Recurring concern

Failure to establish patients’ consent for family involvement in mental health care

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First reported 12 May 2014•Latest report 13 Nov 2023

Definition

What this concern includes

Includes failures in mental-health or associated emergency-care processes to ask about, record or use a patient’s consent for notifying or involving family members about suicidal feelings, mental ill health, deterioration, hospital attendance or related safety concerns.

Not included

  • Excludes general failures to involve families in care planning, discharge or treatment decisions where the specific issue is not establishing consent for family involvement.
  • Excludes failures to communicate with families after consent was reliably established, unless the consent-establishment process itself was also deficient.
  • Excludes generic confidentiality, information-sharing or communication failures without a patient-consent and family-involvement context.
  • Excludes family involvement that is legally or clinically inappropriate because consent was refused or another documented restriction applies.
Reports
7

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
10

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.

NHS England3
Department of Health and Social Care1
Gloucestershire Health and Care NHS Foundation Trust1
Hafod Community Mental Health Team1
Ison Harrison Limited1
Leicestershire Partnership NHS Trust1
North London NHS Foundation Trust1
North Yorkshire Police1
St Pancras Hospital1
Windsor and Maidenhead Community Mental Health Team1
Wokingham Community Mental Health Team1
Yorkshire Ambulance Service NHS Trust1

Concerns and responses across reports

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

  1. Mid Kent and Medway

    AI-generated summary

    Roger Adrian Stevenson · 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

    Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.

    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 clearly record service users' consent to disclosure to family members

    Wider context from the report

    “6. That mental health practitioners did not have means by which to engage with the families of service users, effectively recognising such families as an additional resource able to support mental health treatment by monitoring service users and encouraging them to engage with such treatment (and as an adjunct to that a way of noting that where consent has been given by a service user to disclose matters to family members this is clearly noted so that mental health staff are aware of it and can act promptly in so doing). ”

    Source location

    Roger Adrian Stevenson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS England is responsible for addressing the report’s concerns about local mental health service issues.

    Verbatim wording from the response

    “I note that you have also addressed matters of concern to the Chief Executive of NHS England, and I would expect her response to address the concerns raised around local issues.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    Open published response
  2. Inner North London

    AI-generated summary

    Grazyna WALCZAK · 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

    Grazyna Walczak died after jumping three storeys from her flat on 25 or 26 September 2020 while suffering an acute depressive illness. Before her death, she was assessed as being at low to moderate risk, but was not asked whether her family could be notified. The report also raised concern that a required 72-hour investigation report was completed about five months after her death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to routinely ask patients whether their families may be involved in their care

    Wider context from the report

    “1. Ms Walczak was seen by a psychological wellbeing practitioner from the Camden and Islington iCope service two or three days before her death. She was assessed as being at low to moderate risk to herself. However, she was not asked if she would agree to her family being notified of the situation and of her current mental ill health. Her son would dearly like to have been told what was happening and would have acted accordingly. I heard evidence that iCope does not routinely ask their patients if families may be involved. This seems to be a policy worthy of reconsideration. ”

    Source location

    Grazyna WALCZAK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Next-of-kin information will not be mandatory because patient confidentiality must be protected and access to the service should remain unrestricted.

    Verbatim wording from the response

    “The iCope service has reviewed the policy on contact with clients’ families in light of the PFD report. Up to now the service has not routinely collected information on ‘Next of Kin’ and would contact the person’s GP if that information was needed. iCope does, however, quite often involve relatives or partners in aspects of treatment if appropriate and with the consent of the patient. The service takes the confidentiality of its patients very seriously, so would not want to make it mandatory for people to give NOK information in order to access the service.”

    Source location

    2021-0063-Response-from-St-Pancras-Hospital-Redacted
    Page 1 · response
    Published 8 March 2021

    Open published response
  3. Liverpool and Wirral

    AI-generated summary

    Ceara Marie Thacker · 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

    Ceara Marie Thacker, a 19-year-old University of Liverpool student with a history of self-harm and contact with mental health services, was found deceased hanging on 11 May 2018. Concerns included the lack of discussion about involving her family in care planning and the absence of attempts to cut her down after she was found hanging; the first-aid training received by the person who found her did not cover hangings.

