Recurring concern

Unreliable therapeutic engagement in mental health care

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First reported 7 Aug 2014•Latest report 24 Oct 2025

Definition

What this concern includes

Includes failures of therapeutic engagement in mental-health care, including absence or superficial provision of meaningful interaction, inadequate staff understanding or skills, failure to identify and address barriers to engagement, failure to adapt therapeutic approaches, and failure to reattempt or arrange appropriate alternative engagement when the initial approach is ineffective.

Not included

Excludes generic communication, staffing, training or therapeutic-capacity deficiencies unless they directly impair therapeutic engagement with mental-health patients.
Excludes failures limited to access to a therapy, therapeutic pathway or specialist treatment service where therapeutic engagement itself is not deficient.
Excludes family, carer, pastoral or social engagement concerns unless they are explicitly part of therapeutic engagement with the mental-health patient.
Excludes failures limited to one-to-one care, observation or meaningful activity where therapeutic engagement is not the identified unsafe condition.
Excludes clinical treatment, accommodation or discharge failures that do not directly concern the provision or adaptation of therapeutic engagement.

Reports: 7
Individual concerns: 8
Date range: 2014–2025
Stated actions: 12

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

North London NHS Foundation Trust2

Care Quality Commission1

Clarendon Nursing Home1

Consultant Psychiatrist, Keats House Consulting Rooms1

Department of Health and Social Care1

Essex Partnership University NHS Foundation Trust1

London Borough of Croydon1

NHS England1

Nightingale Hospital1

Nottinghamshire Healthcare NHS Foundation Trust1

Ofcom1

Sussex Partnership NHS Foundation Trust1

The Foundry1

Thornton Heath Medical Practice1

University Hospitals Sussex 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.

24 Oct2025
Essex
Concerns raised2
1. Failure to record therapeutic engagement and interaction during observations
2. Deficit in training for staff undertaking therapeutic engagement and supportive observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Shift observation practice toward therapeutic engagement through updated guidance and training.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Deliver focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
1. Action
  Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Pursue making the electronic engagement field mandatory for level 2, 3 and 4 observations.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
3. Action
  Re-undertake Observation and Engagement competencies for the staff member requiring renewed training.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
4. Action
  Continue reviewing and evolving training and staff-support programmes with relevant experts and learning.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
5. Action
  Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Stephen John Neville · 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

Stephen John Neville, aged 68, was an informal inpatient at Beech Ward for planned ECT after a history of severe treatment-resistant depression, anxiety, agitation, and repeated suicide attempts. He died by hanging while in hospital. The report identified concerns including failures in risk communication and assessment, abrupt medication changes, inadequate therapeutic observations and engagement, insufficient auditing and quality assurance, and failure to mitigate risks associated with an unlocked shower room.

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 therapeutic engagement and interaction during observations
Wider context from the report
“1. There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations. Members of support staff demonstrably misunderstood (and appear to still misunderstand) the nature and purpose of Level 2 ‘intermittent’ (4 to 5 times) hourly observations, apparently routinely conducting such observations every 15 minutes on the hour, the quarter past and so on. Whilst the observations, when made, recorded the location of the patient and (very occasionally) noted what the patient may be doing, nothing was recorded in respect of an interaction or therapeutic engagement, as required by Trust policy. Such a lack of understanding of the basic role of the support worker and/or nursing staff in undertaking such critically important roles disclosed an (on-going) deficit in training. 2. Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT. A purported weekly quality assurance check being undertaken by the Ward Manager in December 2021, which claimed “an audit score of 100%”, was entirely at odds with the evidence at inquest which revealed repeated and significant inadequacies in the nature and quality of the observations undertaken and recorded. 3. Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: “I have no audit tool …. I am not confident that the audits are accurate and complete now … there is no audit process in place to check the quality of observation and engagement documentation.” 4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” 5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
Source location
Stephen John Neville · Prevention of Future Deaths report
Page 3 · 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
Deficit in training for staff undertaking therapeutic engagement and supportive observations
Wider context from the report
“1. There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations. Members of support staff demonstrably misunderstood (and appear to still misunderstand) the nature and purpose of Level 2 ‘intermittent’ (4 to 5 times) hourly observations, apparently routinely conducting such observations every 15 minutes on the hour, the quarter past and so on. Whilst the observations, when made, recorded the location of the patient and (very occasionally) noted what the patient may be doing, nothing was recorded in respect of an interaction or therapeutic engagement, as required by Trust policy. Such a lack of understanding of the basic role of the support worker and/or nursing staff in undertaking such critically important roles disclosed an (on-going) deficit in training. 2. Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT. A purported weekly quality assurance check being undertaken by the Ward Manager in December 2021, which claimed “an audit score of 100%”, was entirely at odds with the evidence at inquest which revealed repeated and significant inadequacies in the nature and quality of the observations undertaken and recorded. 3. Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: “I have no audit tool …. I am not confident that the audits are accurate and complete now … there is no audit process in place to check the quality of observation and engagement documentation.” 4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” 5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
Source location
Stephen John Neville · 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
Shift observation practice toward therapeutic engagement through updated guidance and training.

