8 Apr 2026 Jonathan Mark Thornton · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service Ministry of Justice Northamptonshire Healthcare NHS Foundation Trust Nottingham Prison Nottinghamshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Northamptonshire Healthcare NHS Foundation Trust
Establish regular information-sharing through daily briefings, SIM meetings, drug-strategy discussions, and communication across prison operational and healthcare teams.
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Nottinghamshire Healthcare NHS Foundation Trust
Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
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Nottinghamshire Healthcare NHS Foundation Trust
Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
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Nottinghamshire Healthcare NHS Foundation Trust
Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
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Nottinghamshire Healthcare NHS Foundation Trust
Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
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Nottinghamshire Healthcare NHS Foundation Trust
Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
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Nottinghamshire Healthcare NHS Foundation Trust
Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
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Nottinghamshire Healthcare NHS Foundation Trust
Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
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HM Prison and Probation Service and Ministry of Justice and Nottingham Prison
Issue and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.
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HM Prison and Probation Service and Ministry of Justice and Nottingham Prison
Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.
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HM Prison and Probation Service and Ministry of Justice and Nottingham Prison
Ensure findings from the NOMIS/DPS alerts review inform future enhancements addressing the identified concerns.
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AI-generated summary
Jonathan Mark Thornton · 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
Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future deaths.
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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 formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners . It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this . I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Source location Jonathan Mark Thornton · Prevention of Future Deaths report
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How this respondent action was interpreted
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PFD Monitor interpretation Establish regular information-sharing through daily briefings, SIM meetings, drug-strategy discussions, and communication across prison operational and healthcare teams.
Verbatim wording from the response “Since taking over responsibility for healthcare services at HMP Nottingham on 19 November 2025, we have put in place regular and consistent ways of sharing information within the prison. This includes routine contact through daily morning briefings, SIM meetings, drug strategy discussions, and ongoing conversations with colleagues in reception, healthcare, and across the house blocks.” Source location Response from Northampton Healthcare NHS Foundation Trust
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PFD Monitor interpretation Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
Verbatim wording from the response “1. Introduction of a Formal Information-Sharing Guidance Document (December 2025)” Source location Response from Nottingham Healthcare NHS Foundation Trust
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PFD Monitor interpretation Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
Verbatim wording from the response “3. Guidance Shared with all CFT Staff” Source location Response from Nottingham Healthcare NHS Foundation Trust
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PFD Monitor interpretation Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
Verbatim wording from the response “2. Embedding the Guidance Through Training and Supervision” Source location Response from Nottingham Healthcare NHS Foundation Trust
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PFD Monitor interpretation Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
Verbatim wording from the response “1. Appointment of a Dedicated CFT Link Worker” Source location Response from Nottingham Healthcare NHS Foundation Trust
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PFD Monitor interpretation Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
Verbatim wording from the response “The Link Worker will also arrange and chair a bimonthly interface meeting with Prison Healthcare teams at HMP Nottingham. These meetings will:” Source location Response from Nottingham Healthcare NHS Foundation Trust
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PFD Monitor interpretation Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
Verbatim wording from the response “3. Joint Working with Prison Healthcare Providers” Source location Response from Nottingham Healthcare NHS Foundation Trust
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PFD Monitor interpretation Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
Verbatim wording from the response “4. Quarterly Audit and Reporting” Source location Response from Nottingham Healthcare NHS Foundation Trust
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PFD Monitor interpretation Issue and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.
Verbatim wording from the response “A national Information Sharing Advisory Group (ISAG) is in place, which aims to improve information sharing between health and prisons. In order to improve practice, HMPPS Health and Care Information Sharing guidance was issued to prisons in July 2022 in two formats (A5 booklet and wallet size) and is available on the HMPPS intranet. The guidance aims to improve and achieve a more consistent approach to the sharing of information between all” Source location Response from HMPPS
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PFD Monitor interpretation Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.
Verbatim wording from the response “partner agencies and to give staff confidence in decision making, to reduce risk to self and others, and to achieve better outcomes for all staff, people in prison and people under probation supervision. We will ask the ISAG to consider the circumstances of Mr Thornton’s death to identify learning and whether there is a need for additional updated guidance.” Source location Response from HMPPS
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PFD Monitor interpretation Ensure findings from the NOMIS/DPS alerts review inform future enhancements addressing the identified concerns.
