Recurring concern

Failure to reliably follow up identified mental-health safety concerns

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First reported 5 May 2013•Latest report 25 Jun 2026

Definition

What this concern includes

Includes failures in processes for recording, contacting, escalating, tracking and following up identified mental-health safety concerns, including suicide risk, when initial contact attempts fail or a promised clinical response does not occur.

Not included

  • Excludes routine psychiatric follow-up or appointment-access failures where no identified mental-health safety concern requires a specific follow-up response.
  • Excludes failures limited to mental-health risk assessment, treatment or observation when the follow-up and escalation process is not deficient.
  • Excludes generic communication or documentation deficiencies unless they directly leave an identified mental-health safety concern without follow-up or protective action.
  • Excludes family-contact failures unrelated to an identified mental-health safety concern.
Reports
17

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
38

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 Care3
Birmingham and Solihull Mental Health NHS Foundation Trust2
NHS Birmingham and Solihull Integrated Care Board2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Betsi Cadwaladr University LHB1
Birmingham Women'S and Children'S NHS Foundation Trust1
Black Country Healthcare NHS Foundation Trust1
Central and North West London NHS Foundation Trust1
College of Policing1
Counsellor1
Cumbria Constabulary1
Essex Partnership University NHS Foundation Trust1
Foxhayes Surgery GP Practice1
Home Office1
London Borough of Camden1

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. Devon, Plymouth and Torbay

    AI-generated summary

    David Joyce · Prevention of Future Deaths report

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

    Report summary

    David Joyce, who had a history of mental health difficulties, died by suicide at his home on 31 August 2023 after being found having suspended himself. The concerns included a lack of follow-up and consideration of mental health referral after he first sought help, prescribing Quetiapine without specialist input despite his reported symptoms and overdose, and a delay of 15 weeks before a medication review led to a change in treatment.

    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 initiate follow-up after presentation with deteriorating mental health

    Wider context from the report

    “1. David first presented to the GP surgery on 16th May 2023, reporting a deterioration in his mental health. No follow up was initiated by the surgery despite David’s recorded past medical history of dissociated disorder, self-harm and suicide. There was no evidence that, on that occasion, there had been any consideration of referral to secondary or tertiary mental health services which may have been available to assist David and inform his care; ”

    Source location

    David Joyce · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review records, clinical actions, and processes for supporting, referring, and liaising about high-risk patients with mental health teams.

    Verbatim wording from the response

    “Having closely reviewed the medical records for David I sat down with the medical team at the practice to review his medical records and actions by the individual doctors and the practice. The consensus was the practice should have been more proactive on the 26th June when David represented making a formal referral to the Community Mental Health Team and possibly the CRISIS Team for urgent support given how David’s mental health had deteriorated in the 5 weeks prior to review. ████████ attempt to call and speak to ████████ following her review of David whilst in Police custody clearly caused a breakdown in the formal referral process for David at that time.”

    Source location

    Response from Foxhayes Surgery GP Practice
    Page 4 · response
    Published 21 August 2026

    Open published response

  2. Essex

    AI-generated summary

    Abbigail Louise SMITH · 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

    Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide urgent follow-up after predicted medication non-compliance deterioration

    Wider context from the report

    “3. In October 2021 Abbi suffered a deterioration in her mental health with reported non-compliance of Clozapine medication. The Consultant Psychiatrist emergency plan was not followed: a. Short-term prescription of Diazepam to assist with an exacerbation of distressing symptoms to permit Abbi’s Clozapine to be re-titrated was incorrectly continued as a permanent prescription in the absence of a medical review and this was not compliant with the NICE Guidelines. b. urgent follow-up required for a predicted and inevitable deterioration in the event of continued non-compliance did not take place. c. Abbi’s medical records were not updated as required; there were omissions in the significant information about Abbi’s clinical condition and Abbi was not escalated back to the Consultant Psychiatrist. These matters were then not understood by the mental health professionals as Abbi continued to deteriorate and increase in Abbi Diazepam was prescribed. ”

    Source location

    Abbigail Louise SMITH · 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

    Trigger urgent treatment-plan review jointly by the Care Coordinator and prescriber when patients miss appointments while prescribed time-limited medication.

    Verbatim wording from the response

    “• Non-attendance by a patient prescribed time-limited medication (such as benzodiazepines) will trigger an urgent review of treatment plan, raised jointly by the Care Coordinator and the prescribing medic, to ensure the ongoing appropriateness of the prescription is actively assessed.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 3 · response
    Published 13 August 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

    Escalate medication non-adherence to the responsible Consultant Psychiatrist, discuss it in MDT and zoning meetings, assess risk, and document an agreed action plan.

