Recurring concern

Failure to recognise and adequately assess clinically significant psychotic symptoms

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First reported 13 Jun 2016•Latest report 15 Mar 2023

Definition

What this concern includes

Includes failures in mental health assessment, investigation, triage, review or clinical recognition where they concern identifying and adequately assessing clinically significant psychotic symptoms, including failures that lead to inappropriate discounting of psychosis.

Not included

  • Excludes failures concerning treatment, admission, discharge or care planning unless they are directly part of recognising or assessing clinically significant psychotic symptoms.
  • Excludes generic failures to recognise physical symptoms, deterioration or mental health conditions where psychotic symptoms are not the specific concern.
  • Excludes communication, staffing, training or documentation deficiencies unless they are directly tied to recognition or assessment of clinically significant psychotic symptoms.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2016–2023

First to latest report issue date

Stated actions
0

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.

Birmingham and Solihull Mental Health NHS Foundation Trust1
Lancashire & South Cumbria NHS Foundation Trust1
NHS England1
Oxleas NHS Foundation Trust1
The Phoenix Partnership (Leeds) 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. Birmingham and Solihull

    AI-generated summary

    Jai SINGH · 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

    Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.

    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 the significance of reported psychotic symptoms and provide adequate assessment and treatment

    Wider context from the report

    “4. In Mr. Singh's case it is my conclusion that it is likely that if a psychiatrist had been at a mental health MDT meeting held on the 19th January 2022 they would have identified that he needed to be admitted to ward 2 without further delay. At the very least the need for urgent review by a psychiatrist and CPN would have been recognised and facilitated which would in turn have lead to admission. CPNs in Mr. Singh's case continually failed to identify the significance of repeatedly and consistently reported psychotic symptoms and consequently he did not receive adequate assessment and treatment which increased his risk of self harm and suicide which in turn was not sufficiently identified. The absence of a psychiatrist at the MDT creates a risk that the significance of some symptoms and presentations will not be recognised and further deaths could occur due to lack of appropriate assessment and treatment. ”

    Source location

    Jai SINGH · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Inner South London

    AI-generated summary

    Gary Etherington · 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

    Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.

    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

    Inadequate investigation of symptoms before discounting psychosis

    Wider context from the report

    “2. The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation, underestimated his suicidality and not addressed the concerns of the GP who referred him about his management, and to whom his care passed without any psychiatric follow up or support. ”

    Source location

    Gary Etherington · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Preston and West Lancashire

    AI-generated summary

    Andrew Gus PEEBLES · 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

    The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.

    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 RMNs to assess patients with obvious delusional symptoms

    Wider context from the report

    “(3) No assessment by an RMN of a patient suffering obviously delusional symptoms on several occasions ”

    Source location

    Andrew Gus PEEBLES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026