Recurring concern

Failure to involve families and carers in mental health care planning and decisions

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First reported 16 Jan 2014•Latest report 2 May 2026

Definition

What this concern includes

Includes failures to involve, consult or inform families or carers in mental health risk management, care planning, discharge planning, psychiatric reviews or related care decisions where involvement is appropriate and permitted, including failures arising from unclear routine or policy.

Not included

  • Excludes generic communication, coordination or staffing failures that are not specifically tied to family or carer involvement in mental health care planning or decisions.
  • Excludes failures involving professionals, agencies or services where no family or carer involvement is at issue.
  • Excludes cases where family or carer involvement was not appropriate or permitted because of consent, confidentiality or other documented circumstances.
  • Excludes failures confined to the clinical content or outcome of a decision when family or carer involvement was not part of the concern.
Reports
26

Distinct published reports

Individual concerns
31

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
45

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.

Department of Health and Social Care4
Leicestershire Partnership NHS Trust3
Greater Manchester Mental Health NHS Foundation Trust2
NHS England2
Care Quality Commission1
Cheshire and Wirral Partnership NHS Foundation Trust1
College of Policing1
Cornwall Council1
Department for Education1
Dudley Integrated Health and Care NHS Trust1
East London NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Police1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Health and Safety Executive1

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. East London

    AI-generated summary

    Somtera Bibi · 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

    Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.

    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 a relapse prevention or risk management plan developed with the patient and family members

    Wider context from the report

    “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour. Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically: (i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family (ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020 (iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened (iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members (v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members (vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse ”

    Source location

    Somtera Bibi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and strengthen risk assessment and management processes, including clinical-recording-system changes and staff training.

    Verbatim wording from the response

    “16. The Trust has a large piece of work underway reviewing and strengthening risk assessment and management processes. This will involve changes to our clinical recording system as well as staff training. This is intended to create processes that are more focused on risk formulation, based on current factors and historical risk. For clarity, these processes would always be expected to involve the service user and also family/carers where this is relevant.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

    Open published response

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Naomi Aylott · 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

    Naomi Aylott died on 12 September 2024 after jumping from a railway bridge with the intent to end her own life, following a period of poor mental health and previous suicide attempts. Concerns included that she was not seen face to face by her care co-ordinator, formal risk assessments and care planning were not completed, risk-assessment training and auditing were inadequate, and family involvement during telephone-based care had not been properly considered.

    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 maintain family involvement in care during telephone care-coordinator meetings

    Wider context from the report

    “3. I am concerned that the Andover CMHT do not appear to have considered how to keep a person’s family involved in their care (when there is the appropriate consent to do so) when meetings with the care co-ordinator take place over the phone and not face to face. ”

    Source location

    Naomi Aylott · 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

    Introduce the Triangle of Care framework and updated co-produced training to Isle of Wight and legacy Solent staff.

    Verbatim wording from the response

    “The Triangle of Care is an initiative promoted by the NHS, developed by the Carers Trust, to foster a therapeutic alliance between the service user, their family or carers, and the professional staff involved in their care. It emphasizes partnership, communication, and shared responsibility to promote safety, support recovery, and sustain the wellbeing of both the service user and their carer. Having rolled out the programme to legacy Southern Health staff over a number of years, we are now introducing the Triangle of Care framework to our staff in Isle of Wight and legacy Solent teams (who merged with Southern Health last year to become Hampshire and Isle of Wight Healthcare). Much of this training is co-delivered with carers, carers leads and a former service user with their carer. The training has recently been updated in coproduction with carers.”

    Source location

    Response from Hampshire and Isle of Wight Healthcare
    Page 4 · response
    Published 20 October 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

    Establish ESTHER Improvement Coaches and a staff ambassador network supporting person-centred care and family involvement.

    Verbatim wording from the response

    “The introduction of ESTHER coaching has further enhanced and reinforced the Triangle of Care principles. ESTHER Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous improvement to ensure person-centred care. User involvement is integral to the model, building a network around the patient including family, friends, and key staff. Currently we have in excess of 90 staff members as ambassadors.”

    Source location

    Response from Hampshire and Isle of Wight Healthcare
    Page 4 · response
    Published 20 October 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 Carer Information Plans across services in the RiO electronic patient record, including consent and carer-support information.