Verbatim wording from the response “The current system already contains more granularity than a single “violent” categorisation. However, we recognise that improvements are needed in consistency, clarity and visibility. A dedicated programme of work is scheduled to review alerts later this calendar year, subject to prioritisation, and will be undertaken in collaboration with safety experts, digital and policy colleagues. This work will strengthen both the quality and usability of alerts in order to reduce risk and support safer decision-making. We will ensure that the findings from this review inform future enhancements and address the matters you have raised.” Source location Response from HMPPS
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PFD Monitor interpretation Healthcare information-sharing concerns have been referred to the relevant NHS trusts for separate consideration and response.
Verbatim wording from the response “Although your concerns about the sharing of information between healthcare and prison staff have been referred to Nottinghamshire Healthcare NHS Foundation Trust and Northampton Healthcare NHS Foundation Trust for their separate consideration and response, HMPPS has also considered whether there is any supportive action that it can take.” Source location Response from HMPPS
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7 Nov 2025 Anthony Robert CARD · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers View source
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AI-generated summary
Anthony Robert CARD · 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
Anthony Robert CARD, known as Tony, died by suicide by suspension by ligature at 15 Duke Street, Ipswich, between about noon on 21 and 22 November 2023. The report identifies a concern that, outside Care Act safeguarding criteria, there was no mechanism for police to communicate medium-risk mental-health information to relevant medical or mental-health providers, potentially resulting in missed support or affecting later decision-making.
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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 mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
Wider context from the report “Outside of situations where section 42 of the Care Act 2014 applies, there appears to be no mechanism available to enable front-line police officers who wish, of their own volition and with the subject's consent, to communicate risk information, arising out of an interaction with an adult at Medium risk to self from mental ill-health, to medical or mental health care providers , whom may be the right person or agencies to provide support in the medium term.
The information that an individual has, for example, been reported as presenting in such a way that police have had to consider detaining them under section 136 of the Mental Health Act 1983 could be important risk information that would assist medical or mental health care providers.
Not having this risk information available in future assessments may adversely affect decision-making - e.g. not having this information available could contribute to a decision not to admit compulsorily the patient for mental health care if they were to present again in, say, one week from the police interaction.
If such risk information is not received by treating medical or mental health care providers, there may be omission to offer vital further mental health support.
” Source location Anthony Robert CARD · Prevention of Future Deaths report
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PFD Monitor interpretation Require the Contact and Control Room to confirm NHS 111 Option 2 was signposted or contacted before closing a CAD incident.
Verbatim wording from the response “Suffolk Constabulary commit to:” Source location Response from Suffolk Constabulary
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PFD Monitor interpretation Continue consulting partner agencies to evaluate NHS 111 Option 2’s operability, reliability, staff knowledge, and training needs.
Verbatim wording from the response “Suffolk Constabulary is committed to continuing to consult with partner agencies to encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 Option 2 and whether improvements can be made to strengthen staff knowledge and training. It is respectfully submitted that the existing clinical pathways provide an adequate mechanism for raising mental health concerns in circumstances where statutory thresholds are not met. It is important to consider alongside this the limitations of police powers, the role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health concerns across Suffolk as addressed above.” Source location Response from Suffolk Constabulary
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PFD Monitor interpretation Continue cooperating with partner agencies and sharing relevant information under applicable arrangements to support timely clinically led crisis assessment when suicide risk is identified.
Verbatim wording from the response “SCC will continue to co-operate with other partner agencies and share relevant information in accordance with applicable information-sharing arrangements, to support timely access to clinically led crisis assessment where suicide risk is identified” Source location Response from Suffolk County Council
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PFD Monitor interpretation Existing NHS 111 Option 2 clinical pathways provide an adequate mechanism for raising adult mental health concerns below statutory thresholds.
Verbatim wording from the response “Suffolk Constabulary is committed to continuing to consult with partner agencies to encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 Option 2 and whether improvements can be made to strengthen staff knowledge and training. It is respectfully submitted that the existing clinical pathways provide an adequate mechanism for raising mental health concerns in circumstances where statutory thresholds are not met. It is important to consider alongside this the limitations of police powers, the role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health concerns across Suffolk as addressed above.” Source location Response from Suffolk Constabulary
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PFD Monitor interpretation NSFT holds statutory and operational responsibility for adult mental health care across Suffolk, rather than MASH or the police.