    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 consider and seek consent for family involvement in care planning

    Wider context from the report

    “1. Throughout Ceara’s involvement with the medical professionals and therapists, whether Mersey Care, Mental Health Advisory team at the University or the GPs there is no evidence of any discussion around involving Ceara’s family in drawing up a plan or consideration of requesting consent from Ceara to discuss her situation with parents/family. It is accepted that Ceara was an adult and had full capacity, however, Ceara was a young adult, first time away from home who had history of mental health issues. It would have been helpful to have had these discussions so that if Ceara wanted that additional support from her family this could have been facilitated. That said it is unclear as to whether Ceara would have agreed to her family being involved, however, this line of enquiry would have been helpful. The general approach with young people appears to be to encourage them to discuss their issues with their parents/family rather than asking for consent for the professionals to discuss it with the parents/family. ”

    Source location

    Ceara Marie Thacker · 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

    Bring stakeholders together to scope routine electronic-record prompts for seeking consent to involve families in mental healthcare.

    Verbatim wording from the response

    “There is clear existing guidance on the importance of seeking consent to involve family and friends.¹ Because of this we will focus our action to prevent future deaths on steps that would help ensure it is more reliably and consistently considered. This is potentially a complex undertaking, given the range of electronic patient record systems used in mental health services, and differing patient groups with different needs that need to be reflected within formats used to record information across a range of mental health services, and the need to work within the relevant legal frameworks, including giving due regard to information governance law, the Mental Capacity Act and the Mental Health Act. The NHS England & NHS Improvement mental health programme team will work with our partners in”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Explore linking electronic-record consent prompts to national datasets to enable measurement and targeted improvement support.

    Verbatim wording from the response

    “NHSX and NHS Digital to bring together key stakeholders to scope whether it would be possible to routinely prompt seeking consent to involve families within electronic clinical record systems. We will also explore if the completion of those prompts can be directly linked to national datasets, as this would open the potential for measurement and for targeting improvement support where it is most needed.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue linking with Health Education England on work to improve mental-health staff skills for family-engagement discussions and care planning.

    Verbatim wording from the response

    “We will also continue to link with Health Education England who deliver a range of workstreams focused on improving the skills of all staff working in mental health services,² as these skills underpin sensitive and challenging discussions with service users and care plans that genuinely engage family support. Our Long Term Plan work to transform community mental health care, including for young adults, has a specific focus on improving co-produced personalised care and support planning, in which carer and family involvement is central.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Transform community mental-health care, including for young adults, through co-produced personalised care and support planning that centres carer and family involvement.

    Verbatim wording from the response

    “We will also continue to link with Health Education England who deliver a range of workstreams focused on improving the skills of all staff working in mental health services,² as these skills underpin sensitive and challenging discussions with service users and care plans that genuinely engage family support. Our Long Term Plan work to transform community mental health care, including for young adults, has a specific focus on improving co-produced personalised care and support planning, in which carer and family involvement is central.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 June 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop information-sharing guidance and a consensus statement with Universities UK on when information can be shared without breaching confidentiality.

    Verbatim wording from the response

    “Increasingly universities are routinely asking for consent to contact students’ parents if support is felt to be needed, through registration questions phrased to ensure students understand the need for this. We are currently working with Universities UK to develop information sharing guidance and a consensus statement on when information can be shared without breaching confidentiality, and expect Universities UK to open consultation on draft guidance in the near future.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 June 2025

    Open published response
  4. Gloucestershire

    AI-generated summary

    Robert Glyn Hughes · 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

    Robert Glyn Hughes, a 67-year-old man with a history of low mood, alcohol and diazepam dependence, previous overdoses, and prostate cancer, was found deceased at home on 20 February 2018 after police responded to a concerned friend. The report records a concern that the triangle of care approach, involving permission to contact the patient’s family, was not consistently applied.

    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

    Inconsistent application of the triangle of care approach for seeking patient permission to approach the patient’s family

    Wider context from the report

    “(1) The triangle of care approach, where mental health team practitioners seek permission from the patient to approach the patient’s family, is not consistently applied. ”

    Source location

    Robert Glyn Hughes · 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 practice against the six Triangle of Care standards through executive oversight and Governance Committee monitoring.

    Verbatim wording from the response

    “Our Triangle of Care membership started when the scheme was launched in 2015. Developing our practice to be in line with the six standards expected in the Triangle of Care (https://www.nhsconfed.org/~/media/Confederation/Files/public%20Access/Care Triangle.pdf) has been a dedicated practice development initiative, overseen at Executive level and its progress monitored by our Governance Committee, since that time.”