    Verbatim wording from the response

    “Our new Carer Information Plan officially launched in May 2025, and is available for all services, replacing the previous Carer Communication Plan. Carers were involved in the development of our new plans and the response has been overwhelmingly positive.”

    Source location

    Response from Hampshire and Isle of Wight Healthcare
    Page 5 · response
    Published 20 October 2025

    Open published response

  3. Rutland and North Leicestershire

    AI-generated summary

    James Ralph COCHRANE · 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

    James Ralph Cochrane, who had schizoaffective disorder with fluctuating mood and psychosis, died on 17 November 2023 after jumping from an overbridge into the carriageway and being struck by a vehicle. The report raises concerns about how carers’ views and video evidence are considered and used in safety planning, and about the support provided to carers assisting mental health patients at home.

    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 use carers' views to inform follow-up safety plans

    Wider context from the report

    “The extent to which additional evidence such as video footage and carers views should be taken into account. I heard evidence that work and training has been done to encourage staff to listen to carers views. However, it remains unclear as to whether any views obtained are subsequently used to inform any follow up safety plan made by the health care professionals. ”

    Source location

    James Ralph COCHRANE · 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

    Document carers’ views and support needs in electronic care and safety plans, making them available to clinicians and using them in care decisions.

    Verbatim wording from the response

    “Response: The Trust acknowledges the importance of listening and capturing carers views during assessment and routine follow ups and therefore has ensured that these views can be documented (with consent”

    Source location

    Response from NHS Leicestershire Partnership NHS Trust
    Page 1 · response
    Published 16 September 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

    Roll out the Carers Trust Triangle of Care framework through community mental health team self-assessments, benchmarking and identified improvement actions.

    Verbatim wording from the response

    “In addition, Leicestershire Partnership NHS Trust is rolling out the nationally recognised Carers Trust Triangle of Care (TOC) framework and currently community mental health teams are completing self-assessments (due 31 October 2025), which include benchmarking current practice and identifying any actions needed to include carers throughout a patient’s journey of care. The Trust also follows the Culture of Care programme and implements guidance embedding the 12 Culture of Care standards. These commitments are interlinked and fundamental to carers’ involvement as an integral aspect of patient care. The Trust has also embedded the Patient and Carer Race Equality Framework (PCREF) that supports our services with the delivery of high standards of care via simple and effective patient and carer feedback mechanisms and that ultimately minimises racial inequalities.”

    Source location

    Response from NHS Leicestershire Partnership NHS Trust
    Page 2 · response
    Published 16 September 2025

    Open published response

  4. Oxfordshire

    AI-generated summary

    Cain Alex River Donald · 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

    Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

    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 engage family members effectively in discharge planning

    Wider context from the report

    “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

    Source location

    Cain Alex River Donald · 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

    Insufficient communication with family members about discharge risks and support needs

    Wider context from the report

    “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

    Source location

    Cain Alex River Donald · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement family and carer engagement changes using the triangle of care model in the Psychiatric Intensive Care Unit.

    Verbatim wording from the response

    “More broadly, the Psychiatric Intensive Care Unit has implemented changes since Mr Donald’s death in relation to how they engage with carers and family using the triangle of care model. Our Associate Director of Nursing provided some evidence to you on this work.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 17 June 2025

    Open published response

  5. Cornwall and Isles of Scilly

    AI-generated summary

    Callum James Hargreaves · 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

    Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.

    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 further explore a patient's decision not to involve a relevant family member in discharge notification

    Wider context from the report

    “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024. 1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes. 2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so. The Nearest Relative details on the MH 1 form were not completed. The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further. You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded. ”

    Source location

    Callum James Hargreaves · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Suffolk

    AI-generated summary

    Timothy Robert DE BOOS · 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

    Timothy Robert DE BOOS was declared deceased at his home in Ipswich on 6 February 2024 after a self-inflicted domestic fire, with the medical cause of death recorded as smoke inhalation and severe burns. The report raises concerns about the lack of available Mental Health Unit inpatient beds and about the admission process when the patient, family, and an experienced mental health professional considered voluntary admission necessary.

