Recurring concern

Unreliable Care Programme Approach care coordination

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First reported 24 Jun 2015•Latest report 12 Jan 2026

Definition

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.

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
21

Distinct published reports

Individual concerns
25

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
27

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service3
NHS England3
Sussex Partnership NHS Foundation Trust3
Central and North West London NHS Foundation Trust2
East London NHS Foundation Trust2
Essex Partnership University NHS Foundation Trust2
Ministry of Justice2
Brunswick Ward at Lindridge1
Department of Health and Social Care1
Derbyshire County Council1
Derbyshire Healthcare NHS Foundation Trust1
Dorset Healthcare University NHS Foundation Trust1
Elmbridge Borough Council1
Greater Manchester Mental Health NHS Foundation Trust1
HCRG Care Services Ltd1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West Yorkshire (West)

    AI-generated summary

    BARNABY LUKE AYLWARD · 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

    Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative 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 of care plan documentation to record behavioural fire risks and planned review

    Wider context from the report

    “(2) The mental health care delivered to Mr Aylward was within a Care Planning Approach. The Care Plan documentation did not identify his above behaviours in writing and thus potential risks, nor indicate review and solutions including with housing provision ”

    Source location

    BARNABY LUKE AYLWARD · 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

    Distribute a staff alert requiring hoarding-related risks and planned interventions to be recorded in care plans.

    Verbatim wording from the response

    “An alert will be distributed to all staff working in the Trust raising awareness that where there is a risk relating to hoarding and associated risks this should be included within the care plan and that interventions should be planned to manage the risk. These should be reviewed on a regular basis or as the risk changes. The alert will be distributed by the end of February 2019.”

    Source location

    2018-0387-Responses
    Page 9 · response
    Published 13 May 2019

    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

    Reinforce inclusion of family and carers in care planning and risk management through training, the information leaflet and staff alert.

    Verbatim wording from the response

    “Learning events have previously been provided by the safeguarding team which includes raising awareness to include carers and family in care planning and risk management, this will continue to be reinforced through our mandatory and core clinical training programmes. This will be reinforced through the publication of the above mentioned information leaflet and alert.”

    Source location

    2018-0387-Responses
    Page 9 · response
    Published 13 May 2019

    Open published response
  2. Birmingham and Solihull

    AI-generated summary

    Michael William Cooper · 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 William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in mental health services.

    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 Care Programme Approach follow-up appointments

    Wider context from the report

    “2. An appointment following referral onto the Care Programme Approach on the 18th April 2018 was outside the two week timeframe specified in the Care Programme Approach Policy. This was due to capacity issues within the team and was not an isolated occurrence. Consequently a patient requiring follow up within 2 weeks may be left unsupported which creates a risk to life. ”

    Source location

    Michael William Cooper · 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

    Work with partners to address recruitment and retention challenges so services are appropriately resourced.

    Verbatim wording from the response

    “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.”

    Source location

    Birmingham-and-Solihull-CCG-Response
    Page 9 · response
    Published 4 October 2018

    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 additional investment to expand commissioned mental-health service capacity and provision.

    Verbatim wording from the response

    “5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).”

    Source location

    Birmingham-and-Solihull-CCG-Response
    Page 5 · response
    Published 4 October 2018

    Open published response
  3. Buckinghamshire

    AI-generated summary

    Lewis Daryl COLGAN · 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

    Lewis Colgan died immediately at Princes Risborough Station on 15 September 2017 after jumping onto the track in front of a northbound passenger train. Concerns included the robustness of supervision of care coordinators and care teams, continuity of mental health care during staff changes and sickness, the process for overdue Care Programme Approach meetings, and the robustness of the investigation and resulting actions.

    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 proactive approach to scheduling CPA meetings

    Wider context from the report

    “(3) There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these. Evidence given during the Inquest from different Trust witnesses appeared to identify a difference of opinion as regards what the policy was for frequency of CPA meetings. A concern exists regarding knowledge of what the current policy is and how it is being applied. ”

    Source location

    Lewis Daryl COLGAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Inner North London

    AI-generated summary

    Janet WILLIAMS · 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

    Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to conduct reviews in accordance with CPA protocol

    Wider context from the report

    “3. Ms Williams was not reviewed in accordance with the protocol for a person on a CPA. A medical review with her consultant psychiatrist scheduled for 12 May 2016 was cancelled by her care co-ordinator. The reason given was that the psychiatrist was unwell, though in fact she was not. ”

    Source location

    Janet WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record CPA care plans in the computer system

    Wider context from the report

    “1. Ms Williams’ care plan approach (CPA) was not recorded on the computer system and so there were no automatic alerts generated when she was not seen for review at the appropriate times. The lack of computer record of her CPA was never noted. ”

    Source location

    Janet WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. London (City)

    AI-generated summary

    SARAH LYNNE REED · 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

    Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

    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 holding Care Programme Approach meetings

    Wider context from the report

    “(12) The jury concluded that the delay in holding a Care Programme Approach (CPA) meeting was unacceptable. The evidence showed that a CPA Meeting for assessing a prisoner’s long-term care should have been held within four weeks from reception. In this case it was held after nine weeks. ”

    Source location

    SARAH LYNNE REED · 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

    Disseminate prison-specific guidance on CPA management requirements to all prison sites for comment.

