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
Individual concerns: 55
Date range: 2014–2026
Stated actions: 52

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.

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.

13 Nov2023
Mid Kent and Medway
Concerns raised1
1. Failure to provide 72-hour follow-up after Emergency Department presentation
This report raised 7 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.
Respondent positions 1
1. Position
  NHS England is responsible for addressing the report’s concerns about local mental health service issues.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Roger Adrian Stevenson · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide 72-hour follow-up after Emergency Department presentation
Wider context from the report
“1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed. 2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions. 3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm. 4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department, ”
Source location
Roger Adrian Stevenson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

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

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

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 21 November 2023
Open published response
20 Oct2023
Inner North London
Concerns raised2
1. Failure to refer patients to the crisis team during delays in community mental health follow-up
2. Delays in community mental health team follow-up
This report raised 1 other concern. 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.
Respondent positions 1
1. Position
  Clinical assessment found low self-harm risk, so discharge with routine CMHT referral rather than crisis services was considered appropriate.
  Stated by South West London and St George'S Mental Health NHS TrustDisputes the concern
AI-generated summary

Michael Joseph HINDES · 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 Hindes died by suicide after calling 999 because he felt suicidal and being taken to St George’s Hospital for a half-hour mental health assessment before discharge. The principal concerns were that he was not referred to the crisis team despite a likely minimum one-week wait for community mental health follow-up, and that the assessing nurse did not try to persuade him to involve his family, who were unaware of his mental ill health until after 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 refer patients to the crisis team during delays in community mental health follow-up
Wider context from the report
“He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen. In the meantime, it was not thought necessary to refer him to the crisis team. Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this. The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services. Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt. ”
Source location
Michael Joseph HINDES · 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
Delays in community mental health team follow-up
Wider context from the report
“He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen. In the meantime, it was not thought necessary to refer him to the crisis team. Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this. The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services. Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt. ”
Source location
Michael Joseph HINDES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Clinical assessment found low self-harm risk, so discharge with routine CMHT referral rather than crisis services was considered appropriate.

Verbatim wording from the response
“As you are aware through the Inquest, the clinical risk assessment undertaken at the time by the assessing nurse in the Psychiatric Liaison Team deemed the patient to be of low risk of self-harm and that he was suitable to be discharged home. In addition, with a routine referral to the Community Mental Health Team (CMHT) for ongoing diagnosis/further assessment, as crisis services were not required at that time.”

Source location
Response from South West London and St George's Mental Health
Page 2 · response
Published 19 December 2023
Open published response
25 Sep2023
Manchester West
Concerns raised1
1. Failure to provide planned Care Coordinator or Community Psychiatric Nurse visits
This report raised 3 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 4
1. Action
  Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
3. Action
  Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
1. Action
  Audit the absence-cover process after three months to verify that it is embedded and being followed.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
AI-generated summary

Robert Leigh · Prevention of Future Deaths report

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

Report summary

Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.

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 planned Care Coordinator or Community Psychiatric Nurse visits
Wider context from the report
“1. During the Inquest evidence was heard that: - i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL. iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments. iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences. ”
Source location
Robert Leigh · 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
Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.

Verbatim wording from the response
“Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is completed by the Care Coordinator prior to any planned absence, such as annual leave or a planned medical intervention. This ensures the Care Coordinator has considered any follow up for service users that is required during their period of absence and identifies who will carry out any planned interventions such as administration of depot medications, undertaking face to face visits, and making telephone contacts. If specific follow up is not required during the period of planned absence, the service user, and their families or carers will be provided with the contact details for the team, should they require additional support. The Team Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions required are undertaken by the team.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 2 · response
Published 28 November 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
Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.

Verbatim wording from the response
“For unplanned absences such as sickness, it is expected that the Care Coordinator, at the point of contacting the Team Manager or Senior Practitioner to advise of their absence, will provide a detailed handover of any work that is required to be covered.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 2 · response
Published 28 November 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
Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.

Verbatim wording from the response
“The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 3 · response
Published 28 November 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
Audit the absence-cover process after three months to verify that it is embedded and being followed.