    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 treat the views of experienced mental health professionals, patients and families as sufficient evidence in voluntary inpatient admission decisions

    Wider context from the report

    “2. In Tim’s case, on the 2ⁿᵈ of February 2024 Tim’s family, Tim himself, and Tim’s Mental Health Care Coordinator (a Senior Mental Health Nurse who had been supporting Tim for a year), all wished for his admission to a Mental Health Unit as a voluntary patient. It was heard in evidence that a different team (the Crisis Resolution and Home Treatment Team) were the ‘gatekeepers’ for admission and this team could not review Tim until the next day. When reviewed by Crisis Resolution and Home Treatment Team staff (who had never met Tim before), they believed his crisis had subsided and his admission was denied. In evidence Tim’s Mental Health Care Coordinator was adamant that Tim should have been hospitalised on the 2ⁿᵈ February, as both his family and Tim himself had also wished. I am therefore concerned that the views of an experienced mental health professional, a patient’s family, and the patient themselves, is deemed insufficient evidence for an admission to a Mental Health Unit as a voluntary inpatient. ”

    Source location

    Timothy Robert DE BOOS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Michael Sean Heath · 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

    Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.

    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 ensure carers are informed of Mental Health Act admissions within 24 hours

    Wider context from the report

    “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate; ”

    Source location

    Michael Sean Heath · 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

    Reinforce carer-notification expectations through daily staff huddles.

    Verbatim wording from the response

    “Noting that this did not occur in the case of Mr Heath, the Trust has emphasised this expectation through daily staff huddles across GMMH. The wards have implemented a process to ensure written information is provided to carers within 72 hours of admission. All Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & recorded, and information pack provided, that they are required to follow up. Compliance with these requirements is currently being audited across the Trust, this audit is due to be completed by the end of December 2024.”

    Source location

    Response from Great Manchester Mental Health NHS
    Page 1 · response
    Published 3 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement written carer information within 72 hours and require Ward Managers to follow up missing records through daily reports.

    Verbatim wording from the response

    “Noting that this did not occur in the case of Mr Heath, the Trust has emphasised this expectation through daily staff huddles across GMMH. The wards have implemented a process to ensure written information is provided to carers within 72 hours of admission. All Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & recorded, and information pack provided, that they are required to follow up. Compliance with these requirements is currently being audited across the Trust, this audit is due to be completed by the end of December 2024.”

    Source location

    Response from Great Manchester Mental Health NHS
    Page 1 · response
    Published 3 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Audit compliance with carer identification, recording and information-pack requirements.

    Verbatim wording from the response

    “Noting that this did not occur in the case of Mr Heath, the Trust has emphasised this expectation through daily staff huddles across GMMH. The wards have implemented a process to ensure written information is provided to carers within 72 hours of admission. All Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & recorded, and information pack provided, that they are required to follow up. Compliance with these requirements is currently being audited across the Trust, this audit is due to be completed by the end of December 2024.”

    Source location

    Response from Great Manchester Mental Health NHS
    Page 1 · response
    Published 3 October 2024

    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

    Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.

    Verbatim wording from the response

    “Within your listed matters, you have raised over-arching concerns regarding Policing, the management of mental health patients, the quality of collaboration between mental health services both abroad and in the UK upon repatriation whilst the patient remains ill and GP decision-making – and I note that there is no specific reference to the actions of Trafford Council within those listed concerns. As these concerns do not relate to the actions nor decision-making of Trafford Council, you will appreciate that I am unable to specifically address these with a respective timetable for action.”

    Source location

    Response from Trafford Council
    Page 1 · response
    Published 3 October 2024

    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

    Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.

    Verbatim wording from the response

    “Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not be able to provide any assistance with those concerns.”

    Source location

    Response from NWAS
    Page 2 · response
    Published 3 October 2024

    Open published response

  8. County Durham and Darlington

    AI-generated summary

    Matthew Clive GALE · 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

    Matthew Clive Gale died on 19 March 2023 after being detained under the Mental Health Act and granted Section 17 leave. The conditions of his leave, including that he should not be left alone, were not properly recorded or communicated to his family. The report raised concern about inconsistent compliance with providing Section 17 leave forms and the removal of a requirement for the accompanying person to sign the form, creating a risk of future deaths.

    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 inform accompanying carers of section 17 leave conditions

    Wider context from the report

    “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form. The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data. Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria. Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system. The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken. ”

    Source location

    Matthew Clive GALE · 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

    Failure to provide section 17 leave forms to accompanying carers

    Wider context from the report

    “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form. The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data. Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria. Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system. The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken. ”

    Source location

    Matthew Clive GALE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include Section 17 leave and accompanying-role responsibilities in mandatory Trust-wide preceptorship for newly joining registered nurses.