Verbatim wording from the response
“Response: In line with the details set out in the Trust’s learning statement filed with the Court, with respect to the Trust’s approach to Observation and Engagement, the Trust continues to shift focus to Therapeutic engagement rather than observation alone. This aligns with the national working group the Trust participated in across 2024 and led to the development of the Mental Health / Learning Disability Nurse Director guidance document.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 1 · response
Published 5 November 2025
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
Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.

Verbatim wording from the response
“The Ward Manager has also undertaken a check of all staff Observation and Engagement competencies to ensure confidence in current staff practice. As part of this process the Ward Manager checked that all staff have completed Oxevision E-Observation training, which includes training on documenting o-benservations to ensure therapeutic engagement is captured. This ensures a focus on the quality of the therapeutic engagement and observation.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Deliver focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.

Verbatim wording from the response
“To further enhance Trust routine online training, the Ward Manager is providing a number of focused face to face training sessions with ward staff to further gain assurance around interpretation and understanding. This will include highlighting the importance of recording therapeutic engagement and space for reflection on learning. This is due to be completed by the end of December 2025.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.

Verbatim wording from the response
“As part of the Trustwide learning response, the learning from this inquest has been shared through the care unit quality and safety meeting to ensure shared learning across the wider care unit. This has also been shared with the Training team with a specific focus on Oxevision e-observation training to ensure this training robustly guides staff on engagement techniques and importance of the quality of recording of the engagement. This training was reviewed in February 2025 following the Trust’s recent review of the Oxevision SOP.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Pursue making the electronic engagement field mandatory for level 2, 3 and 4 observations.

Verbatim wording from the response
“Finally, it is noted that the e-observations box on the electronic form is the same box wherein engagement would also be documented and is not a mandatory field. A request has been made to Oxehealth asking for this to be mandated box for all observations levels 2, 3 and 4. Oxehealth have confirmed this is achievable and this change is in progress.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Re-undertake Observation and Engagement competencies for the staff member requiring renewed training.

Verbatim wording from the response
“At this Inquest it was evident that one Health Care Assistant (HCA) did not understand the requirements of level 2 observation in relation to the random nature of level 2 observations. It is of that that they had been absent from work for a period of 9 months before the inquest. The Ward Manager is working with this staff member to re-undertake Observation and Engagement Competencies.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Continue reviewing and evolving training and staff-support programmes with relevant experts and learning.

Verbatim wording from the response
“The trust recognises it is important that it continually reviews and evolves all training and staff support programmes and this is undertaken by the Training Team with relevant experts, taking into account new guidance and learning.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.

Verbatim wording from the response
“Building on this review, further enhancements were introduced following inquest-related reflections. In November 2025, three new Oxevision audits were implemented to strengthen oversight of observation and therapeutic engagement, incorporating both staff and patient feedback:”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 3 · response
Published 5 November 2025
Open published response
23 Jun2025
Inner North London
Concerns raised1
1. Lack of staff understanding of therapeutic engagement in mental health care
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Recruit 24 additional Registered Nurses and implement a three-nurse, two-support-worker day-shift staffing ratio across acute inpatient wards.
  Stated by North London NHS Foundation TrustStated planned
2. Action
  Implement the Perfect Day model with standardized ward timetables, daily electronic handover templates and documentation of multidisciplinary and observation decisions.
  Stated by North London NHS Foundation TrustStated completed
3. Action
  Progress ward Culture of Care recommendations arising from multidisciplinary away days and senior leadership review.
  Stated by North London NHS Foundation TrustStated in progress
1. Action
  Progress Topaz ward’s quality-improvement programme on therapeutic engagement through the division-wide improvement programme.
  Stated by North London NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Staff understand therapeutic engagement and professional curiosity, although staffing, time and documentation barriers have affected implementation.
  Stated by North London NHS Foundation TrustDisputes the concern
AI-generated summary