    Verbatim wording from the response

    “• Upon staff becoming aware that a patient is not taking their medication as prescribed, immediate escalation is made to the responsible Consultant Psychiatrist, the case is discussed at the multidisciplinary team (MDT) meeting, risk is formally assessed and RAG-rated within the zoning meeting, and an agreed action plan is documented; a copy of the MDT minutes is uploaded to the patient’s electronic record (PARIS) and circulated to all relevant professionals.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 4 · response
    Published 13 August 2026

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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

    Use the MaST tool across community teams to monitor caseloads and identify patients needing additional support or follow-up.

    Verbatim wording from the response

    “Trust services also use the MaST tool to monitor and audit caseloads. MaST employs an algorithm which takes into account a number of different factors that might influence a patient's needs – like housing, medications, disabilities and other health conditions – and highlights where a patient may need additional support. The dashboard highlights patients who may be at increased risk of crisis. It also flags when patients have not been contacted recently, or need a follow-up appointment. While MaST is not designed to replace clinical expertise and judgement in managing their caseloads, it brings a range of relevant information into one place, enabling informed, evidence-based decisions.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    Open published response

  3. Milton Keynes

    AI-generated summary

    Brian Thomas RINGROSE · 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

    Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.

    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 escalate concerns and arrange follow-up after incomplete mental health assessment

    Wider context from the report

    “Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

    Source location

    Brian Thomas RINGROSE · Prevention of Future Deaths report
    Page 4 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require escalation to emergency-department clinicians, continued emergency-department medical care and liaison-team availability for reassessment when patients cannot engage or remain medically unfit.

    Verbatim wording from the response

    “b. Inadequate Assessment Our revised protocol mandates that when a patient cannot engage due to intoxication (alcohol or drugs) or other factors rendering them unfit, the HLT must escalate concerns to the ED team, advise that the patient remains under ED care for ongoing medical management, and the HLT remain available for reassessment. This ensures continuity of care and avoids missed opportunities for intervention. This applies equally in cases where the patient is under police arrest within the ED.”

    Source location

    Response from Central and North West London NHS Foundation Trust
    Page 2 · response
    Published 4 August 2025

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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 immediate escalation of concerns to the treating medic or nurse in charge through the Operational Policy.

    Verbatim wording from the response

    “c. Failure to Escalate Concerns We have strengthened our escalation pathways. A standing agenda item has been added to monthly cross-team meetings to review HLT practices. Our Operational Policy now explicitly requires immediate escalation of concerns to the treating medic or nurse in charge.”

    Source location

    Response from Central and North West London NHS Foundation Trust
    Page 2 · response
    Published 4 August 2025

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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 Emergency Department adult-discharge SOP defining discharge responsibilities, documentation requirements, safety-netting, and safeguards for higher-risk patients.

    Verbatim wording from the response

    “In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.”

    Source location

    Response from Milton Keynes University Hospitals
    Page 8 · response
    Published 4 August 2025

    Open published response

  4. Cumbria

    AI-generated summary

    Matthew Brierley · Prevention of Future Deaths report

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

    Report summary

    Matthew Brierley died in the car park of Buttermere Court Hotel on 24 April 2024, after being arrested, bailed and placed under conditions that prevented him from living at home or having unsupervised contact with his children and stepdaughter. The inquest concluded that his death was suicide. Concerns included the potentially prolonged period before decisions were made about his devices and case, the use of standard bail conditions without an apparent specific risk assessment, and the lack of proactive follow-up support after his release on bail.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide proactive contact and support to men at elevated suicide risk

    Wider context from the report

    “(3) Police acknowledged the increased risk and completed a standard assessment form when Matthew was released - he denied any risk and also declined referral to Liaison and Diversion service. A Family Contact Officer was also appointed but the onus remained on Matthew to seek help and there was no proactive contact which might have been helpful as men in Matthew's situation are less likely to seek help due to feelings of shame and embarrassment. ”

    Source location

    Matthew Brierley · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete research reviewing five years of post-custody suicide data to identify commonalities and inform prevention.

    Verbatim wording from the response

    “1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:”

    Source location

    Response from National Police Chief's Council
    Page 1 · response
    Published 13 January 2025

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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

    Introduce an evidence-led post-release risk assessment process with mandatory referrals to partner support agencies for identified high-risk individuals.