    Source location

    2019-0042-Response-by-2gether-NHS-Trust
    Page 2 · response
    Published 24 May 2019

    Open published response
  5. North Yorkshire (West)

    AI-generated summary

    Samuel Thomas Lindor Carroll · 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

    Samuel Thomas Lindor Carroll contacted emergency services stating that he felt suicidal and wanted to jump off a bridge, and was taken to hospital for a mental health assessment before being discharged. He was later found hanging from a tree and died from asphyxia due to hanging by ligature. The report raised concerns that police and ambulance staff did not ask whether he consented to family or friends being informed, meaning no family or friends were alerted to his hospital attendance or discharge.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of police officers to ask for consent before sharing information about suicidal feelings or hospital attendance

    Wider context from the report

    “1. The Police Officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal or that he was being taken to the Hospital. 2. The Ambulance service did not ask Mr Carroll if he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to Hospital. 3. As a consequence no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following an earlier expression of suicidal ideation. ”

    Source location

    Samuel Thomas Lindor Carroll · 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 instruction to training on eliciting consent to inform a nominated person about a suicidal individual's location and mental wellbeing concerns.

    Verbatim wording from the response

    “In light of your report, I will make sure that this training includes instruction to staff to make sure that steps are taken to elicit consent to inform a nominated person of their location and the concerns for their mental wellbeing. This must be balanced against considerations of whether that nominated person may potentially exacerbate the situation, given that feelings of suicidality often emanate from relationship / familial difficulties.”

    Source location

    2016-0384-Response-by-North-Yorkshire-Police
    Page 2 · response
    Published 27 October 2016

    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

    Because Mr Carroll appeared capacitated, was an adult, and had been handed over to professionals, officers had no expectation to notify friends or relatives.

    Verbatim wording from the response

    “As you have noted, officers did not make contact with friends or relatives before Mr Carroll was taken by ambulance to hospital. Given his apparent possession of mental capacity, his adulthood and the handover to other professionals for his onward care, there has previously been no expectation that officers would make such intimations.”

    Source location

    2016-0384-Response-by-North-Yorkshire-Police
    Page 1 · response
    Published 27 October 2016

    Open published response
  6. Leicester City and South Leicestershire

    AI-generated summary

    William Abel · Prevention of Future Deaths report

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

    Report summary

    William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would 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 discuss family involvement and provide information about the mental health problem and its treatments

    Wider context from the report

    “3. NICE guidelines (Clinical guidance 136) state that health care professionals should discuss whether the patient would like the family to be involved in their care, and to provide them with information to understand the mental health problem and its treatments. This guideline does not appear to have been met in this case. ”

    Source location

    William Abel · 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

    Document family members’ presence, offer them opportunities to provide views and observations, and include this information in assessment outcomes.

    Verbatim wording from the response

    “Family members’ presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual. This information will be documented on the assessment form by the assessing professional and form part of the outcome of assessment.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    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

    Remind Triage Car and Crisis Team staff about the family-involvement protocol and patient choice through managers and team meetings.

    Verbatim wording from the response

    “The Triage Car and Crisis Team have both been reminded of this protocol via their team manager and their team meetings during November 2015.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce an assessment-outcome and plan form providing patients and, with consent, accompanying carers or family members written advice and access information.

    Verbatim wording from the response

    “The service is introducing an outcome of assessment and plan record form to support the routine work of the Triage Car and Crisis Teams, ensuring that all patients come into contact with the Triage Car Mental Health Practitioner team are given key written information clarifying the immediate advice given, and where and how to access help should they need it. This will also be given to a carer, friend or family member if they are present at the assessment and the patient has consented to their involvement. We will implement this change for the Triage Car team by the end of December 2015 and the wider Crisis Team by the end of January 2015.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    Open published response
  7. Inner West London

    AI-generated summary

    Keiran Michael John Toman · 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

    Keiran Michael John Toman had fixed delusions, withdrew from social and psychiatric support, and subsequently starved himself to death due to paranoia before being found deceased in a hotel. The report raised concerns that psychiatric services did not maintain contact with his family despite his lack of insight and capacity, potentially leaving him isolated and increasing the risk of deterioration and death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient review of patient decisions about permission to contact next of kin or family

    Wider context from the report

    “(5) That permission to contact next of kin/ family decisions taken by patients may not be reviewed often enough by those providing psychiatric care, such that information in relation to changes in treatment, mental state, discharge, provider of care etc may not be being appropriately communicated to the detriment of patients. ”

    Source location

    Keiran Michael John Toman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026