Recurring concern

Failure to provide timely continuing mental health reviews and follow-up

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First reported 17 Jan 2014•Latest report 25 Jun 2026

Definition

What this concern includes

Includes absent or delayed scheduled, early, annual, post-crisis, post-emergency or transfer-of-care mental health reviews and follow-up after a continuing need has been established.

Not included

  • Initial access to mental health assessment before a continuing review or follow-up need is established.
  • Routine non-mental-health primary-care follow-up.
  • Treatment-quality failures after a timely required review or follow-up occurred.
Reports
47

Distinct published reports

Individual concerns
55

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
52

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 Care7
NHS England6
NHS Birmingham and Solihull Integrated Care Board4
Pennine Care NHS Foundation Trust3
Sussex Partnership NHS Foundation Trust3
Betsi Cadwaladr University LHB2
Central and North West London NHS Foundation Trust2
East London NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Leicestershire Partnership NHS Trust2
Midlands Partnership University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
North London NHS Foundation Trust2
Recipient name withheld2
South West London and St George'S Mental Health NHS Trust2

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 provide routine follow-up after mental health consultation

    Wider context from the report

    “2. David presented to the GP surgery again on 26th June. He reported that he’d had a ‘severe mental breakdown due to ongoing psychosis’ which had resulted in him taking an overdose and being arrested for being in possession of a weapon, and he’d been advised by Police mental health services to contact his GP for support. When he spoke to the GP, David informed her that he considered his most significant issue currently was depression, and said that he had not taken Quetiapine since he moved to Exeter some years previously. Despite the fact that David indicated depression to be his overriding concern, he had taken an overdose which resulted in hospital attendance, and he’d not taken Quetiapine for some time (and seemingly for different symptoms), the GP prescribed Quetiapine, without seeking guidance or input from a psychiatrist or mental health professional about whether that was an appropriate medication in the circumstances. No routine follow up appears to have taken place following that consultation. The next communication does not occur until the GP is informed that there had been a further suicide attempt resulting in a Mental Health Act Assessment of David on 22nd August. ”

    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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use the 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

    Ronald William MEIKLE · 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

    Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

    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

    Delays or insufficiency in psychiatric assessment and proactive mental health review

    Wider context from the report

    “Concern 8: Delay or insufficiency in mental health and psychiatric input The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review. Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and death. ”

    Source location

    Ronald William MEIKLE · 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

    Improve waiting-list management by setting escalation thresholds, increasing remote clinics and reviewing priority weekly by clinical risk and waiting time.

    Verbatim wording from the response

    “Concern 8: Delay or insufficiency of mental health and psychiatric input We have worked on our waiting list management, setting clearer escalation thresholds, and increasing the use of remote clinics. The mental health and clinical leads review waiting lists every week and prioritise patients based on clinical risk and time waiting to ensure timely assessment and follow-up. We have also expanded clinical capacity by introducing advanced clinical practitioner roles to support routine reviews, while escalating more complex cases directly to consultant psychiatrists. Recruiting to substantive consultant posts remains a key priority for the service.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 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

    Expand clinical capacity through advanced clinical practitioner roles for routine reviews and direct escalation of complex cases to consultant psychiatrists.

    Verbatim wording from the response

    “Concern 8: Delay or insufficiency of mental health and psychiatric input We have worked on our waiting list management, setting clearer escalation thresholds, and increasing the use of remote clinics. The mental health and clinical leads review waiting lists every week and prioritise patients based on clinical risk and time waiting to ensure timely assessment and follow-up. We have also expanded clinical capacity by introducing advanced clinical practitioner roles to support routine reviews, while escalating more complex cases directly to consultant psychiatrists. Recruiting to substantive consultant posts remains a key priority for the service.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

    Open published response

  4. Buckinghamshire

    AI-generated summary

    Barry HARMER · 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

    Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of face-to-face psychiatric review in community care

    Wider context from the report

    “(3) The fact that Barry had not had any face to face psychiatric review at any point during the time he was open to Oxford Health was not addressed in the PSII and it remains unclear how this can be escalated for immediate attention in the community, where circumstances are changing, where the need for a voluntary admission has been agreed, but no bed is available. ”

    Source location

    Barry HARMER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Surrey

    AI-generated summary

    Suzanne Julia ELLERBY · 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

    Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services

    Wider context from the report

    “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”

    Source location

    Suzanne Julia ELLERBY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services

    Wider context from the report

    “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”

    Source location

    Suzanne Julia ELLERBY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer

    Wider context from the report

    “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”

    Source location

    Suzanne Julia ELLERBY · 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

    Draft and share the Personalised Care Framework with systems to support early adoption of safer mental-health care transitions.

