Recurring concern

Unreliable assessment of patients’ mental state

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First reported 30 Apr 2014•Latest report 17 Mar 2026

Definition

What this concern includes

Includes failures of the mental-state assessment process, including delayed or missed assessment, failure to undertake an appropriate mental state examination, and materially inconsistent or inadequate assessment of mental state.

Not included

Excludes general mental health risk assessments unless the asserted deficiency specifically concerns assessment of the patient’s mental state.
Excludes failures of treatment, referral, admission, discharge or escalation where mental-state assessment is not itself the unsafe condition.
Excludes generic staffing, training, documentation or communication deficiencies unless they directly impair the mental-state assessment process.
Excludes assessments of physical condition or unrelated clinical states.

Reports: 24
Individual concerns: 25
Date range: 2014–2026
Stated actions: 36

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.

Department of Health and Social Care6

NHS England3

East London NHS Foundation Trust2

Essex Partnership University NHS Foundation Trust2

Greater Manchester Police2

HM Prison and Probation Service2

North London NHS Foundation Trust2

Birmingham and Solihull Mental Health NHS Foundation Trust1

Black Country Healthcare NHS Foundation Trust1

BTCM Limited1

Care Quality Commission1

Central and North West London NHS Foundation Trust1

Cheshire and Wirral Partnership NHS Foundation Trust1

Cornwall Council1

Crown Prosecution Service1

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.

16 Apr2015
Manchester South
Concerns raised1
1. Failure to provide differentiated mental health assessments for children in custody
This report raised 27 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

Kesia Lena Mary Leatherbarrow · 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

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

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 differentiated mental health assessments for children in custody
Wider context from the report
“The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults. ”
Source location
Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Page 7 · concerns
Open source report
28 Jan2015
Surrey
Concerns raised2
1. Failure to record the outcome of mental state assessments after inpatient leave
2. Lack of a system ensuring sufficient mental state assessment of patients returning from inpatient leave
This report raised 1 other concern. 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

Katherine Liana Bonaventura · 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

Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment 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 record the outcome of mental state assessments after inpatient leave
Wider context from the report
“It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.” It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area. It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return. It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit. ”
Source location
Katherine Liana Bonaventura · 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
Lack of a system ensuring sufficient mental state assessment of patients returning from inpatient leave
Wider context from the report
“It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.” It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area. It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return. It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit. ”
Source location
Katherine Liana Bonaventura · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Aug2014
County Durham and Darlington
Concerns raised1
1. Failure to sufficiently enquire into mental state and risk when hearing voices are reported
This report raised 7 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 2
1. Action
  Complete supervised observation, evaluation and competency development for telephone assessment practice.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
2. Action
  Share recommendations with the crisis team and reinforce consultation with colleagues and medical staff for complex assessments.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
AI-generated summary

Jeffrey Gash · 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

Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.

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 sufficiently enquire into mental state and risk when hearing voices are reported
Wider context from the report
“4. Given that there was an insufficiency of enquiry into the deceased’s state of mind and in particular, a failure to further explore the issue of him claiming to hear voices, on inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had not agreed to it voluntarily, then there ought to have been a compulsory assessment. ”
Source location
Jeffrey Gash · 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
Complete supervised observation, evaluation and competency development for telephone assessment practice.

Verbatim wording from the response
“As you have described, the individual nurse involved in the care of Mr Gash recognised in the inquest that she should have been more detailed in her questioning of him in relation to specific symptoms. This individual has, since the inquest, spent some time reflecting on this with her clinical supervisor. In addition, from September 2013 to January 2014 the individual nurse went through a period of informal capability management. During this time she did not undertake the shift co-ordinator role responsibilities and worked all shifts alongside a more senior and experienced member of the team. She observed best practice assessments and her assessment practice was observed and”

Source location
2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
Page 1 · response
Published 18 August 2014
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 recommendations with the crisis team and reinforce consultation with colleagues and medical staff for complex assessments.

Verbatim wording from the response
“Since Mr Gash's sad death, the individual nurse has critically reflected upon this at length with the team manager during her period of informal capability management described under point 1 above. I agree that more in-depth exploration of his reasons for not wishing to attend should have been undertaken. The Trust Did Not Attend policy does highlight that the nurse should have contacted the GP immediately to agree a management plan, in situations where high risks have potentially been identified. As noted above, the individual nurse has undergone a period of observed practice such that the Advanced Practitioner and Team Manager are now satisfied that she would now manage this situation differently, in that issues would be explored in more depth.”

Source location
2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
Page 3 · response
Published 18 August 2014
Open published response
30 Apr2014
West Yorkshire (East)
Concerns raised1
1. Failure to provide prompt assessment, diagnosis and treatment of mental illness
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.

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

Mary WANYA · Prevention of Future Deaths report

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

Report summary

Mary Wanya died after falling through a hospital window on 1 November 2011 while in an acutely confused and agitated state. The window restrictor was defective, allowing the window to be fully opened. Concerns included delays in psychiatric assessment, the assessment and treatment of mental illness on the Medical Admissions Unit, her earlier diagnosis and discharge, and the inadequacy of the Trust’s investigation report.

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 prompt assessment, diagnosis and treatment of mental illness
Wider context from the report
“1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James’s University Hospital to assess Mary Wanya. In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment. (ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service. (iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay. (iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided. (v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill. The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness. ”
Source location
Mary WANYA · 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 raised1

Failure to provide differentiated mental health assessments for children in custody

Concerns raised2

Failure to record the outcome of mental state assessments after inpatient leave

Lack of a system ensuring sufficient mental state assessment of patients returning from inpatient leave

Concerns raised1

Failure to sufficiently enquire into mental state and risk when hearing voices are reported

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.2

Concerns raised1

Failure to provide prompt assessment, diagnosis and treatment of mental illness

Actions described in response 2