Verbatim wording from the response “Your Regulation 28 Report is addressed to both Suffolk Constabulary and Suffolk County Council (Adult Social Care), however is not addressed to Norfolk and Suffolk NHS Foundation Trust (“NSFT”). It is important to note that NSFT hold both the statutory and operational responsibility for adult mental health care across Suffolk.” Source location Response from Suffolk Constabulary
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PFD Monitor interpretation A new MASH pathway is not viable because projected referrals would impose substantial operational impact and require structural redesign.
Verbatim wording from the response “A new MASH referral pathway for adult mental health concerns is not, in our respectful submission, viable. Creating a pathway for Medium-risk adult mental health referrals falling short of section 42 of the Mental Health Act would generate an estimated 500 additional referrals per month, creating substantial operational impact across the police and Adult Social Care. This would require a structural redesign of MASH which, in our view, would not lead to improved outcomes due to adult mental health sitting wholly within the remit of NSFT as opposed to within MASH. As addressed below, NHS 111 Option 2 already exists as the appropriate clinical route for sharing concerns falling outside of the statutory framework.” Source location Response from Suffolk Constabulary
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PFD Monitor interpretation Adult mental health provision and clinical pathways are the responsibility of NHS commissioners and mental health providers.
Verbatim wording from the response “The responsibility for adult mental health provision and clinical pathways as identified by the report rests predominantly with NHS commissioners and NHS mental health providers (this is without prejudice to SCC’s distinct statutory responsibilities in respect of mental health social care, including Care Act functions and, where applicable, joint aftercare duties under the Mental Health Act).” Source location Response from Suffolk County Council
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PFD Monitor interpretation SCC will not create a new MASH pathway for adult mental health-only referrals outside safeguarding or adult social care functions.
Verbatim wording from the response “Where information relates solely to adult mental health concerns and does not meet statutory adult safeguarding criteria and/or does not otherwise engage adult social care functions, SCC is not the appropriate recipient for clinical triage or onward clinical referral into adult mental health pathways. Where a contact nonetheless indicates an appearance of care and support needs, SCC will consider whether Care Act assessment duties are engaged.” Source location Response from Suffolk County Council
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10 Oct 2025 Jillian Anne Steedman · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to inform the ongoing ECT consultant of mental health deterioration View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jillian Anne Steedman · 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
Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support arrangements.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to inform the ongoing ECT consultant of mental health deterioration
Wider context from the report “(2) Mrs Steedman’s consultant responsible for ongoing Electroconvulsive Therapy (ECT) was not informed of her mental health deterioration . Previous adjustments to the frequency of ECT had proved beneficial.
” Source location Jillian Anne Steedman · Prevention of Future Deaths report
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review information-sharing protocols for collaboration with professionals in other organisations.
Verbatim wording from the response “We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named” Source location Response from Essex Partnership University
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.
Verbatim wording from the response “We have strengthened our governance by reviewing our information-sharing protocols with specific reference to how we work with professionals in other organisations. We have introduced structured communication methods for handovers and shared care plans which we have made accessible to all involved professionals including care home and social care staff. We are working in a more collaborative culture through regular multidisciplinary team meetings which is supporting our patient’s safety and planning. The Trust has relooked at its named” Source location Response from Essex Partnership University
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12 May 2025 Paul Christopher REEVES · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to communicate concerning behaviour and environmental damage to mental health staff View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Riverside
Review and update the national Support Planning Procedure to record hospital contacts, required clinical escalation and post-hospital support-plan reviews.
View source
Riverside
Train and remind staff to communicate behavioural changes, environmental damage, deterioration and other welfare concerns promptly through appropriate clinical escalation channels.
View source
Riverside
Add welfare-escalation and relevant legal-status requirements to the organisation-wide Quality Audit Tool for auditors to check.
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Paul Christopher REEVES · 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 Christopher Reeves died in hospital on 9 April 2024 after ingesting and aspirating mud following the use of unknown drugs or psychoactive substances, and suffering a cardiac arrest during re-intubation. The principal concerns related to inadequate communication between his supported accommodation and mental health team, uncertainty about staff responsibilities, escalation of concerns about his deteriorating condition, and staff knowledge, skills or training in responding to his behaviour in the community.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate concerning behaviour and environmental damage to mental health staff
Wider context from the report “2. During a welfare check on Mr Reeves on the morning of 26 March 2024, it was noted that Mr Reeves was ‘agitated’ and that ‘there were broken glasses and pulled electrical panel in his flat’. It was also noted that Mr Reeves ‘didn’t know what had happened’. The mental health unit contacted staff at Maygrove Road on 27 March 2024 and it was accepted in evidence that the concerns about Mr Reeves’ behaviour and the damage caused to his flat were not mentioned to the mental health staff . In the circumstances, these matters not having been raised with the mental health staff deprived the mental health team of an opportunity to assess Mr Reeves’ mental state and leave status , and to consider whether or not he should have remained on leave. The manager at Maygrove Road told me in evidence that they would not expect staff to raise these matters with the mental health team; something which I found to be ‘irrational’.