    Verbatim wording from the response

    “1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:”

    Source location

    Response from National Police Chief's Council
    Page 1 · response
    Published 13 January 2025

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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 Home Office has no authority to intervene in operational policing matters or comment on police officers’ operational decisions.

    Verbatim wording from the response

    “How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

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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

    Operational decisions about following custody guidance are the responsibility of individual police forces and their chief officers.

    Verbatim wording from the response

    “How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

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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

    Current police guidance readily available to forces clearly sets out actions to support detainees and prevent custody and post-custody suicides.

    Verbatim wording from the response

    “The Detention and Custody Authorised Professional Practice (APP) produced by the College of Policing (henceforth ‘the College’) sets the standards for police engagement with detainees after their arrest, including any offers of support. This includes operational advice on managing the risk of suicide for persons under investigation, such as Matthew. The College is independent of government; its role is to set high professional standards for policing; sharing what works best; acting as the national voice of policing; and ensuring police training and ethics is of the highest possible quality.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing policing guidance, custody risk assessment and partnership arrangements are considered sufficient to address suicide and post-release support risks.

    Verbatim wording from the response

    “increased risk of suicide (such as those matching Mr Brierley’s demographics). We have produced comprehensive practitioner advice for officers and staff that outlines a series of measures to mitigate against this risk and have also added the latest guidance document from the Faculty of Forensic and Legal Medicine on how to care for suspects of sexual assault in police custody. (Please find further details here).”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 13 January 2025

    Open published response

  5. North Wales (East and Central)

    AI-generated summary

    Hannah Elizabeth Browning · 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

    Hannah Elizabeth Browning, who was receiving treatment for mental health issues and had a history of self-harm and suicidal thoughts, expressed an intention to end her life on 10 October 2018. She subsequently placed a ligature around her neck and sustained a hypoxic brain injury, dying at Wrexham Maelor Hospital on 12 October 2018. The principal concern was that inadequate arrangements and insufficient efforts were made by Mental Health Services to protect her and contact her after she indicated an immediate risk of harm.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate arrangements to protect people under mental health care after indications of an immediate risk of harm

    Wider context from the report

    “That despite giving an indication of an immediate and fixed plan to harm herself, which she then acted upon, the Mental Health Services made inadequate arrangements to protect her and made no attempt to contact her to either seek to ensure her safety or to advise her of the intention to review her case at an MDT five days later and to reinforce the interim options available to her in crisis. Despite hearing evidence at the inquest of the steps taken by BCUHB and WCBC (who act in partnership for the provision of Mental Health Services) to improve the service, I was not provided with any assurances as to measures which had or could be taken to ensure that every possible effort is made to contact a person under their care, who has communicated a credible indication of an immediate risk of harm to themselves. ”

    Source location

    Hannah Elizabeth Browning · 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

    Develop a social work checklist guiding risk assessment, escalation, communication, recording and crisis planning for mental health and duty cases.

    Verbatim wording from the response

    “Actions to Date – development of a checklist. (Please see Checklist attached as Appendix 1)”

    Source location

    2021-0106-Response-from-Wrexham-County-Borough-Council
    Page 1 · response
    Published 14 April 2021

    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

    Implement an additional 4:30pm safety huddle to review heightened risks, minute actions, coordinate out-of-hours mitigation and escalate unresolved risks.

    Verbatim wording from the response

    “4. BCUHB implementation of an additional Safety huddle. A morning safety huddle is already in place, BCUHB have developed a further safety huddle at the end of each day (4.30pm) which::”

    Source location

    2021-0106-Response-from-Wrexham-County-Borough-Council
    Page 2 · response
    Published 14 April 2021

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Disseminate the checklist and safety-huddle procedures to Community Mental Health Team social work staff.

    Verbatim wording from the response

    “All of the above actions have been shared with the Community Mental Health Team Social work team manager who has disseminated these to all social work staff within the team. In addition to the above actions the below actions are planned over the time period identified below.”

    Source location

    2021-0106-Response-from-Wrexham-County-Borough-Council
    Page 3 · response
    Published 14 April 2021

    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

    Develop Local Authority mental health, escalation, risk-management, pathway, and reporting and recording policies and procedures, including crisis planning.

    Verbatim wording from the response

    “Actions Planned for development over the next 6-9 months include:”

    Source location

    2021-0106-Response-from-Wrexham-County-Borough-Council
    Page 3 · response
    Published 14 April 2021

    Open published response

  6. East London

    AI-generated summary

    Thiago Araujo · 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

    Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.

