Recurring concern

Unreliable Care Programme Approach care coordination

First to latest report 24 Jun 2015 — 12 Jan 2026

Reports that mention this concern
21
Times this concern has been raised
25
Stated actions linked to this concern
27

What this concern includes

Includes failures of the named Care Programme Approach and its dedicated care-coordination controls, including allocation of a care coordinator, structured reviews, medication review, care planning, role definition, risk management, inter-professional coordination and required follow-up.

What is not included
  • Excludes medication-review failures that are not part of the Care Programme Approach.
  • Excludes generic care coordination, communication or governance deficiencies where the Care Programme Approach is not explicitly involved.
  • Excludes failures of unrelated discharge, treatment or referral processes unless they are specifically identified as CPA controls.
  • Excludes final membership conclusions; the cited assertions support consideration of this parent only.

Reports and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    STUART CHRISTOPHER JAMES BERRY · 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

    STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.

    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 CMHT and Care Coordinator performance under the Care Programme Approach

    Wider context from the report

    “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically: (a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death: (b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy. (c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy. (d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy. (e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting. (f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration. (g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family. ”

    Source location

    STUART CHRISTOPHER JAMES BERRY · 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

    Standardise sample-based community mental health caseload audits across localities.

    Verbatim wording from the response

    “(a) Performance of the CMHT and the allocated Care Coordinator (under CPA/EPUT policy) EPUT maintains a governance framework that includes regular clinical supervision, weekly MDT forums, escalation procedures, and case auditing to identify and address gaps. We recognise the expectation that staff practise in line with Trust policy. Trust-wide audit requirements were reviewed in January 2026. While the final Trust standard is being confirmed through the Community First Project, our interim approach combines:”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 3 · response
    Published 20 January 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

    Introduce a care-coordination competency framework for new starters as part of probation.

    Verbatim wording from the response

    “The practitioner involved is currently subject to the Trust’s capability process. To complement formal training, EPUT is in the process of introducing a Care Coordination Competency Framework for all new starters. This framework will sit alongside the valued and essential on-the-job learning already provided within teams and will form a core component of each new staff member’s probationary period.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 5 · response
    Published 20 January 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

    Provide targeted complexity-and-escalation training, reflective supervision, and monthly CPD review for Care Coordinators.

    Verbatim wording from the response

    “Training and supervision improvements: Care Coordinators are receiving targeted training on recognising complexity and the thresholds for escalation, supported through reflective, restorative supervision. This was rolled out in 2024. Monthly CPD review sessions are in place for staff (these have been in place since beginning of 2025) which incorporate elements of restorative supervision, as appropriate. Staff 1:1 and staff mediation sessions also remain in place.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 8 · response
    Published 20 January 2026

    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

    The concerns reflect professional practice failures rather than a systemic organisational failure of care-planning systems or governance.

    Verbatim wording from the response

    “b. Failures in Care Planning In reviewing Mr Berry’s case, there is no evidence to suggest a systemic organisational failure. The required systems, governance structures, and escalation processes were in place and functioning. The concerns identified relate to professional practice, rather than a failure of the systems themselves.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 4 · response
    Published 20 January 2026

    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

    Existing supervision, MDT escalation, governance, and proportionate sample-based audits are considered sufficient; exhaustive case-by-case auditing is not required.

    Verbatim wording from the response

    “(a) Performance of the CMHT and the allocated Care Coordinator (under CPA/EPUT policy) EPUT maintains a governance framework that includes regular clinical supervision, weekly MDT forums, escalation procedures, and case auditing to identify and address gaps. We recognise the expectation that staff practise in line with Trust policy. Trust-wide audit requirements were reviewed in January 2026. While the final Trust standard is being confirmed through the Community First Project, our interim approach combines:”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 3 · response
    Published 20 January 2026

    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

    Proactive detailed review of every case is operationally infeasible because community caseloads are large and existing resources are limited.

    Verbatim wording from the response

    “Given the size of the caseload—approximately 380 patients—it is neither operationally feasible nor supported by existing resources for senior staff to proactively review every case in detail. The system therefore relies on clinicians applying sound judgement, using supervision effectively, and escalating concerns appropriately through MDT structures. These processes were available, embedded, and repeatedly communicated. In Mr Berry’s case, they were not utilised as required, and the necessary out-of-cycle CPA update following a change in risk did not take place. This represents a professional practice failure, not a failure of organisational systems.”