Louise Elizabeth Amy Crane · 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 Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action 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 staff understanding of therapeutic engagement in mental health care
Wider context from the report
“2) Lack of Professional Curiosity / Therapeutic Engagement – Audits This was a matter picked up during the Trust’s own investigation. The Trust’s action plan includes audits to monitor compliance with certain aspects of Trust policy etc. However, the Topaz Ward manager gave evidence that there had been issues with audits in the past, which had been escalated (prior to Ms Crane’s death) but no response received. I was not reassured that further audits would be sufficient to address the concerns already identified. In addition to the above, numerous members of staff from Topaz Ward gave evidence during the inquest and it appeared that many of them struggled with the concept of ‘therapeutic engagement’. Some maintained that Ms Crane had received a sufficient level of therapeutic engagement from Ward staff, contrary to the findings of the Trust’s own investigation and the subsequent findings of the jury. This suggests a potentially widespread lack of understanding, and underlying knowledge of ‘therapeutic engagement’ and its importance in mental health care. ”
Source location
Louise Elizabeth Amy Crane · 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
Recruit 24 additional Registered Nurses and implement a three-nurse, two-support-worker day-shift staffing ratio across acute inpatient wards.

Verbatim wording from the response
“1) A Safe Staffing skill mix review was completed by the Nursing Directorate and approved by the Executive Management Committee to upgrade the staffing model of all acute inpatient wards within the Hospital Division. This means that an additional 24 Registered Nurses will be recruited by October 2025 to initiate the new staffing ratio of 3 Nurses and 2 Health care support workers on day shift (previously 2 nurses and 3 Health care support workers). The increased number of qualified clinical staff will support with dedicated quality time to engage in therapeutic engagement time on the wards. We have also reviewed the input from other allied health professionals (Occupational Therapists, Activity Coordinators and ward Psychologists) to improve engagement via a range of professionals on the inpatient wards.”

Source location
Response from North London NHS Foundation Trust
Page 5 · response
Published 14 July 2025
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
Implement the Perfect Day model with standardized ward timetables, daily electronic handover templates and documentation of multidisciplinary and observation decisions.

Verbatim wording from the response
“4) It is also acknowledged that some of the therapeutic engagement with patients/actions which would evidence professional curiosity were not being captured within our clinical documentation. To support improvement, the Division has rolled out the ‘Perfect Day’ model which essentially standardises the inpatient ward day timetable across all our wards. The Perfect Day model provides a timetable for the day which is predictable and understandable by all staff, patients and visitors. It also provides a standardised digital template for handovers that is completed daily and uploaded to the electronic patient record (EPR) system every day before 11am evidencing key information such as risk, barriers to discharge etc.”

Source location
Response from North London NHS Foundation Trust
Page 6 · response
Published 14 July 2025
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
Progress ward Culture of Care recommendations arising from multidisciplinary away days and senior leadership review.

Verbatim wording from the response
“Between November 2024 and January 2025 the Trust delivered 15 full away days for the wards on the Highgate campus. These away days used the new NHS ‘Culture of Care’¹ standards as their focus and included all the ward multidisciplinary teams and senior management. Discussions around the importance of therapeutic engagement and professional curiosity were central to these sessions, focusing on identifying barriers and implementing strategies for improvement. They were facilitated by Organisational Development colleagues who compiled reports on the learning from the away days about the different cultures on our wards and reported back to the senior leadership group to support each individual ward with developing their approach to patient care. A set of overarching recommendations was also made and these are currently being progressed as part of the ongoing programme of work.”

Source location
Response from North London NHS Foundation Trust
Page 8 · response
Published 14 July 2025
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
Progress Topaz ward’s quality-improvement programme on therapeutic engagement through the division-wide improvement programme.