    Verbatim wording from the response

    “We accept that in this case a CPA meeting should have been arranged sooner. Ms Reed’s mental health and social functioning had deteriorated to the degree that this should have been prioritised. Further, we recognise that a CPA meeting would have allowed more detailed discussion regarding medication management.”

    Source location

    2017-0238-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 1 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Formally ratify the prison-specific CPA management guidance as a new policy by 1 October 2017.

    Verbatim wording from the response

    “As a result of this case CNWL Offender Care has produced prison specific guidance highlighting these requirements which has been disseminated to all prison sites”

    Source location

    2017-0238-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 1 August 2017

    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

    CPA meetings are controlled by healthcare providers, so HMPPS would not necessarily be involved in them.

    Verbatim wording from the response

    “Care Programme Approach (CPA) Meetings Your next concern is about the scheduling of CPA meetings and attendance at them. Whilst you have directed this concern to HMPPS, CPA meetings are controlled by healthcare providers, and whilst we stand ready to assist where appropriate, we would not necessarily expect to be involved in these meetings. I am aware that the CNWL NHS Foundation Trust has responded to you separately on this point.”

    Source location

    2017-0208-Response-by-NOMS
    Page 3 · response
    Published 1 August 2017

    Open published response
  6. Inner North London

    AI-generated summary

    Songul BOZDAG · 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

    Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.

    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 record the need for a care plan approach on the computer system

    Wider context from the report

    “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016. 2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory. 3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error. 4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system. 5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis. These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life. ”

    Source location

    Songul BOZDAG · 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

    Provide monthly supervision for all care coordinators, covering care-plan delivery, reviews, CPA status and record-keeping, with regular compliance audits.

    Verbatim wording from the response

    “The key system for monitoring the ongoing support provided to service users by a care coordinator is monthly supervision. This had not been robustly undertaken within the CMHT and I am pleased to report that this is now working in line with Trust procedures with all care coordinators receiving monthly supervision. Standing agenda items in supervision include CPA status, delivery of the care plan including monitoring of visits and medical reviews and the standard to record keeping. Regular audits are being undertaken to maintain a robust oversight on the process and also actively respond to any gaps in the system in a timely way and to provide assurance that staff are working to agreed record keeping standards and practice.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    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 internal monitoring processes to identify gaps in CPA reviews and regular contact.

    Verbatim wording from the response

    “In addition to the above a review of internal monitoring process has been undertaken to assure the Trust that systems are sufficiently robust and will flag up any cases where service users on CPA are not being seen regularly or reviewed by their consultant. Teams have access to live reports which allows real time activity by the Team and can be drilled down to provide data on an individual service user. The Team administrator also sends out weekly prompts around key performance indicators to the Operational Team Lead and this includes activity for patients on CPA.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    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 teams with live activity reports and weekly performance prompts covering CPA patients.

    Verbatim wording from the response

    “In addition to the above a review of internal monitoring process has been undertaken to assure the Trust that systems are sufficiently robust and will flag up any cases where service users on CPA are not being seen regularly or reviewed by their consultant. Teams have access to live reports which allows real time activity by the Team and can be drilled down to provide data on an individual service user. The Team administrator also sends out weekly prompts around key performance indicators to the Operational Team Lead and this includes activity for patients on CPA.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    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 London Borough of Tower Hamlets is handling formal processes addressing the care coordinator’s conduct, with Trust support.

    Verbatim wording from the response

    “Before setting out the steps that the Trust is taken in relation to improving systems I would like to reassure you that the issues highlighted in relation to the conduct of the care co-ordinator. One of the first actions taken was an audit of the care coordinators case load to ascertain if she was working to agreed record keeping standards and practice. The gaps in the care that she provided to Ms Bozdag are currently being dealt with by her employer, the London Borough of Tower Hamlets, through formal processes with the full support of the Trust and the individual in question is not working with patients whilst these processes are ongoing.”

    Source location

    Response from East London NHS Foundation Trust
    Page 1 · response
    Published 25 September 2017

    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

    Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.

    Verbatim wording from the response

    “With the systems that are now implemented at the CMHT I hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    Open published response
  7. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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 appoint a care coordinator under the Care Programme Approach

    Wider context from the report

    “(14) A Care Co-ordinator was not appointed, even though at the Inquest, it was confirmed that Mr Lee was being looked after on the Care Programme Approach (CPA). The appointment of a Care Co-ordinator is at the heart of this framework and it was clear that such an appointment could have been helpful if not crucial in Mr Lee’s case. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Leicester City and South Leicestershire

    AI-generated summary

    Victoria Georgia Halliday · 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

    Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality 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

    Failure to review patients after 2 admissions within 6 months

    Wider context from the report

    “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified. ”

    Source location

    Victoria Georgia Halliday · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to adhere to the care programme approach

    Wider context from the report

    “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified. ”

    Source location

    Victoria Georgia Halliday · 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

    Develop a Standard Operating Procedure clarifying CPA roles, care-coordinator allocation, transfers, community allocation and required reviews.

