond to incoming referrals.” Source location 2015-0113-Response-by-Norfolk-Suffolk-NHS-Trust
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8 Jan 2015 Eve Cullen · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to treat clinically identified urgent referrals as urgent View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Herefordshire and Worcestershire Health and Care NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Herefordshire and Worcestershire Health and Care NHS Trust
Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.
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Herefordshire and Worcestershire Health and Care NHS Trust
Implement the standardised urgent-referral process in Wyre Forest.
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Herefordshire and Worcestershire Health and Care NHS Trust
Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.
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Herefordshire and Worcestershire Health and Care NHS Trust
Gather data and review the effectiveness of the recently implemented referral process, identifying issues requiring attention.
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AI-generated summary
Eve Cullen · 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
Eve Cullen, who had epileptic seizures and a fluctuating peri-ictal confusional state, went missing from her family home on 17 July 2014 and was later found dead in an alleyway on 9 August 2014. The concerns were that a hospital referral was not actioned, two urgent referrals were not treated as urgent, and there was no uniform definition or timeframe for urgent 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 treat clinically identified urgent referrals as urgent
Wider context from the report “(1) The failure to action the referral from the Queen Elizabeth Hospital
(2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent
(3) The lack of any uniform agreement as to what constitutes an 'urgent' referral
I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded.
She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way.
Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient.
I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made.
” Source location Eve Cullen · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.
Verbatim wording from the response “Unfortunately, it has not to date been the case that the same process applies in respect of the other areas in which the Trust provides services in Worcestershire, however we are working with the North CCG’s to address this, as it is our ambition to introduce a standardised system across the County. The Trust is working towards performance measures for all categories of referrals and will incorporate into a policy, which will distinguish between urgent and routine referrals with defined timescales for contact.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the standardised urgent-referral process in Wyre Forest.
Verbatim wording from the response “Whilst this process has recently been implemented, data is being gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
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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 Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.
Verbatim wording from the response “I confirm that since receiving your correspondence the Trust has written to all general practitioners in Redditch & Bromsgrove on 4 February 2015 identifying a protocol for the referral of mental health patients and the timescales in which they can be seen. This clarifies that referrals marked urgent should be triaged within 24 hours. The triage process may involve a discussion with the referrer, a discussion with the individual and/or a face to face assessment.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Gather data and review the effectiveness of the recently implemented referral process, identifying issues requiring attention.
Verbatim wording from the response “Whilst this process has recently been implemented, data is being gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.