While I found that there was insufficient evidence to suggest that this would have altered the outcome for Mr Reeves, it raises serious concerns about communication that would enable mental health professionals properly to assess the needs and status of patients in the community, particularly given the accommodation ‘generally supports residents with mental health needs’.
” Source location Paul Christopher REEVES · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the national Support Planning Procedure to record hospital contacts, required clinical escalation and post-hospital support-plan reviews.
Verbatim wording from the response “• We have reviewed our national Support Planning Procedure. The procedure now specifically states that:” Source location Response from The Riverside Group Limited
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train and remind staff to communicate behavioural changes, environmental damage, deterioration and other welfare concerns promptly through appropriate clinical escalation channels.
Verbatim wording from the response “• Staff have been reminded of the importance of sharing behavioural changes, environmental damage or unusual incidents with the relevant mental health team — not only for safeguarding, but to ensure a collaborative, well-informed approach to care. The Senior Team Manager, ████████, held a Maygrove Service Improvement Meeting with the staff team on 4 February 2025 and a follow up via email was shared on 27 May 2025. This was addressed and completed within our three-month improvement plan completed in May 2025.” Source location Response from The Riverside Group Limited
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add welfare-escalation and relevant legal-status requirements to the organisation-wide Quality Audit Tool for auditors to check.
Verbatim wording from the response “• We already audit Support Plans and verify that local arrangements are in place to monitor customer welfare as part of the quality audit process. However, we will now include specific guidance in the audit tool to ensure that auditors check that: Safety Plans clearly detail which external agencies or teams must be contacted when colleagues have concerns about a customer who is on Section 17 leave from hospital, under a Community Treatment Order or subject to other legal restrictions (e.g. Section 41). The audit tool will also check that any concerns regarding customer welfare have been escalated appropriately, for example, by ensuring teams make direct contact with the Social Worker or Duty Team.” Source location Response from The Riverside Group Limited
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support Officers are not authorised or trained to restrain residents because their remit is supportive and non-clinical.
Verbatim wording from the response “Support Officers are not authorised or trained to restrain residents. Their remit is supportive and non-clinical. Although this was an isolated incident and the coroner confirmed that it did not alter the outcome for Mr Reeves, we have used it as a learning opportunity. On 4 February 2025, Support Officers were reminded of their responsibilities in responding to residents in visible distress or potential danger. Further to the above, this included a reminder that any concerns regarding a customer’s mental or physical health should be reported to the appropriate teams, including management, without delay within 24 hours and that any issues or concerns related to assigned customers should be escalated to management and the clinical team for appropriate action.” Source location Response from The Riverside Group Limited
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25 Mar 2025 Oladeji Adeyemi Omishore · Prevention of Future Deaths report Inner West London
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Concerns raised 3
Failure to circulate mental health information promptly during I grade calls View source Lack of dispatcher training on passing possible mental health concerns over the airwaves View source Dispatcher pod failures causing mental health concerns to be missed under work pressure View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Oladeji Adeyemi Omishore · 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
Oladeji Adeyemi Omishore died on 4 June 2022 after being tasered during an incident involving police officers on Chelsea Bridge and then entering the River Thames; his medical cause of death was complications arising from drowning. The report identified concerns about the recording and transmission of mental health information by call handlers and dispatchers, and about training for responding officers in tactical options before taser deployment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to circulate mental health information promptly during I grade calls
Wider context from the report “6. That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues , in the format most likely to be digested and passed on by dispatchers that is “golden line” or NICL codes.
” Source location Oladeji Adeyemi Omishore · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of dispatcher training on passing possible mental health concerns over the airwaves
Wider context from the report “8. That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health.
” Source location Oladeji Adeyemi Omishore · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Dispatcher pod failures causing mental health concerns to be missed under work pressure
Wider context from the report “10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.