    Verbatim wording from the response

    “In order to ensure roles and responsibilities of health and social care professionals involved in the CPA process are clear, understood and adhered to, a Standard Operating Procedure (SOP) is under development. Included in this SOP it will confirm and clarify the process to identify a Care Co-ordinator for patients in in-patient services, and will confirm and clarify the transfer and allocation process for the identification of the Care Co-ordinator in the community team, and associated reviews required.”

    Source location

    Response from Leicestershire Partnership NHS Trust
    Page 3 · response
    Published 20 October 2016

    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

    Complete a formal twice-yearly CPA audit across adult mental health inpatient and community services and develop resulting action plans.

    Verbatim wording from the response

    “A formal bi-annual CPA audit across AMH in-patient and community services has recently been completed and action plans developed. There are specific questions within the audit in relation to the CPA Care Plan, showing a clear description of needs and there being a description of the action to be taken and by whom. The audit completed in 2014 showed good compliance in these areas.”

    Source location

    Response from Leicestershire Partnership NHS Trust
    Page 4 · response
    Published 20 October 2016

    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

    Publish a revised Mental Health Act Code of Practice strengthening patient rights and involvement of families, carers and friends.

    Verbatim wording from the response

    “You have raised concerns about the quality of care planning in Victoria Halliday’s case. We published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code. This included strengthening the rights of patients and better involvement of patients’ family, carers and friend in their care so that they can provide the much needed support for patients to manage their condition and support recovery and independent living in the community.”

    Source location

    2016-0370-Response-by-Department-of-Health
    Page 2 · response
    Published 20 October 2016

    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

    Local mental health commissioners and providers are responsible for taking necessary action when care-planning shortfalls are identified.

    Verbatim wording from the response

    “You have raised concerns about the quality of care planning in Victoria Halliday’s case. We published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code. This included strengthening the rights of patients and better involvement of patients’ family, carers and friend in their care so that they can provide the much needed support for patients to manage their condition and support recovery and independent living in the community.”

    Source location

    2016-0370-Response-by-Department-of-Health
    Page 2 · response
    Published 20 October 2016

    Open published response
  9. Blackburn, Hyndburn and Ribble Valley

    AI-generated summary

    Tracey Lynch · 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

    Tracey Lynch, who had emotionally unstable personality disorder, died by suicide after hanging herself in her room at Oswald House on 9 October 2015. The report identified concerns about the lack of a final discharge meeting, familiarisation visits and appropriate escorted transport, and about the absence of adequate assessments and care planning after her presentation changed and she was transferred between services.

    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 arrange a care programme approach meeting before discharge

    Wider context from the report

    “4. Having been detained by the Police and having then been assessed by Mental Health Practitioners Tracey Lynch was then detained under Section 3 of the Mental Health Act 1983. She was taken from Preston Police Station to The Harbour at Blackpool. She was placed on a different ward and with a different responsible clinician, ████████ Without carrying out any form of assessment whatsoever and with only a cursory glance at previous records ████████ immediately rescinded the Section 3 and without any consideration of the change in circumstance and presentation of Miss Lynch arranged for her immediate discharge to Oswald House. The evidence was that the Consultant Psychologist ████████ who had previously been dealing with Miss Lynch attempted to contact ████████ but her offer of assistance was refused. Having been detained for a second time there was no assessment and no care programme approach meeting arranged. That appeared to be a serious systems failure. ”

    Source location

    Tracey Lynch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Derby and Derbyshire

    AI-generated summary

    Louise Sharon Henry · 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

    Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

    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 ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities

    Wider context from the report

    “1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co-ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co-ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity. ”

    Source location

    Louise Sharon Henry · 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

    Review and clarify the respective roles and responsibilities of mental health and social care workers at the Service Manager Interface Meeting.

    Verbatim wording from the response

    “In order to address these concerns the Council and DCHFT intend to review:-”

    Source location

    2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
    Page 3 · response
    Published 16 January 2015

    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 Care Programme Approach Policy with clearer guidance on the relationship between CPA and Self-Directed Support.

    Verbatim wording from the response

    “2. Preliminary discussions have already taken place between Health and Social Care senior managers about the interface between CPA and SDS. Both organisations are clear that the two policies are intended to be complementary. It is acknowledged there may be cases where the individual is subject to CPA but where a social worker is the lead practitioner. The Council is clear that in following SDS, this will also fulfil the requirements of CPA. A plan involving senior managers from both organisations has been agreed to update the DCHFT Care Programme Approach Policy to provide clearer updated guidance upon this issue.”

    Source location

    2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 January 2015

    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

    Cascade the Service Manager Interface Meeting's role-clarification outcomes to staff through line-management supervision.

    Verbatim wording from the response

    “4. The Council has also established that there is still some work to be done in terms of education for health and social care workers on the expectations of each service pathway. The outcomes of the Service Manager Interface Meeting described above will be cascaded down to staff via line management supervision.”

    Source location

    2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 January 2015

    Open published response
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Data last updated 7 September 2026