    Verbatim wording from the response

    “As previously advised, following the May 2024 audit results the Trust implemented the following to improve Section 17 leave requirements:”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust
    Page 1 · response
    Published 19 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review, amend, approve and roll out the Section 17 leave policy, including signed leave documentation, accompanying-person confirmation and ward-held copies.

    Verbatim wording from the response

    “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust
    Page 1 · response
    Published 19 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and deliver targeted Section 17 leave training to Associate Directors of Nursing and Quality.

    Verbatim wording from the response

    “The Associate Director of Nursing and Quality has developed and delivered targeted training to all Associate Directors of Nurses (ADONs) around Section 17 leave, including the changes to policy and procedures and the need to ensure that processes are being followed and documented. This training is currently being disseminated across the relevant parts of the Trust with oversight of the ADONs. Within the last three weeks, 957 (70%) of substantive ward staff within the Trust have been trained in the new Section 17 leave policy. In addition to this, Section 17 leave/time away from the ward training has been delivered to temporary workers, community staff, corporate services, and professional groups to ensure they are aware of the changes. Compliance with training continues to be closely monitored by the ADONs to ensure the Trust captures all relevant staff.”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust
    Page 2 · response
    Published 19 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use Section 17 leave folders, flowcharts, templates and contact cards to give staff, patients and accompanying persons accessible leave requirements and contact information.

    Verbatim wording from the response

    “In order to further assist staff with the requirements of Section 17 leave, staff have been provided with leave folder templates and contact cards, which are now in use across the relevant parts of the Trust. At the front of the leave folders a flowchart that has been produced to remind staff of the requirements of Section 17 leave. The leave folder also contains a copy of the most recent Section 17 leave form and the leave/time away from the ward monitoring form to enable easy access. Contact cards are now also given to the patient and the accompanying person, which have details of the ward contact details, any conditions of leave, a check that a copy of the section 17 leave form has been provided and details of time and date which patient is due to return.”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust
    Page 2 · response
    Published 19 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue auditing clinical records to assess compliance with Section 17 leave procedures.

    Verbatim wording from the response

    “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust
    Page 2 · response
    Published 19 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Assess the impact of the amended Section 17 leave policy changes.

    Verbatim wording from the response

    “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust
    Page 2 · response
    Published 19 August 2024

    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

    Section 17 leave and monitoring forms will remain in paper format rather than being converted to electronic forms.

    Verbatim wording from the response

    “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been”

    Source location

    Response from Tees Esk and Wear Valleys NHS Foundation Trust
    Page 1 · response
    Published 19 August 2024

    Open published response

  9. Manchester South

    AI-generated summary

    Susan Mary Regan · 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

    Susan Mary Regan, aged 61, experienced deteriorating mental and physical health, including malnutrition, dehydration, disturbed behaviour and possible self-harm, before being admitted to hospital and later discharged with support. On 25 July 2020, she took her own life at home. The principal concerns were that the Home Treatment Team did not consult her sons about possible hospitalisation and did not properly record or communicate a care plan with them.

    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 undertake the required enquiry with family members about possible psychiatric admission

    Wider context from the report

    “1) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Mrs Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit. Admission to also be considered if Ms Regan would continue to show non-compliance on her medications. Such an enquiry was not undertaken. 2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons. ”

    Source location

    Susan Mary Regan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Dorset

    AI-generated summary

    Andrew Arden Nixon · 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

    Andrew Arden Nixon’s mental health deteriorated from around October 2020, and after referral and assessment by mental health services he was found suspended by a ligature in wooded grounds in North Dorset on 3 March 2021. The principal concerns were that family members or carers were not fully involved in risk assessment and care planning, and that criteria for considering a Carer’s Assessment were not applied at the earliest appointment.

    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 involve family members and carers fully in risk assessment and decisions

    Wider context from the report

    “2. I have concerns with regard to the following: i. The failure to ensure that family members/carers are fully involved from the outset in the risk assessment process and that they have a full comprehension of steps being taken and/or decisions being made. I believe the Trust should take a more proactive approach. ii. There should be criteria to be applied as to who should be considered for a Carer’s Assessment at the earliest appointment with the Home Treatment Team. Such criteria should include whether the patient has given permission to share information; whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the carer in relation to steps taken and decisions made and whether they need further help. iii. Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient. ”

    Source location

    Andrew Arden Nixon · 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

    Maintain Triangle of Care accreditation and deploy 42 leads across mental health and learning-disability services.

