Concerns raised 1
Infrequent consultant psychiatrist review of recently sectioned and treated inpatients View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Christopher Glyn Jones · 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
Christopher Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.
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 Infrequent consultant psychiatrist review of recently sectioned and treated inpatients
Wider context from the report “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date , as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months .
” Source location Christopher Glyn Jones · Prevention of Future Deaths report
Open source report
9 Dec 2015 Jake Robinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jake Robinson · 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
Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before his 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 prioritise Community Mental Health Team appointments for patients at high risk of harm
Wider context from the report “4) There was no explanation in the review as to why the appointment clash between Trafford Aim and the Community Mental Health Team led to the appointment with the CMHT being rearranged . Particularly as Jake had made two recent serious attempts of self-harm in July 2015 and was at the very least recognised as a high risk of accidental harm . Given that Trafford Aim were not prescribing Jake at this time the Court had some difficulties in understanding what their role was given that he was also under Phoenix Futures for his substance misuse.
” Source location Jake Robinson · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send all mental health service commissioners NHS England expectations for commissioned arrangements covering urgent correspondence, clinical risk assessment, shared care, incident learning, and vulnerable patients who miss appointments.
Verbatim wording from the response “In order to reduce the risks of recurrence of a similar incident at these and other organisations across Greater Manchester so that referrals are managed and monitored by the responsible commissioning and provider organisations I intend to undertake the following actions by 29 April 2016.” Source location 2015-0474-Response-by-GMCA
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reflect further on whether obtaining information about future appointments and clinicians would improve patient care.
Verbatim wording from the response “In conclusion, the RAID Team stated that in their opinion there was no evidence of acute mental illness and that his primary concern currently was illicit drug use. At that time their plan included leaving him under the care of Phoenix Futures as he had a good rapport with his keyworker, he was discharged from RAID with it being stated that he was aware of crisis pathways. In retrospect however we were not aware of when his next appointments were and who they were going to be with. I am not sure whether availing ourselves of this information would have made a major difference but it is certainly something we will reflect on further.” Source location 2015-0474-Response-by-Bodmin-Road-Health-Centre
Open published response
Concerns raised 2
Delays in offering psychiatric follow-up appointments View source Failure to respond to non-attendance with clinical risk consideration View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Leicester City Council Leicestershire Partnership NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Leicestershire Partnership NHS Trust
Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.
View source
Leicestershire Partnership NHS Trust
Develop a partial-booking system for outpatient appointments.
View source
Leicestershire Partnership NHS Trust
Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.
View source
Leicestershire Partnership NHS Trust
Remind community mental health staff to follow the Did Not Attend policy for missed appointments.
View source
Leicestershire Partnership NHS Trust
Conduct regular spot checks of compliance with the Did Not Attend policy.
View source
Leicestershire Partnership NHS Trust
Review the Did Not Attend policy and introduce a flow chart for responding to missed appointments.
View source
Leicestershire Partnership NHS Trust
Circulate an interim missed-appointment flow chart to community mental health teams.
View source
Leicestershire Partnership NHS Trust
Contact new patients and recent non-attenders with appointment reminders, and alert clinicians to missed appointments for risk assessment.
View source
Leicestershire Partnership NHS Trust
Audit compliance with the Did Not Attend policy during quarter two of 2016/17.
View source See 6 more actions
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AI-generated summary
Barry Thraves · 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 Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and GP.
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 in offering psychiatric follow-up appointments
Wider context from the report “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months ; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time.
” Source location Barry Thraves · Prevention of Future Deaths report
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 to respond to non-attendance with clinical risk consideration
Wider context from the report “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time .
” Source location Barry Thraves · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.
Verbatim wording from the response “In the period between completion of the investigation and leading up to the Coroner’s inquest LPT has been undertaking a programme of specific work to ensure that the maximum use of clinical appointment slots are available in the Adult Mental Health Outpatients department thereby increasing the availability of appointments to our patients. This will reduce the numbers of people who are not attending appointments.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a partial-booking system for outpatient appointments.
Verbatim wording from the response “LPT is also working towards a ‘partial booking’ system for outpatient appointments whereby appointments are booked much closer to the scheduled date to be seen allowing for a more flexible use of available appointments and a reduction in cancelled clinics. Cancelling of clinics is sometimes unavoidable but it is subject to Clinical Director approval and an action plan to monitor compliance and improvement is scrutinized for assurance at the LPT Quality Assurance Committee.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.
Verbatim wording from the response “Since the beginning of November 2015 what are known as ‘open contacts’ on the patient electronic record (RiO) are being monitored on a weekly basis. This is where a patient has had an appointment date that has passed but the episode of care has not been closed on the record, either by a record of the appointment having taken place or evidence of a further appointment offered. These will be drawn to the” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind community mental health staff to follow the Did Not Attend policy for missed appointments.
Verbatim wording from the response “Actions taken/planned:” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regular spot checks of compliance with the Did Not Attend policy.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Did Not Attend policy and introduce a flow chart for responding to missed appointments.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate an interim missed-appointment flow chart to community mental health teams.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact new patients and recent non-attenders with appointment reminders, and alert clinicians to missed appointments for risk assessment.
Verbatim wording from the response “Specifically our new patients are now being contacted a week before their scheduled appointment to remind them of the appointment date and time. If a patient is unable to attend then the appointment can be offered to someone else. Patients who missed their last appointment are also telephoned to remind them to attend and these patients are also bought to the attention of the clinician so that an assessment can be made as to whether or not any further action is required. A text reminder facility is available to patients who opt into the service and the publicity for this is being reviewed to encourage take up.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the Did Not Attend policy during quarter two of 2016/17.
Verbatim wording from the response “We have informed our entire medical and nursing staff, in writing dated 1 December 2015 that they MUST write to GPs informing them about patients who Do Not Attend at our outpatient clinics as stated in the LPT DNA policy. In addition we will carry out an audit of the DNA policy to check compliance against the standards in the policy during quarter 2 of 2016/17. The record keeping audit, being scheduled for January 2016 will also include the recording of compliance with the standards within the revised discharge policy as described under point 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern about psychiatric follow-up falls to Leicestershire Partnership Trust, which will respond separately.
Verbatim wording from the response “This concern relates to Leicestershire Partnership Trust’s involvement with Mr Thraves and I am aware that the Trust will be responding to you on this point.” Source location 2015-0443-Response
Open published response
4 Jun 2015 Alice Anne McMeekin · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1
Discharge without timely and adequate follow-up care for a person remaining at risk View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Alice Anne McMeekin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.
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 Discharge without timely and adequate follow-up care for a person remaining at risk
Wider context from the report “2.The Partnership Trust
The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day.
3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence . The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care , which could, as a consequence have made a difference.
It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder.
” Source location Alice Anne McMeekin · Prevention of Future Deaths report
Open source report
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to initiate youth offending and mental health monitoring after case transfer View source
This report raised 27 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” Source location Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Open source report
5 Dec 2014 Paul Leslie HYDE · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Lack of a referral follow-up system View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Paul Leslie HYDE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.
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 a referral follow-up system
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Source location Paul Leslie HYDE · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
Verbatim wording from the response “The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool.” Source location 2014-0527-Response-by-Sussex-Partnership-NHS
Open published response
17 Jan 2014 JULIA SHEEREN DELL · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 1
Failure to act on a care plan received from the Community Mental Health Team View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
JULIA SHEEREN DELL · 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
Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to act on a care plan received from the Community Mental Health Team
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” Source location JULIA SHEEREN DELL · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.