” Source location Oladeji Adeyemi Omishore · Prevention of Future Deaths report
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PFD Monitor interpretation Update Despatch Course lesson plans to train dispatchers to relay possible mental-health concerns over the airwaves promptly.
Verbatim wording from the response “We acknowledge the importance of dispatchers being fully aware of and training in recognising and relaying possible mental health concerns. Lesson plans for the MetCC Academy Despatch Course will be updated to explicitly emphasise the importance of passing on such information over the airwaves, particularly in light of the increased use of Taser involving black men and individuals suffering from mental ill health.” Source location Response from Metropolitan Police
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PFD Monitor interpretation Enhance dispatcher training and lesson plans on communicating CAD-assigned units to responding officers.
Verbatim wording from the response “We recognise the need for greater clarity and understanding among dispatchers regarding what information needs to be communicated more generally. Training will be enhanced to address the confusion identified in the evidence, specifically in relation to other units being assigned via Computer Aided Despatch (CAD) and the necessity for dispatchers to fully understand and communicate this to responding officers. Lesson plans will be updated accordingly.” Source location Response from Metropolitan Police
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update dispatcher training and lesson plans to relay key information, including mental-health concerns and the number of units en route.
Verbatim wording from the response “We note the concerns regarding the potential systemic failures within the individual pods within despatch. Training will be updated to ensure despatchers are equipped to pass on key information, including mental health concerns and the number of units en route, given the importance of this information in informing officers’ application of the National Decision Model. This will also be incorporated into revised lesson plans.” Source location Response from Metropolitan Police
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2 May 2024 Evie Jane DAVIES · Prevention of Future Deaths report Cheshire
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Concerns raised 2
Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors View source Delays in GP review of correspondence relevant to mental health team action View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Evie Jane DAVIES · 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
Evie Jane Davies was found deceased at home on 2 December 2021 after taking a significant overdose of medication that had not been prescribed to her. The report states that this was likely a deliberate act intended to end her life, amid deteriorating mental health and significant personal stressors. The principal concern was insufficient real-time information sharing between the café71 crisis service, the mental health team and the GP, potentially preventing prompt follow-up of people at risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors
Wider context from the report “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team , and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person . They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team . In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner.
” Source location Evie Jane DAVIES · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in GP review of correspondence relevant to mental health team action
Wider context from the report “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team . I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner.
” Source location Evie Jane DAVIES · Prevention of Future Deaths report
Open source report
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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 Audit referrals sent to Café 71 every six months and report findings through Acute Care and First Response governance meetings.
Verbatim wording from the response “The following learning has been undertaken by both the Trust and Café 71 to streamline how key information regarding individuals involved with mental health services can be shared with Café 71” Source location Response from Cheshire and Wirral Partnership
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with CWP and GP colleagues to improve the timeliness and content of correspondence about Crisis Line contacts.
Verbatim wording from the response “GP’s, along with other professionals can contact the Crisis Line directly and request mental health crisis support for individuals they are concerned about. CWP have a system in place to inform the GP when an individual has contacted Crisis Line and in line with the concern you raised we will work with CWP and GP colleagues to improve the timeliness and content of that correspondence.” Source location Response from Cheshire and Merseyside
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Café 71 does not operate in isolation; staff can obtain relevant mental-health information from Trust crisis-line staff with the individual’s consent.
Verbatim wording from the response “Café 71 do not have access to the Trust’s electronic Patient record system (SystmOne). However, the staff from Café 71 will contact crisis line staff to discuss any risk concerns, the teams work closely to ensure that the relevant information relating to a patient’s mental health is available to Café 71 staff. Café 71 staff can phone the crisis line to request further information, but more often the member of staff requiring the information will physically call into the office. Contacts between services are undertaken with patient knowledge and consent. The Trust would seek consent from the individual to refer them to Café 71.” Source location Response from Cheshire and Wirral Partnership
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25 Mar 2024 Christopher Edward SIDLE · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to circulate important emails to relevant CRHTT personnel View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Christopher Edward SIDLE · 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
Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.
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× 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 circulate important emails to relevant CRHTT personnel
Wider context from the report “5. Important emails were not circulated to relevant personnel within the CRHTT . The evidence remains unclear what happened to the emails and why they did not reach the appropriate member of the team.
” Source location Christopher Edward SIDLE · Prevention of Future Deaths report
Open source report
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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 Operate one generic CRHTT email address with a defined process for qualified practitioners to check and action messages.