Verbatim wording from the response
“In addition, Topaz ward specifically engaged in an additional Quality Improvement programme of working on ‘Improving Therapeutic Engagement on the ward’. Although this is still in its initial stages, it will be progressed with the wider programme of work being undertaken by the division.”

Source location
Response from North London NHS Foundation Trust
Page 8 · response
Published 14 July 2025
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
Staff understand therapeutic engagement and professional curiosity, although staffing, time and documentation barriers have affected implementation.

Verbatim wording from the response
“Following the inquest, the staff team on Topaz ward have been supported to further reflect on the care provided to Ms Crane, in particular in regard to the findings around lack of professional curiosity and therapeutic engagement. We are satisfied that there is understanding amongst staff about what this is, but it is recognised that there have been barriers to implementing it effectively. Factors involved include staffing levels and skill mix, lack of time due to number of tasks staff are responsible for and standards of clinical documentation. One of the overarching aims of the ongoing improvements is to support staff so that they have time to ensure that every individual’s clinical needs are met. As part of the on-going mandated support program, the Division has initiated several actions to address this:”

Source location
Response from North London NHS Foundation Trust
Page 5 · response
Published 14 July 2025
Open published response
29 Feb2024
Nottinghamshire
Concerns raised1
1. Insufficient staff skills and knowledge for encouraging engagement with patients
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Daniel Mark Edward TUCKER · 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

Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.

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
Insufficient staff skills and knowledge for encouraging engagement with patients
Wider context from the report
“3. Inadequate skills/knowledge/training on how to encourage patients to engage I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment. A psychiatrist not involved in Dan’s care gave evidence about the advice he would have given to colleagues on how to seek to assist a patient who, like Dan, was unwilling or unable to engage with staff: first, identify the likely reasons for the patient’s lack of engagement; second, having regard to those reasons, develop plans and strategies to address the specific barriers identified. I heard little evidence that either of these steps was followed by any of the staff involved in Dan’s care. One barrier was identified (his previous negative experiences on the ward and wish to be transferred to another ward or hospital) but seemingly forgotten after an initial transfer request to the Bed Management team, which was not then followed up. Even with the benefit of hindsight, the doctors, nurses and healthcare assistants involved in Dan’s care seemed unable to offer any insight into the reasons for his difficulties engaging beyond his diagnosis of EUPD or articulate any strategies or techniques that might have helped him overcome them. ”
Source location
Daniel Mark Edward TUCKER · Prevention of Future Deaths report
Page 3 · concerns
Open source report
28 Feb2019
South London
Concerns raised1
1. Failure to provide therapeutic engagement
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Yong Keng Hong · 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

Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide therapeutic engagement
Wider context from the report
“(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
Source location
Yong Keng Hong · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Aug2016
Inner North London
Concerns raised1
1. Failure to address inpatients’ inability to engage with offered therapy
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Forcing patients to participate in therapy as a condition of hospital admission would conflict with the Mental Capacity Act.
  Stated by Florence Nightingale Hospitals Ltd.Unable to act
AI-generated summary

John Richard William JONES · Prevention of Future Deaths report

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

Report summary

John Jones, aged 48, died instantaneously after jumping in front of a moving train at West Hampstead Railway Station on 18 April 2016. During his month-long admission to the Nightingale Hospital, he largely remained alone in his room and did not engage with the available group therapy. The principal concern was that the hospital environment appeared suboptimal for addressing his difficulty accepting help and providing effective treatment.

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 address inpatients’ inability to engage with offered therapy
Wider context from the report
“I heard at inquest that, during his month long residence at the Nightingale, Mr Jones declined to engage with any of the 35 hours per week of group therapy on offer. He did see his consultant psychiatrist for a one to one session three times a week, and he went for a short walk with his parents most days. However, for the majority of his time in hospital, this extremely bright and able but very unwell man, simply stayed in his room alone. He engaged with nurses who popped in to see him on a polite but only ever superficial level. Sometimes he used his computer, but he did not even come out for meals with the other patients. He had a good appetite, but asked for meals to be brought to his room, which they were. This seems a very sub optimal therapeutic environment, most particularly as Mr Jones’s psychiatrist said that the reason for admitting him to hospital was to enable him to access the therapy on offer. I appreciate that Mr Jones himself declined the therapy, but the difficulty he had in accepting help was surely part and parcel of the reason for this episode of mental ill health, and had to be addressed. Whether a patient’s engagement is made a condition of stay at the hospital, whether it is secured by offering a different form of therapy e.g. on a one to one basis, or whether there is some other way of ensuring better treatment, is of course a matter for you. ”
Source location
John Richard William JONES · 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
Forcing patients to participate in therapy as a condition of hospital admission would conflict with the Mental Capacity Act.

