Recurring concern

Failure to recognise distress and increased risk communicated through behaviour

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First reported 28 Dec 2014•Latest report 4 May 2024

Definition

What this concern includes

Includes failures to interpret behaviour as a possible communication of distress, unmet need or increased risk, including normalising persistently unusual behaviour, misclassifying distress-related behaviour as obstruction or misconduct, and failing to trigger further assessment or protective action when behaviour changes or remains unusual.

Not included

  • Excludes generic mental-health recognition, professional-curiosity or behavioural-management deficiencies where the report does not identify behaviour as communicating distress, unmet need or increased risk.
  • Excludes failures to treat or support a person after behaviour-related distress or risk has been reliably recognised.
  • Excludes ordinary disagreement about the interpretation of behaviour where relevant distress and risk were appropriately considered.
  • Excludes physical illness or intoxication recognition concerns unless the reported behaviour is specifically the means by which distress or increased safety risk was communicated.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
5

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.

Cookham Wood Prison1
G4S1
G4S Forensic & Medical Services (UK) Ltd1
HM Prison and Probation Service1
HM Prison Service1
London Borough of Tower Hamlets1
Medway Youth Offending Team1
Ministry of Justice1
Norfolk and Suffolk NHS Foundation Trust1
Oxleas NHS Foundation Trust1
Tees, Esk and Wear Valleys NHS Foundation Trust1

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. Suffolk

    AI-generated summary

    Paul David TEMPLETON · Prevention of Future Deaths report

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

    Report summary

    Paul David Templeton died at Ipswich Hospital on 20 April 2023 following termination of life support after asphyxiation. The Jury found that prolonged refusal to eat or drink while detained under the Mental Health Act should have been recognised as action to end his life and as elevating his suicide risk, including by other means. The report raises concern that the response from Norfolk & Suffolk NHS Foundation Trust did not adequately address these failures in suicide risk assessment.

    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 recognise prolonged refusal to eat or drink as action to end life

    Wider context from the report

    “In the words of the Jury: “Initial and all subsequent assessments seriously fail to recognise that Paul’s prolonged choice not to eat or drink were in fact indications of ‘action’ to end his own life and therefore he should have been considered as a suicide risk.” Action is needed to prevent future failure to recognise (a) when the prolonged choice of a patient detained under the Mental Health Act not to eat or drink should be regarded as an action to end their own life; and (b) when such a patient’s prolonged choice not to eat or drink should be recognised as elevating that patient’s suicide risk (including of suicide by means other than malnourishment). ”

    Source location

    Paul David TEMPLETON · 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

    Hold a reflective multidisciplinary away day using food-and-drink case studies to strengthen holistic clinical risk assessment.

    Verbatim wording from the response

    “In response to your concerns (a) & (b) we have acted to secure assurance that assessors working within Willows ward have the skills and awareness required to undertake comprehensive holistic risk assessments, including an understanding and awareness of the significance of food and drink in mental health risk assessment. A reflective Multi-Disciplinary Team (MDT) Away Day was held on 15th and 17th May 2024. During this, the team explored the application of clinical risk assessment skills to a range of different cases. This was undertaken to support the transition of knowledge into clinical practice and provide assurance of consistency between staff members. The case studies included scenarios related to food and drink to raise staff awareness. To maintain a good standard of clinical practice this will be discussed in clinical supervision and reviewed within future team meetings.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 1 · response
    Published 15 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Discuss food-and-drink risk assessment in clinical supervision and review it in future team meetings.

    Verbatim wording from the response

    “In response to your concerns (a) & (b) we have acted to secure assurance that assessors working within Willows ward have the skills and awareness required to undertake comprehensive holistic risk assessments, including an understanding and awareness of the significance of food and drink in mental health risk assessment. A reflective Multi-Disciplinary Team (MDT) Away Day was held on 15th and 17th May 2024. During this, the team explored the application of clinical risk assessment skills to a range of different cases. This was undertaken to support the transition of knowledge into clinical practice and provide assurance of consistency between staff members. The case studies included scenarios related to food and drink to raise staff awareness. To maintain a good standard of clinical practice this will be discussed in clinical supervision and reviewed within future team meetings.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 1 · response
    Published 15 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use daily team huddles to prompt consideration of eating and drinking in holistic clinical risk assessments.

    Verbatim wording from the response

    “To ensure focus on appropriate clinical risk assessment, the Team are using Daily Team huddles to prompt assessors to consider holistic care / including eating and drinking within their clinical risk assessments. To support this, we have also made changes to the SBAR (Situation Background Assessment Recommendation) record that the team use to communicate and share patient information at handover. The revised SBAR provides more information about eating and drinking (identifying quantity not just appetite) to inform clinical risk assessment.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 1 · response
    Published 15 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise SBAR handover records to capture eating-and-drinking quantity, not only appetite, for clinical risk assessment.

    Verbatim wording from the response

    “To ensure focus on appropriate clinical risk assessment, the Team are using Daily Team huddles to prompt assessors to consider holistic care / including eating and drinking within their clinical risk assessments. To support this, we have also made changes to the SBAR (Situation Background Assessment Recommendation) record that the team use to communicate and share patient information at handover. The revised SBAR provides more information about eating and drinking (identifying quantity not just appetite) to inform clinical risk assessment.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 1 · response
    Published 15 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and deliver bespoke training linking suicide prevention with malnourishment, with subject-matter expert support.

    Verbatim wording from the response

    “The challenge for the Trust is to secure a training package which sufficiently addresses both clinical risk assessment and food and nutrition. The national approved training, required as mandatory by the Trust, does not reference suicide through malnourishment. The Trust’s 3PS (Presenting, predisposing, precipitating, perpetuating & protective factor training) programme highlights the importance of good nourishment but does not link this to suicide. We recognise that to deliver content linking suicide prevention training with content referencing malnourishment we will need to develop and deliver a bespoke package of training supported by subject matter experts. We are in the process of discussing this with our Physical Health team and raising this with NHS England and the Royal College of Psychiatrists for their broader consideration.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 2 · response
    Published 15 April 2024

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    Margaret Atkinson · 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

    Margaret Atkinson, who had a long history of mental health illness and was in prison healthcare, was found unresponsive in her cell on 24 January 2016 after staff observed clothing around her neck and delayed entering the cell; she died in hospital on 2 February 2016. The jury found that staff should have entered earlier, and the report identified difficulties in describing such situations and assessing risk when unusual behaviour had become accepted as normal.

    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 recognise increased risk from persistently unusual behaviour

    Wider context from the report

    “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk. Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare. ”

    Source location

    Margaret Atkinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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 recognise distress communicated through behaviour

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · Prevention of Future Deaths report
    Page 3 · 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 ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.

    Verbatim wording from the response

    “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

    Source location

    2014-0555-Response-by-Ministry-of-Justice
    Page 5 · response
    Published 28 December 2014

    Open published response
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Data last updated 7 September 2026