    Source location

    2026-0015 - Response from Essex Partnership University Foundation Trust
    Page 5 · response
    Published 20 January 2026

    Open published response

  2. Essex

    AI-generated summary

    DARREN NEIL TURNER · 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

    Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.

    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 allocate a Care Coordinator under the Care Programme Approach

    Wider context from the report

    “(d) Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. This failure (resulting from significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death - and in respect of which no DATIX was ever raised) was a feature that contributed to the serious failure in discharge planning in this case. ”

    Source location

    DARREN NEIL TURNER · 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

    Strengthen care-coordinator referral and allocation through shared referral-inbox access, weekly monitoring and a weekly Flow and Capacity Meeting.

    Verbatim wording from the response

    “On admission, where appropriate, a referral is made for a care coordinator. Community services are using a zoning template which clearly flags new referrals from inpatient services. At the weekly community MH team locality meeting all referrals are discussed for allocation and in-reach planning.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 17 March 2025

    Open published response

  3. Manchester South

    AI-generated summary

    Carl Garry Thompson · 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

    Carl Garry Thompson died from a drug overdose while on leave from Arden Ward, Stepping Hill Hospital, and was likely to have died on the night of 9 March 2022. Concerns included inadequate risk assessments and planning for his leave, insufficient response and escalation after family concerns about increased risk, and failure to provide a face-to-face Community Mental Health Team assessment or allocate a care coordinator before leave.

    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 allocate a CMHT Care Coordinator during prolonged inpatient admission

    Wider context from the report

    “8. I am concerned that prior to his commencing leave on the 7th March, Carl had not been allocated a CMHT Care Coordinator, despite being an inpatient for over 3 months, since 31st December 2021. ”

    Source location

    Carl Garry Thompson · 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 CMHT allocation and discharge coordination through increased staffing, reduced waiting lists, weekly ward attendance and duty-worker participation in relevant ward rounds.

    Verbatim wording from the response

    “The investigation recognised that during the time period of CT’s death, CMHT was on the Trust Risk Register in relation to staffing vacancies and patients awaiting allocation. The current position is more positive with an improved staffing establishment, a reduced waiting list and CMHT is no longer on risk register.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 5 · response
    Published 17 May 2023

    Open published response

  4. Dorset

    AI-generated summary

    Ryan Albert Frederick Merna · 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

    Ryan Albert Frederick Merna died from injuries sustained in a knife attack at his home on 14 August 2016. The concerns included that information about the perpetrator possessing a knife and sleeping rough was not probed, recorded, or raised at a care programme meeting, resulting in a missed opportunity to reassess risk.

    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 raise offensive-weapon disclosures at Care Programme Meetings

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Surrey

    AI-generated summary

    MARY NABILIA GWANYAMA · 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

    Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

    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 follow the Care Programme Approach during discharge

    Wider context from the report

    “5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed. ”

    Source location

    MARY NABILIA GWANYAMA · 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

    Update CPA and Acute Care Services policies to require a pre-discharge CPA meeting for every homeless inpatient.

    Verbatim wording from the response

    “The Trust accepts that a discharge CPA meeting was not held prior to Ms Gwanyama being discharged from the Abraham Cowley Unit and, given she was homeless at the time and her housing situation was uncertain, such a meeting should have taken place. Accordingly, the Trust’s CPA policy and Acute Care Services Operational Protocol will be updated to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge.”

    Source location

    2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 1 · response
    Published 23 April 2021

    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

    District and Borough Housing Departments are responsible for finding settled accommodation following the Trust’s statutory referral of homeless patients.

    Verbatim wording from the response

    “Whilst we fully appreciate your concerns about no policy being in place, it is unfortunately not possible for the Trust to have a policy in place that prevents patients from being discharged into homelessness from our inpatient units. The onus is our duty to engage appropriately with the statutory referral to District and Borough Councils’ Housing Departments to find a homeless person settled accommodation. The pre-discharge planning would also involve our homelessness”

    Source location

    2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 1 · response
    Published 23 April 2021

    Open published response

  6. London (West)

    AI-generated summary

    Bathsheba Shepherd · 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

    Bathsheba Bianca Kay Shepherd, known as Kay, was fatally stabbed by her housemate at some point between 10 and 11 November 2015 and was pronounced deceased on 11 November 2015. The report identified concerns about her being housed with a dangerous and vulnerable housemate, failures in risk assessment and rehousing, and her lack of GP registration and associated support.