Verbatim wording from the response
“The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 3 · response
Published 28 November 2023
Open published response
12 May2023
North Northumberland and South Northumberland
Concerns raised1
1. Failure to provide Consultant Psychiatrist review after 30 May 2018
This report raised 12 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

Odessa Carey · 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

Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment 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 provide Consultant Psychiatrist review after 30 May 2018
Wider context from the report
“4. Discharge from the Community Treatment Team on 6 August 2018 There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning. A more assertive approach to engagement may have been appropriate. I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator. I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature. I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment. ”
Source location
Odessa Carey · Prevention of Future Deaths report
Page 3 · concerns
Open source report
6 Mar2023
East London
Concerns raised1
1. Failure to provide at least weekly care co-ordinator reviews for amber-zoned patients
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

Evelina Vilkiene · 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

Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.

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 at least weekly care co-ordinator reviews for amber-zoned patients
Wider context from the report
“3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly. ”
Source location
Evelina Vilkiene · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Jan2023
Inner North London
Concerns raised1
1. Failure of the crisis team to reassess patients and reopen crisis-team cases when clinically indicated
This report raised 8 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

Andrew Mark Largin · 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

Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.

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 the crisis team to reassess patients and reopen crisis-team cases when clinically indicated
Wider context from the report
“2. The report also identified that, despite receiving an email from the Homerton University Hospital community rehabilitation team on 2 February, saying that Mr Largin had been seen on 1 February and was still very depressed, the crisis team failed to reassess him or to re-open his case to the crisis team, but instead referred the community team to the neighbourhood team. ”
Source location
Andrew Mark Largin · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Jan2023
Gwent
Concerns raised1
1. Failure to provide planned community follow-up within the required timeframe
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.
Actions described in response 2
1. Action
  Pilot embedded psychological care with outpatient follow-up and smoother transition pathways.
  Stated by Aneurin Bevan University LHBStated in progress
2. Action
  Finalize, consult on and submit the Disengagement and Did Not Attend policy for ratification.
  Stated by Aneurin Bevan University LHBStated in progress
AI-generated summary

Lucy Amanda 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

Lucy Amanda Jones developed a serious mental illness in 2019 and died by hanging on 12 March 2022. She remained on a waiting list for Cognitive Behavioural Therapy and was not seen in the community after a planned follow-up in January 2022; attempts to contact her were limited to two phone calls, with no cold call made when she could not be contacted.

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 planned community follow-up within the required timeframe
Wider context from the report
“1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022. 2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy. No efforts were made to “cold call” when Lucy could not be contacted. ”
Source location
Lucy Amanda Jones · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Pilot embedded psychological care with outpatient follow-up and smoother transition pathways.

Verbatim wording from the response
“In regard to this particular case, since this time the Health Board has invested further in psychological input to acute treatment areas and is piloting a model of embedded psychological care which gives some provision for outpatient follow-up. This allows for smoother transitions, increased relational consistency (rather than needing to develop a new therapeutic relationship with a different clinician), and more effective care pathways. There is, of course, also the growth in the ‘Open Dialogue’ model of care (a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always include the patient) and this is being provided by multi-disciplinary staff embedded in both acute care environments and community provision.”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 16 January 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
Finalize, consult on and submit the Disengagement and Did Not Attend policy for ratification.

Verbatim wording from the response
“With regard to the policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage, the Adult Mental Health and Specialist Services Directorate has developed a policy to guide clinicians in their next steps when a person does not attend”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 16 January 2023
Open published response
7 Sep2022
Inner North London
Concerns raised1
1. Failure to identify patients requiring service review for multidisciplinary discussion and follow-up
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.
Actions described in response 3
1. Action
  Implement the updated CDAT operational policy and daily duty tracker, with same-day logging and senior daily cross-checks for follow-up.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Review and monitor the new duty-tracking process through scheduled review, audit and governance processes to ensure effective embedding.
  Stated by North London NHS Foundation TrustStated planned
3. Action
  Include the new duty-tracking process in induction for new CDAT staff.
  Stated by North London NHS Foundation TrustStated planned
AI-generated summary

Demet AKCICEK · 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

Demet Akcicek was found dead in bed beside her sleeping seven-year-old son on the morning of 27 May 2022. The inquest determined that she died after taking an excess of prescribed and online-obtained medication, and that she did not intend to take her life. Concerns included a failure by a mental health service worker to arrange follow-up after a welfare call, and an insufficiently clear record of that call.