    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 act on an inpatient admission plan following identification of acute suicide risk

    Wider context from the report

    “4. By 4 February 2020 the Camden and Islington community recovery team identified an acute risk of suicide in Mr Araujo, faced with his non-compliance with community treatment they considered an admission into inpatient care. No actions were taken to affect this plan. ”

    Source location

    Thiago Araujo · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Cheshire

    AI-generated summary

    Mr Sam Spooner · Prevention of Future Deaths report

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

    Report summary

    Mr Sam Spooner died at Leighton Hospital on 31 August 2018 after being found unresponsive following an act intended to end his life. The report identified concerns about inadequate multi-agency information sharing, coordination and intervention despite known suicide risk, and excessive reliance on his family to keep him safe.

    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 adequately intervene after a suicide attempt and further suicide preparations

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”

    Source location

    Mr Sam Spooner · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain and publish a national GP curriculum covering assessment and management of mental health problems, including suicide risk and safety planning.

    Verbatim wording from the response

    “The assessment and treatment of patients with mental health difficulties is a core component of being a GP. RCGP has published a detailed curriculum for general practitioners nationally and it is used both to assess doctors aspiring to work as a general practitioner as well as the standards against which we are viewed as qualified GPs. Within this, there is a detailed section on the Care of People with Mental Health Problems. https://www.rcgp.org.uk/training-exams/training/gp-curriculum-overview/online-curriculum-2018/managing-complex-care/3-10-mental-health-problems/3-10-knowledge-and-skills.aspx Key components in this regard are the requirements to:”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 27 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide a two-module suicide-prevention course with case-based strategies and resources for primary-care intervention.

    Verbatim wording from the response

    “These elements of competence are assessed via the licensing examination, Membership of the Royal College of General Practitioners. In addition to the above, RCGP produces educational material such as a specific learning module on suicide prevention, which is available via our website. This two-module course:”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 27 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish guidance for GPs on assessing, managing and referring patients with suicidal ideation, including a toolkit and quick-reference leaflet.

    Verbatim wording from the response

    “To compliment the above course, we have published guidance to general practitioners on the assessment, immediate management and onward referral for patients with suicidal ideation. This is via a detailed “toolkit” and for ease of reference I have enclosed “Suicide Prevention Top Ten Tips” leaflet which gives general guidance in this area.”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 27 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Refer the coroner’s report to the Professional Standards Department to consider whether member guidance on suicidal clients and suicide-risk management should be strengthened.

    Verbatim wording from the response

    “The British Association of Counselling and Psychotherapy has published a range of guidance for its members in working with suicidal clients and managing the risk of suicide. These are available for our members to download from our website. I will pass your report onto our Professional Standards Department for consideration and review as to whether it might be possible to strengthen any current guidance in light of these distressing events.”

    Source location

    2019-0378-Response-from-British-Association-for-Counselling-and-Psychotherapy_Redacted
    Page 1 · response
    Published 27 December 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing RCGP mental-health education, guidance and service-improvement work is considered an adequate response to suicide-prevention concerns.

    Verbatim wording from the response

    “From the above, RCGP already undertakes considerable work in this important area as we see it as a key priority. I will ensure that the sad case of Mr Spooner is brought to the attention of our mental health leads and our educational convenors so that we can continue to do what we can to improve services for patients such as Mr Spooner.”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 3 · response
    Published 27 December 2019

    Open published response

  8. Birmingham and Solihull

    AI-generated summary

    David Jonathon Jukes · Prevention of Future Deaths report

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

    Report summary

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

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

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

  9. Avon

    AI-generated summary

    Natasha Elizabeth Victoria Abrahart · 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

    Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.

    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 arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years

    Wider context from the report

    “The NICE guideline Depression in Adults: Recognition and management (CG90) states in section 1.5.2.7 “A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important” In this case Sertraline was prescribed but the NICE guideline was not followed by the mental health trust or the GP practice. The expert indicated that the review at 1 week is to ensure that the patient is taking the medication, to check for any side effects including suicide risk and to see what has happened; that review can be done by the G.P. or the mental health team but there needs to be a known appointment. ”

    Source location

    Natasha Elizabeth Victoria Abrahart · 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

    Add an SSRI and suicidality prompt to the first mental health assessment template.

    Verbatim wording from the response

    “Following the inquest touching upon NA’s death, we have added an additional field on our first mental health assessment template regarding SSRI and suicidality: “If SSRI newly prescribed: counsel re side effects and risk increase suicidality; when is follow up?””