    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 resolve the interagency Care Programme Approach process

    Wider context from the report

    “(1) I was concerned to find that even though 5 years had elapsed between Kay’s death and the hearing of the Inquest the issue of the way in which the Care Programme Approach was being conducted between the local authority and the NHS Trust was still the subject of discussion and had not been resolved to the satisfaction of the manager responsible for the process. The delay in my view represents a threat to the lives of others in similar situations. ”

    Source location

    Bathsheba Shepherd · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  7. Brighton and Hove

    AI-generated summary

    Timothy Julian STEELE · 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

    Timothy Julian STEELE was a 28-year-old man with a lifelong history of low mood, depression and suicidal ideation, who made multiple suicide attempts during 2020 and died at his home in Brighton on 10 August 2020. The report identified concerns that his referral was lost, that he was not followed up because of inefficient processes and failure to appoint a Lead Practitioner promptly, and that the Care Programme Approach was not followed. It also identified a fragmented approach to policies across different areas of Sussex.

    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 follow Care Programme Approach guidance

    Wider context from the report

    “(1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him. In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance “Refocusing the CPA- Policy and Positive Practical Guidance” does not appear to have been followed. ”

    Source location

    Timothy Julian STEELE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Lincolnshire

    AI-generated summary

    Toby Peter Edward Nieland · 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

    Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

    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 an adequate Care Programme Approach

    Wider context from the report

    “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 4 · 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 to appoint a care coordinator to monitor care under an appropriate care plan

    Wider context from the report

    “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan; ”

    Source location

    Toby Peter Edward Nieland · 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

    Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.

    Verbatim wording from the response

    “Learning from the death of Mr Nieland, the Trust will strengthen the policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 4 · response
    Published 26 October 2020

    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 the Care Programme Approach to ensure appropriate care-coordinator allocation, including for all patients with dual diagnosis.

    Verbatim wording from the response

    “v. To review the Care Programme Approach to ensure the right decisions are made about allocating care coordinators to patients and also to ensure that all patients with a dual diagnosis are allocated a care coordinator. Lead: The Trust Quality and Safety Lead – by 31 April 2021.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 8 · response
    Published 26 October 2020

    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

    Care coordination and assertive outreach concerns relate to services commissioned by the CCG and provided by Lincolnshire Partnership NHS Trust.

    Verbatim wording from the response

    “This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust. If Care coordination is in place it is imperative that the substance misuse services work in partnership with the mental health team to provide a comprehensive individually tailored care package.”

    Source location

    2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
    Page 3 · response
    Published 26 October 2020

    Open published response

  9. Suffolk

    AI-generated summary

    Darren Edward KING · 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

    Darren King died at home after an epileptic seizure while in the bath, with drowning recorded as the medical cause of death. The report identified concerns about inadequate follow-up when a high-risk patient with learning disabilities disengages, the lack of a clear escalation process, and the absence of a structured medication review within the care plan.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a structured medication review within the overall Care Plan Approach

    Wider context from the report

    “3. The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral/escalation routes should they have a concern. ”

    Source location

    Darren Edward KING · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Manchester North

    AI-generated summary

    Mr Nicky Raymond Reilly · Prevention of Future Deaths report

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

    Report summary

    Mr Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal 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 continue the Care Program Approach after transfer to the Prison Service

    Wider context from the report

    “Whilst NR had been an in-patient at Broadmoor he had been subject to the Care Program Approach (CPA). There was no explanation as to why this was not continued when he was transferred back into the Prison Service. The lack of continuation of the CPA and the missed opportunities this presented, particularly in respect of earlier input from Psychiatry, for someone with such complex needs is of concern to the Court. Care plans relating to NR, as discussed below, should have had the benefit of Psychiatric input. ”

    Source location

    Mr Nicky Raymond Reilly · 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

    Healthcare providers or prison mental health services determine whether an individual requires continuation of the Care Programme Approach.

    Verbatim wording from the response

    “Your first concern is that, when Nicky was returned to the prison estate from Broadmoor, the Care Programme Approach (CPA) was not continued. As the CPA is a clinically-led programme to support those with mental health needs, the healthcare provider, or mental health services at a prison, is responsible for determining whether a CPA is required for an individual.”

    Source location

    2019-0014-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 24 May 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026