Verbatim wording from the response “These have now been merged into one generic team email address. The process for receipt and management of emails to the CRHTT generic team e mail address has been reviewed.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide administrative and senior support-worker capacity to monitor the CRHTT inbox during weekday and weekend periods.
Verbatim wording from the response “To increase resilience, administrative support has now been allocated to assist the PIC with weekday administrative tasks which includes monitoring the inbox.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit implementation of the CRHTT email-management and night-handover processes over six months.
Verbatim wording from the response “Night shift is covered by 2 clinicians and 2 senior support workers with shared responsibility. All contacts are recorded on to the Night Handover Log. The embedding of this new process will be monitored through a six-month audit which will commence 20.05.24.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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15 May 2023 Rebecca Alice Fisher · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Poor-quality documentation and information sharing between officers and supervision View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Rebecca Alice Fisher · 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
Rebecca Alice Fisher was found deceased by her family on 15 April 2022 after being reported missing from a mental health ward following unescorted leave. A post-mortem found a fatal dose of drugs, including pregabalin. The principal concern was that Greater Manchester Police did not assess her as a high-risk missing person, resulting in delays to mobile telephone enquiries and specialised input; concerns also included gaps in staff understanding, documentation, information sharing, and the implementation of training and guidance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor-quality documentation and information sharing between officers and supervision
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit .
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.
” Source location Rebecca Alice Fisher · Prevention of Future Deaths report
Open source report
19 Jul 2018 Jeroen ENSINK · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to communicate identified mental health concerns to custody staff View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jeroen ENSINK · 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
Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.
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× 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 communicate identified mental health concerns to custody staff
Wider context from the report “7. Both arresting officers formed the view that ████████ was suffering mental health or substance abuse problems, and both included these two factors in their statements , but the custody sergeant gave evidence that no mental health concerns were brought to his attention .
” Source location Jeroen ENSINK · Prevention of Future Deaths report
Open source report
2 Dec 2016 Peter Daniel Usher · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to obtain and communicate relevant police and family information during admission View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Metropolitan Police Service NELFT NHS NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NELFT NHS NHS Foundation Trust
Review and update s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.
View source
NELFT NHS NHS Foundation Trust
Create a generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.
View source
Metropolitan Police Service
Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.
View source
Metropolitan Police Service
Design a bespoke handover form with NELFT for use at the 136 suite.
View source
Metropolitan Police Service
Hold a progress-review meeting on the bespoke handover form.
View source See 2 more actions
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AI-generated summary
Peter Daniel Usher · 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
Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain and communicate relevant police and family information during admission
Wider context from the report “4. The police had received contact from family members whilst they were present at the hospital, confirming the concerns of family members due to the text received. This was not passed on to the hospital staff . It became apparent during the course of the Inquest that the police also had access to information which was relevant to the circumstances of the preceding events which would have been relevant to the mental state of the deceased. It would appear that inadequate questions were asked by the receiving hospital team in relation to the circumstances leading to admission .
” Source location Peter Daniel Usher · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.
Verbatim wording from the response “1, 2, 3, 4 | With emphasis on the requirement to comply with:” Source location 2016-0428-Response-by-NELFT-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.
Verbatim wording from the response “9 | To create a generic and secure nhs.net account for s136 suite, which would be monitored and used by the bleep holders to receive the collateral | OJ/VP/RK | 31.03.2017” Source location 2016-0428-Response-by-NELFT-NHS-Trust
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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 Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.
Verbatim wording from the response “1.1 – The s136 paperwork completed by officers on the street is Form 434. The form has two particular areas that by their description can create ambiguity when completing them. The first is towards the top where it has the words “Friends/Family” and a space adjacent to it for the officer to fill out. I believe this needs to be more specific and should be changed to “Next of Kin.” This will give the officers more clarity when completing the form and eliminating the potential risk of important information being missed. The second is further down and reads “Name of person handing over” then as above there is a space adjacent for the officer to complete. This leaves some doubt as to whether the person accepting responsibility needs to sign. Under the s136 Pathway it clearly states that a signature is required.” Source location 2016-0428-Response-by-Borough-Mental-Team
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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 Design a bespoke handover form with NELFT for use at the 136 suite.
Verbatim wording from the response “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.” Source location 2016-0428-Response-by-Borough-Mental-Team
Open published response
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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 progress-review meeting on the bespoke handover form.
Verbatim wording from the response “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.” Source location 2016-0428-Response-by-Borough-Mental-Team
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.