Verbatim wording from the response
“It is acknowledged you concluded that Mr Jones experienced a sub-optimal therapeutic environment by virtue of his unwillingness to participate or engage in the formal therapy programmes that were on offer. However, it is further evidenced that to insist and/or force such engagement as a condition of remaining in hospital would run counter to the guiding principles of the Mental Capacity Act (2005). It is however accepted that this lack of engagement gave the impression that the hospital provided only a superficial level of service which amounted to a sub-optimal therapeutic experience. That is not to say that the regular, thorough consultations between consultant, patient, input from nurses and on occasion family sought to determine a plan of care which was agreed by all, and consented to by the patient throughout his treatment.”

Source location
2016-0300-Response-by-Nightingale-Hospital
Page 1 · response
Published 19 August 2016
Open published response
21 Apr2015
Brighton and Hove
Concerns raised1
1. Failure to conduct observations and therapeutic engagement in accordance with policy
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Bruce LONGDEN · 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

Bruce LONGDEN’s death was investigated by an inquest, but the circumstances of the death are referred to separately in the Record of Inquest. The substantive concerns included failures to follow Sussex Partnership Trust protocols, poor communication between trusts, inadequate understanding of his mental health condition and terminology, and delayed reporting of his absconsion to Sussex Police.

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 observations and therapeutic engagement in accordance with policy
Wider context from the report
“(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :- a) Transfer of Sussex Partnership Trust patients to the acute hospital and b) Observations and Therapeutic Engagement policy These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond. 2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust 3)Poor communication within Brighton & Sussex University Hospital Trust particularly: • Failure to appreciate the significance of Mr Bruce Longden’s mental health condition • Failure to understand the terminology used by the mental health liaison team • Failure of the Mental Health Team to adhere to commonly understood terminology • Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost ”
Source location
Bruce LONGDEN · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Aug2014
Inner North London
Concerns raised1
1. Failure to explore therapeutic input from an alternative healthcare professional
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Noleen Mary McPHARLANE · 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

Noleen Mary McPHARLANE had longstanding contact with mental health services and a history of overdoses and self-inflicted wounds. She died after ingesting an excess of a drug purchased on the internet, although her intentions were unclear. Concerns included that her suicide thoughts and continued illicit amitriptyline use were not directly explored, and that there was no consideration of input from an alternative healthcare professional despite limited therapeutic engagement.

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 explore therapeutic input from an alternative healthcare professional
Wider context from the report
“3. The clinical specialist, ████████, by profession a mental health nurse, saw Noleen McPharlane once a fortnight. The sessions were scheduled to last 50 minutes, but frequently only lasted 20 or 30 minutes. He told me that this was because she did not initiate conversation and responded to questions only briefly. He did not feel he had a good rapport with her. No other health professional from Highgate Hospital saw her. ████████ did speak to his manager, another clinical specialist (by profession a social worker) about Ms McPharlane, and twice over the year to a psychiatrist. However, there was never any exploration of the possible therapeutic benefit of direct input from an alternative healthcare professional. ████████ now thinks that would have been appropriate. ”
Source location
Noleen Mary McPHARLANE · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to record therapeutic engagement and interaction during observations

Deficit in training for staff undertaking therapeutic engagement and supportive observations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Concerns raised1

Lack of staff understanding of therapeutic engagement in mental health care

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

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

Concerns raised1

Insufficient staff skills and knowledge for encouraging engagement with patients

Concerns raised1

Failure to provide therapeutic engagement

Concerns raised1

Failure to address inpatients’ inability to engage with offered therapy

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

Concerns raised1

Failure to conduct observations and therapeutic engagement in accordance with policy

Concerns raised1

Failure to explore therapeutic input from an alternative healthcare professional

Actions described in response 8

Actions described in response 4

Respondent positions 1

Respondent positions 1