    Verbatim wording from the response

    “NHS England continues to support systems to improve care for people with mental health problems needing help from secondary mental health services. NHS England has drafted guidance called the Personalised Care Framework (PCF), that sets out the core aspects of care for people who require help from secondary or integrated primary health services, the Voluntary Community and Social Enterprise (VCSE) and secondary care mental health services. It has been shared as a draft with systems to facilitate early adoption.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 18 November 2025

    Open published response

  6. North London

    AI-generated summary

    Sidi Chax Bojang · 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

    On 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.

    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 obtain psychiatrist review before discharge

    Wider context from the report

    “Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse. ”

    Source location

    Sidi Chax Bojang · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. 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

    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

    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

    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 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

  8. West London

    AI-generated summary

    Jonathan Mark George Hamer · 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

    Jonathan Mark George Hamer, who had bipolar affective disorder and was receiving community mental health care, died by suicide on 24 April 2024 after going onto railway tracks in front of a train. Concerns included communication failures during care-coordinator absences, the lack of systems to redirect or action unanswered communications, and the failure to prioritise and regularly review his case.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of scheduled case reviews and expected patient contact

    Wider context from the report

    “3. Jonathan’s case was not “zoned” that is, given a priority coding on the case management system. Therefore, there was no expected period for case review or regularity of expected contact. The multi-disciplinary meetings and supervision meetings when Jonathan’s case was discussed failed to recognise and address this issue. Appropriate zoning and regular reviews are a fundamental part of mental health care and should be embedded and prioritised as part of each patient’s care planning. ”

    Source location

    Jonathan Mark George Hamer · 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

    Conduct daily zoning, risk and care-plan reviews for unzoned, red, amber, green and otherwise enhanced-support patients, with escalation and senior oversight.

    Verbatim wording from the response

    “▪ Unzoned Patients: Any patient not currently assigned a zone is flagged and updated by the Team Manager and Consultant Psychiatrist, with oversight maintained via daily huddle discussions to ensure appropriate zoning is agreed and recorded. Senior Managers also complete regular reviews across the Community Service Line on teams with unzoned patients to ensure action is taken immediately.”

    Source location

    Response from South West London and St George’s Hospitals NHS Trust
    Page 4 · response
    Published 17 April 2025

    Open published response

  9. South Yorkshire (Western)

    AI-generated summary

    David Stables · 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 Stables had a history of mental health issues and attended his GP in February and March 2024 with anxiety, sleep difficulties and poor appetite. The inquest concluded that he died by suicide, with bilateral transection of the ulnar arteries and incised wounds to the wrists. The principal concern was that no mental health or medication reviews were recorded between April 2020 and February 2024, and it was unclear whether reviews had taken place but were not recorded or had not taken place when they should have.

    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 conduct full mental health reviews when required

    Wider context from the report

    “(1) I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been. (2) (3) ”

    Source location

    David Stables · 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 all current SSRI patients, prioritising those discharged from mental health services, using the new template and completing mental health and medication reviews.

    Verbatim wording from the response

    “2. We have reviewed each patient who is currently taking a selective serotonin reuptake inhibitors (SSRI) medication using the new template, starting with patients who have been discharged from a mental health service, as was Mr Stables. All patients have received a mental health review and a mental health medication review, who have been discharged from a mental health service.”

    Source location

    Response from Dearne Valley Group Practice
    Page 1 · response
    Published 9 December 2024

    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

    Contact patients discharged from mental health services, arrange initial reviews, and provide SSRI follow-up every one to four weeks until stable, then six-monthly reviews.

    Verbatim wording from the response

    “3. We have updated the process for future patients following discharge from any mental health service. Now, when we receive notification that a patient has been discharged from any mental health service, we will contact the patient to book them an appointment for an initial mental health review. If the patient has been prescribed an SSRI, we will review the patient between 1 to 4 weeks (as determined by the reviewing clinician and with the patient’s agreement) and ongoing until they are stable. Once a patient is stable, they will be recalled for review every 6 months whilst they are being prescribed SSRI medication.”

    Source location

    Response from Dearne Valley Group Practice
    Page 1 · response
    Published 9 December 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use scheduled reminders to prompt clinicians to complete patients’ mental health and medication reviews.

