Recurring concern

Unsafe individualised treatment planning for acute mental health risk

Get email alerts

Request correction

First reported 1 Jun 2015•Latest report 1 Jun 2026

Definition

What this concern includes

Includes failures in treatment selection or planning for patients with acute mental-health or suicide risk where the plan is unsuitable for the identified risk, repeats an ineffective approach, fails to consider appropriate admission or other treatment options, or disregards the patient's informed unwillingness to participate.

Not included

Excludes generic mental-health service capacity, referral, staffing or communication deficiencies unless they directly constitute an unsafe treatment-planning decision.
Excludes treatment-quality concerns outside acute mental-health or suicide-risk management unless the reports support the same individualised treatment-planning condition.
Excludes failures limited to delivering an otherwise appropriate treatment plan after it has been selected.
Excludes generic consent or patient-involvement failures where treatment selection was otherwise clinically appropriate and the patient's wishes were not material to the reported safety concern.

Reports: 7
Individual concerns: 7
Date range: 2015–2026
Stated actions: 3

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

West London NHS Trust3

Central and North West London NHS Foundation Trust1

Essex Partnership University NHS Foundation Trust1

Imperial College Healthcare NHS Trust1

LPFT Legal Services1

NAViGO Health and Social Care CIC1

NHS Birmingham and Solihull Integrated Care Board1

NHS England1

North London NHS Foundation Trust1

Portland Road Practice1

Recipient name withheld1

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 Jun2026
Essex
Concerns raised1
1. Promotion of inappropriate psychotherapy for immediate suicide risk despite the patient’s unwillingness
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Katharine Emma Corrigan · 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

Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.

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
Promotion of inappropriate psychotherapy for immediate suicide risk despite the patient’s unwillingness
Wider context from the report
“9. Expert evidence was that Dialectic Behavioural Therapy can be useful for a patient like Ms Corrigan to attempt to find strategies for learned maladaptive behaviours with complex trauma. Ms Corrigan’s family were encouraged to privately fund intensive psychoanalytical psychotherapy as a mitigation for Ms Corrigan’s significant risk of killing herself. Expert evidence was that this was not a therapy modality which was understood to be appropriate for Ms Corrigan: a. specifically, to mitigate a significant and immediate risk of her ending her life b. for a detained patient with her presenting mental state and risks and, c. when Ms Corrigan had indicated that she did not wish to participate in it. d. When Ms Corrigan had not completed DBT. e. who was reporting nightmares and flashbacks of complex trauma. f. When it was understood by the professionals that this therapy would last for years and would involve delving into the unconscious. ”
Source location
Katharine Emma Corrigan · Prevention of Future Deaths report
Page 5 · concerns
Open source report
6 Jul2023
Inner West London
Concerns raised1
1. Failure to select the best treatment plan for individual patients, including appropriate admission
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Remind crisis-assessment staff that they may request senior consultant discussion regardless of the proposed disposition.
  Stated by West London NHS TrustStated completed
2. Action
  Embed trusted-assessment working between CATT and Psychiatric Liaison teams for joint admission and home-treatment decisions.
  Stated by West London NHS TrustStated in progress
AI-generated summary

Mr Oleg Khala · 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 Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.

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 select the best treatment plan for individual patients, including appropriate admission
Wider context from the report
“2. That the role of CATT to look for alternatives to admission may risk CATT discharging patients who would benefit from admission and risk the repeat of making treatment plans that had recently failed such as in this case. Rather than looking for admission alternatives being a core function, should CATT rather better be focussed on the best treatment plan for the individual patient and thus admission being viewed as a clear option where appropriate rather a last resort, as it often appears to be presented in such cases before the coroner? ”
Source location
Mr Oleg Khala · Prevention of Future Deaths report
Page 4 · 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
Remind crisis-assessment staff that they may request senior consultant discussion regardless of the proposed disposition.

Verbatim wording from the response
“CATT team members (and other non-medical and trainee medical staff undertaking assessments of patients in crisis) have been reminded that they can request senior discussion with On-call Consultants irrespective of decision to admit, to offer an admission to a home-based care pathway or to discharge.”