    Source location

    2019-0504-Response-from-University-of-Bristol_Redacted
    Page 4 · response
    Published 14 May 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

    Schedule routine reviews one week after starting an SSRI, with booked or known follow-up appointments and appropriate follow-up after cancellations or non-attendance.

    Verbatim wording from the response

    “In response to the concerns expressed within your Regulation 28 report, we have moved appointments to review patients when starting an SSRI routinely to 1 week, if this is manageable for the patient, and have this as a ‘booked’ or ‘known’ appointment in accordance with NICE guidance.”

    Source location

    2019-0504-Response-from-University-of-Bristol_Redacted
    Page 4 · response
    Published 14 May 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

    Recruit a permanent mental health nurse, define a role reviewing higher-risk or SSRI-starting patients at seven days, and plan use of the new resource with local partners.

    Verbatim wording from the response

    “Since the inquest we have requested additional funding from the University to advertise for a permanent Mental Health Nurse to join our team and this has been agreed. We are currently working on an advert and job description. The job plan for this member of the team would include reviewing patients under 30 thought to be at risk of suicide, or starting on SSRI, at 7 days. We are liaising with local partners, mental health advisory service and psychology team to plan how best to utilise this new resource.”

    Source location

    2019-0504-Response-from-University-of-Bristol_Redacted
    Page 4 · response
    Published 14 May 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

    Distribute a Trust-wide alert requiring adherence to NICE antidepressant-prescribing guidance, documented seven-day review responsibility, and auditable team responses.

    Verbatim wording from the response

    “We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.”

    Source location

    2019-0504-Response-from-AWP
    Page 1 · response
    Published 14 May 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

    Require medical leads to discuss the prescribing alert with all line reports to reinforce effective communication.

    Verbatim wording from the response

    “We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.”

    Source location

    2019-0504-Response-from-AWP
    Page 1 · response
    Published 14 May 2020

    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

    Changing QOF depression review criteria requires national-level action, with feedback routed through the local CCG.

    Verbatim wording from the response

    “The current QOF (Quality Outcomes Framework) for depression states that a depression interim review should be undertaken at 10-56 days. Having reviewed the guidance around treatment of depression we would suggest that changing the achievement criteria within this QOF domain is a potential area for positive change. A change to this time frame might improve mental health outcomes across primary care, if it were updated at national level to reflect best practice. We intend to feed this back to our local CCG in the near future.”

    Source location

    2019-0504-Response-from-University-of-Bristol_Redacted
    Page 3 · response
    Published 14 May 2020

    Open published response

  10. Birmingham and Solihull

    AI-generated summary

    Paul Price · 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

    Paul Price had a history of depression and anxiety, and was found outside his room on 04/06/18 after falling from a window; he was pronounced deceased at hospital, with the medical cause of death recorded as multiple injuries. Concerns included delays in communicating mental-health assessment information to his GP, incompatible IT systems, and a failure to return a call about concerns for his wellbeing.

    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 arrange follow-up after mental health concerns are raised

    Wider context from the report

    “2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up. ”

    Source location

    Paul Price · 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 system changes, including an automated phone system, to record and audit internal and external calls and support message forwarding.

    Verbatim wording from the response

    “3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.”

    Source location

    Paul-Price-Response
    Page 2 · response
    Published 19 September 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Increase out-of-hours capacity by assigning a Band 7 senior clinician each evening to manage, triage and assess Home Treatment Team calls.

    Verbatim wording from the response

    “To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.”

    Source location

    Paul-Price-Response2
    Page 2 · response
    Published 19 September 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Reorganise administrative call handling and signed handover to qualified staff for action.

    Verbatim wording from the response

    “To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.”

    Source location

    Paul-Price-Response2
    Page 2 · response
    Published 19 September 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Recruit additional Home Treatment service staff, proceeding ahead of funding confirmation after submitting a business case to Commissioners.

    Verbatim wording from the response

    “To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.”

    Source location

    Paul-Price-Response2
    Page 2 · response
    Published 19 September 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish an out-of-hours switchboard safeguard requiring advice from a 24/7 bed-management clinician when clinical staff cannot respond.

    Verbatim wording from the response

    “In addition, we have placed an additional safeguard in place via our out of hours main switchboard, whereby in the event of failure to secure a response from clinical”

    Source location

    Paul-Price-Response2
    Page 2 · response
    Published 19 September 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Trust disputes that its computer systems were down on 1 June 2018; it attributes the missed message to staff error.

    Verbatim wording from the response

    “3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.”

    Source location

    Paul-Price-Response
    Page 2 · response
    Published 19 September 2018

    Open published response
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Data last updated 7 September 2026