    Verbatim wording from the response

    “Somerset NHS Foundation Trust (SFT) Mental Health and Learning Disabilities Directorate has been part of the Triangle of Care accreditation scheme since it began. On 12 May 2016, the Trust was awarded a second quality star by ████████ of the Carers’ Trust.”

    Source location

    Response from NHS Somerset
    Page 1 · response
    Published 16 September 2022

    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

    Add carer-assessment review and family-liaison checks to Home Treatment Team review checklists and caseload boards.

    Verbatim wording from the response

    “• The Home Treatment Team plan to include carers assessment in their checklist for clinical review meetings so that carers assessment is reviewed on a weekly basis, as well as to their caseload boards where carers assessment will be marked as complete once families and carers have been asked about their carer needs and been signposted to relevant information. The team currently review”

    Source location

    Response from NHS Somerset
    Page 5 · response
    Published 16 September 2022

    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

    Recruit Home Treatment Team peer-support workers to provide outreach and check carers’ understanding of care plans.

    Verbatim wording from the response

    “• Home Treatment Teams are in the process of recruiting peer support workers who will undertake to perform an outreach function to families and carers on the caseload, checking attendance and understanding of the plan of care.”

    Source location

    Response from NHS Somerset
    Page 6 · response
    Published 16 September 2022

    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

    Include consideration and discussion of carers assessments in the caseload management tool.

    Verbatim wording from the response

    “• We will include the standard that carers assessment has been considered and discussed with family and carers in the caseload management tool.”

    Source location

    Response from NHS Somerset
    Page 6 · response
    Published 16 September 2022

    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

    Launch a co-produced quality-improvement project to strengthen earlier family and carer involvement in care planning, decision-making and risk-information sharing.

    Verbatim wording from the response

    “• We will design a Quality Improvement project which is co-produced with experts by caring, experts by experience and experts by training to explore further mechanisms by which we can ensure greater and earlier family and carer involvement in care planning, and decision making, and sharing risk information.”

    Source location

    Response from NHS Somerset
    Page 6 · response
    Published 16 September 2022

    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

    Recommend that frontline assessors record previous carer involvement with mental health services.

    Verbatim wording from the response

    “We will be able to gather information about previous patient involvement from our electronic records and we will add carer involvement as a recommendation to frontline staff undertaking assessments.”

    Source location

    Response from NHS Somerset
    Page 7 · response
    Published 16 September 2022

    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

    Remind staff to record consultation attendees and patients’ preferred people for involvement in care.

    Verbatim wording from the response

    “Recording who is present during a consultation should be a routine part of record keeping and we will ensure that staff are reminded of this. Dialog+ also includes a tick box and free text box with the prompt to establish at an early stage who the patient would wish to involve in their care.”

    Source location

    Response from NHS Somerset
    Page 7 · response
    Published 16 September 2022

    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

    Roll out sharing of care plans with families at hospital discharge and checking understanding of care and safety plans.

    Verbatim wording from the response

    “• A recent quality improvement project (2020-21) focused on initiatives to increase family and carer involvement and has led to the roll out of a plan to share care plans with families at discharge from hospital, and check understanding of care/safety plans, and a shared safety planning initiative in Children’s services.”

    Source location

    Response from NHS Somerset
    Page 9 · response
    Published 16 September 2022

    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

    Include family and carer involvement in care planning, safety planning, contact details and confidentiality monitoring through routine caseload management.

    Verbatim wording from the response

    “• As part of our Directorate governance processes, The Mental Health Directorate expects all staff to complete a routine caseload management tool. This includes monitoring of family and carer involvement in care planning (in Dialog+), family and carers involvement in safety/escalation planning, collecting Next of Kin and carer contact details, and to check that confidentiality is discussed and reviewed regularly with the patient.”

    Source location

    Response from NHS Somerset
    Page 8 · response
    Published 16 September 2022

    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

    Require discharged patients to have a consented, co-produced safety plan shared with identified family, friends or carers where possible.

    Verbatim wording from the response

    “• All patients discharged from the service should have a co-produced safety plan which is shared with consent wherever possible with identified family/friend of carer. Our routine record keeping audit includes this as part of its assurance.”

    Source location

    Response from NHS Somerset
    Page 9 · response
    Published 16 September 2022

    Open published response
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Data last updated 7 September 2026