    Verbatim wording from the response

    “4. Patients starting an SSRI for the first time will also be seen every 1 to 4 weeks until they are stable, after which they will also be reviewed every 6 months whilst they are taking the medication. If patients choose to stop the medication themselves without our knowledge, this will be picked up at the review date and a mental health review and discussed with the patient. We are using scheduled tasks for”

    Source location

    Response from Dearne Valley Group Practice
    Page 1 · response
    Published 9 December 2024

    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 patients starting SSRIs every one to four weeks until stable, then every six months while they continue taking the medication.

    Verbatim wording from the response

    “4. Patients starting an SSRI for the first time will also be seen every 1 to 4 weeks until they are stable, after which they will also be reviewed every 6 months whilst they are taking the medication. If patients choose to stop the medication themselves without our knowledge, this will be picked up at the review date and a mental health review and discussed with the patient. We are using scheduled tasks for”

    Source location

    Response from Dearne Valley Group Practice
    Page 1 · response
    Published 9 December 2024

    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

    Mental health and medication reviews had occurred; the material problem was missing clinical-record coding.

    Verbatim wording from the response

    “We recognise the concerns you have raised about the lack of recording of mental health review and medication reviews. I have been assured that reviews had taken place, but they were not clearly or accurately recorded by the clinicians who consulted with Mr Stables. I am writing to set out the steps we have taken to assure that we will record this correctly going forward.”

    Source location

    Response from Dearne Valley Group Practice
    Page 1 · response
    Published 9 December 2024

    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

    Secondary mental health teams review patients remaining under their care; the practice assumes care after discharge.

    Verbatim wording from the response

    “6. Patients who are still under the care of a secondary care mental health team will be reviewed by them, we will take over their care and treatment plan when the patient is discharged back to us.”

    Source location

    Response from Dearne Valley Group Practice
    Page 2 · response
    Published 9 December 2024

    Open published response

  10. Surrey

    AI-generated summary

    Zarah RAVN · 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

    Zarah Ravn, aged 49, was found deceased at home on 3 September 2023 from mixed drug toxicity after consuming unprescribed oramorph and oxycodone alongside prescribed quetiapine. The substantive concerns included failures to carry out regular mental health, physical and medication reviews, inadequate monitoring of those reviews, and a lack of follow-up after HRT was prescribed following a reported deterioration in her mental 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

    Lack of yearly mental health reviews

    Wider context from the report

    “Lack of compliance with NICE guidelines in carrying out yearly medication reviews, mental health reviews and physical reviews leading to lack of opportunity to take necessary interventions including medication adjustments and provision of necessary support. ”

    Source location

    Zarah RAVN · 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 and disseminate a Severe Mental Illness Annual Reviews Policy linking physical, mental-health and medication reviews, templates, coding and recall safeguards.

    Verbatim wording from the response

    “We enclose a copy of the Practice’s new Severe Mental Illness Annual Reviews Policy. This policy creates a process for making sure that patients with an SMI have annual physical, mental health and medication reviews. The policy should be self-explanatory, but we have summarised below, with some additional comments about the rationale behind the changes made:”

    Source location

    Response from Ashlea Medical Practice
    Page 2 · response
    Published 14 May 2024

    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

    Carry out monthly checks that SMI-register searches result in completed annual reviews.

    Verbatim wording from the response

    “The new Annual SMI review policy was approved on 30 March 2024 and has been disseminated to staff. Our IT Assistant has been carrying out monthly reviews to check that the searches she is doing is resulting in annual checks being completed. Feedback so far indicates that the system is working well: patients are attending for their physical and mental health/medication reviews, and with a better attendance rate too because the patient is now getting the doctor’s appointment booked by the HCA before they leave the physical health check appointment.”

    Source location

    Response from Ashlea Medical Practice
    Page 3 · response
    Published 14 May 2024

    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

    Formally audit compliance with the SMI review policy in September 2024 and re-audit or review it thereafter as required.

    Verbatim wording from the response

    “Compliance with the new SMI review policy will be formally audited in September 2024 to check that it is working and that staff are complying with the requirements. It will be reaudited if necessary within 3-6 months and then added for review on an ongoing basis at the Practice’s annual compliance meeting.”

    Source location

    Response from Ashlea Medical Practice
    Page 3 · response
    Published 14 May 2024

    Open published response
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Data last updated 7 September 2026