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 identify patients requiring service review for multidisciplinary discussion and follow-up
Wider context from the report
“When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”. The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged. In addition, the duty worker accepted in court that her note of the conversation was insufficient. I found the note difficult to understand and the duty worker was not able fully to explain its meaning. The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future. ”
Source location
Demet AKCICEK · 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 the updated CDAT operational policy and daily duty tracker, with same-day logging and senior daily cross-checks for follow-up.

Verbatim wording from the response
“Firstly I would like to offer sincere apologies to Ms Akcicek’s family on behalf of both the CDAT team and the Trust for this error which led to her not being followed up by the team. In order to address this and prevent it happening again, the team manager and service manager have updated the CDAT Operational Policy and have implemented a daily duty sheet/tracker. All matters dealt with on duty are logged immediately on this sheet which are then cross checked at 4.30pm daily by the senior on duty to handover and ensure appropriate follow up for all issues logged. A copy of the amended Operational policy incorporating this new process is enclosed with this response.”

Source location
Response from Camden and Islington NHS Foundation Trust
Page 1 · response
Published 5 October 2022
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 and monitor the new duty-tracking process through scheduled review, audit and governance processes to ensure effective embedding.

Verbatim wording from the response
“This new process has been discussed at the team business meeting and was officially started on 24th October. It will be reviewed in 6 weeks’ time and monitored going forward through audit and governance processes, to ensure that it is embedded in the team’s usual business practice and is working effectively. It will be included in the induction of new staff who join the team.”

Source location
Response from Camden and Islington NHS Foundation Trust
Page 1 · response
Published 5 October 2022
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
Include the new duty-tracking process in induction for new CDAT staff.

Verbatim wording from the response
“This new process has been discussed at the team business meeting and was officially started on 24th October. It will be reviewed in 6 weeks’ time and monitored going forward through audit and governance processes, to ensure that it is embedded in the team’s usual business practice and is working effectively. It will be included in the induction of new staff who join the team.”

Source location
Response from Camden and Islington NHS Foundation Trust
Page 1 · response
Published 5 October 2022
Open published response
12 Jul2022
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Lack of a route back into the Mental Health Service after CRHT discharge
This report raised 3 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

Kieran Joseph Kevan CRIMMINS · 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

Kieran Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.

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 route back into the Mental Health Service after CRHT discharge
Wider context from the report
“(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies. My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy. ”
Source location
Kieran Joseph Kevan CRIMMINS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
9 Aug2021
Norfolk
Concerns raised1
1. Lack of early mental health review
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.
Respondent positions 1
1. Position
  The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
  Stated by Norfolk and Suffolk NHS Foundation TrustRedirects responsibility
AI-generated summary

Terence Robert TUTTLE · 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

Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious 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
Lack of early mental health review
Wider context from the report
“1.Lack of proper dietician assessment and mental health review at an early stage. ”
Source location
Terence Robert TUTTLE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.

Verbatim wording from the response
“Out of the concerns listed below I would advise that NSFT are able to respond to the second part, in italics, of the first point only. The other points would be for the QEH to respond to:”

Source location
2021-0265-Response-from-Hellesdon-Hospital_Published-1
Page 1 · response
Published 12 August 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide 72-hour follow-up after Emergency Department presentation

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to refer patients to the crisis team during delays in community mental health follow-up

Delays in community mental health team follow-up

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide planned Care Coordinator or Community Psychiatric Nurse visits

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.4

Concerns raised1

Failure to provide Consultant Psychiatrist review after 30 May 2018

Concerns raised1

Failure to provide at least weekly care co-ordinator reviews for amber-zoned patients

Concerns raised1

Failure of the crisis team to reassess patients and reopen crisis-team cases when clinically indicated

Concerns raised1

Failure to provide planned community follow-up within the required timeframe

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 identify patients requiring service review for multidisciplinary discussion and follow-up

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.3

Concerns raised1

Lack of a route back into the Mental Health Service after CRHT discharge

Concerns raised1

Lack of early mental health review

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Respondent positions 1

Respondent positions 1

Actions described in response 4

Actions described in response 2

Actions described in response 3

Respondent positions 1