Source location
Response from West London NHS Trust
Page 4 · response
Published 10 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Embed trusted-assessment working between CATT and Psychiatric Liaison teams for joint admission and home-treatment decisions.

Verbatim wording from the response
“The Clinical Directors, Service Managers, Clinical Leads and Team Managers responsible for CATT and Psychiatric Liaison are in regular discussion about interface matters between their services and cases of concern are reviewed regularly. All are in agreement that it is best practice for assessments to take place and decisions to be made jointly wherever possible, and work is ongoing to embed a culture of ‘trusted assessment’ between the teams in respect of decisions to admit to beds or home-based treatment pathways under CATT.”

Source location
Response from West London NHS Trust
Page 6 · response
Published 10 July 2023
Open published response
26 Oct2022
Lincolnshire
Concerns raised1
1. Failure to consider Mental Health Act admission criteria
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Vincenzo Joseph Michael LIPPOLIS · 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

Vincenzo Joseph Michael LIPPOLIS, aged 21, died on 1 November 2021 after being found hanging in woodland at Sand Dunes, Mablethorpe. Concerns were raised about why he was not admitted under the Mental Health Act after a recent suicide attempt and why a recommended face-to-face assessment was replaced by a telephone call, after which the case was closed the same day.

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 Mental Health Act admission criteria
Wider context from the report
“In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”
Source location
Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
24 Jun2022
Inner West London
Concerns raised1
1. Failure of treatment planning to manage patient risks
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

ZSOLT KIRJAK · 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

ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.

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 treatment planning to manage patient risks
Wider context from the report
“2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide. The treatment plan prescribed did not manage the Patient’s risks. ”
Source location
ZSOLT KIRJAK · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Feb2021
Inner West London
Concerns raised1
1. Failure to consider appropriate admission
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Valeria Munoz Biggs · 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

Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.

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 appropriate admission
Wider context from the report
“3. That where appropriate admission should be considered to diagnose, and treat the patient and manage risk of self-harm. ”
Source location
Valeria Munoz Biggs · Prevention of Future Deaths report
Page 3 · concerns
Open source report
4 Oct2018
Birmingham and Solihull
Concerns raised1
1. Failure to provide psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Michael Paul Wheeler · 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

Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.

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 psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations
Wider context from the report
“1. Mr. Wheeler’s family have provided evidence that he was extremely paranoid by the 24th of July 2018 and this was causing him to act irrationally and at times aggressively, they were very fearful for his safety and reported this to the mental health nurses he saw on the 24th and 25th. Despite these concerns Mr. Wheeler was not reviewed by a Psychiatrist and therefore his condition went undiagnosed with no treatment plan. Furthermore it is noted that there was no plan to review Mr. Wheeler at all on the 26th July 2018. ”
Source location
Michael Paul Wheeler · Prevention of Future Deaths report
Page 1 · concerns
Open source report
1 Jun2015
Inner North London
Concerns raised1
1. Failure to consider hospital admission for a patient presenting significant suicide risk
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
  Stated by North London NHS Foundation TrustStated completed
AI-generated summary

Mark Patrick DANIELS · 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

Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.

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 hospital admission for a patient presenting significant suicide risk
Wider context from the report
“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”
Source location
Mark Patrick DANIELS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.

Verbatim wording from the response
“████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several”

Source location
2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Page 1 · response
Published 1 June 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Promotion of inappropriate psychotherapy for immediate suicide risk despite the patient’s unwillingness

Concerns raised1

Failure to select the best treatment plan for individual patients, including appropriate admission

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to consider Mental Health Act admission criteria

Concerns raised1

Failure of treatment planning to manage patient risks

Concerns raised1

Failure to consider appropriate admission

Concerns raised1

Failure to provide psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations

Concerns raised1

Failure to consider hospital admission for a patient presenting significant suicide risk

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 2

Actions described in response 1