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
Individual concerns: 31
Date range: 2014–2026
Stated actions: 45

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social 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.

25 Feb2022
Essex
Concerns raised1
1. Failure to involve patients’ carers as equal partners in the development and review of Section 117 after-care plans
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Stephanie Moyce · 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

Stephanie Moyce, who had a history of mental health issues and repeated suicide attempts, took her own life on 30 July 2021 and was discovered by her partner. The report identified concerns about unclear responsibility for care and oversight after psychotherapy discharge, inadequate discharge planning and safety-netting, the lack of routine multidisciplinary discussion, and insufficient involvement of her carer in Section 117 after-care reviews.

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 patients’ carers as equal partners in the development and review of Section 117 after-care plans
Wider context from the report
“4. The evidence in this case indicated that, contrary to EPUT’s own established Protocol, a patient’s carer (in this case her long-term partner who no confidentiality issue were identified) are not in practice always “seen as equal partners in the development and review of Section 117 after-care plans” and involved directly in such reviews. ”
Source location
Stephanie Moyce · Prevention of Future Deaths report
Page 3 · concerns
Open source report
1 Nov2021
West Yorkshire Eastern
Concerns raised2
1. Failure to heed family warnings about a patient’s fitness for discharge
2. Failure to involve family in section rescission decisions
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Ensure Triangle of Care principles are enacted consistently for service users and family members.
  Stated by Leeds and York Partnership NHS Foundation TrustStated planned
2. Action
  Review and share Triangle of Care principles with staff to improve family and carer involvement.
  Stated by Leeds and York Partnership NHS Foundation TrustStated completed
AI-generated summary

Neil Peter Bastock · 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

Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

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 heed family warnings about a patient’s fitness for discharge
Wider context from the report
“3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including: a) Mr Bastock left the ward on occasions and once did not return until 5am. b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him. c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded. d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered. e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section. f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales). ”
Source location
Neil Peter Bastock · 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 involve family in section rescission decisions
Wider context from the report
“1. The decision to rescind the section on 17.09.2020 was made: a. by a responsible clinician who had been in this role for only two weeks. b. his family were not involved in the decision at all and only became aware of it after it had been made. c. no formalised assessment of his mental capacity was made prior to the decisions. d. his care plan had not been updated. e. the pressure on bed availability in the Newsam Centre may have influenced the decision. ”
Source location
Neil Peter Bastock · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Ensure Triangle of Care principles are enacted consistently for service users and family members.

Verbatim wording from the response
“We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.”

Source location
2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 4 November 2021
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 and share Triangle of Care principles with staff to improve family and carer involvement.

Verbatim wording from the response
“We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.”

Source location
2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 4 November 2021
Open published response
20 Dec2019
Manchester (West)
Concerns raised2
1. Failure to invite family members to relevant MDT meetings
2. Failure to inform families and seek their views about decisions to remove a Mental Health Act section
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Revise and introduce the organisation-wide MH28 care planning and care coordination policy, including decision-making, communication, review, transition and discharge tools.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
2. Action
  Provide further training to management teams on the revised care planning and care coordination policy.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
3. Action
  Revise and implement MH12 Section 117 planning and MH10 family and external communication policies for people detained under the Mental Health Act.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
1. Action
  Establish an audit framework and conduct regular reviews to monitor compliance and service delivery across the revised care planning procedures.
  Stated by TRU (Transitional Rehabilitation Unit) LtdStated completed
AI-generated summary

David Richard Fowler · 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

David Richard Fowler, who had a significant history of mental illness, substance misuse and a brain injury, died after falling from a motorway bridge on 26 December 2018 with the intention of ending his life. Eight days earlier, his detention under section 3 of the Mental Health Act 1983 was removed without a community plan or legal framework. The report identified concerns that his family was not invited to the relevant meeting or consulted, and that there was confusion about responsibility for informing family members.

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 invite family members to relevant MDT meetings
Wider context from the report
“In David’s case, no steps were taken to invite ████████ (or any other family member) to the MDT meeting on the 18th December 2018 when the decision was made by the Responsible Clinician to remove David from the confines of section 3 (and section 17) of the Mental Health Act 1983. It is a requirement of the Mental Health Act 1983 that the nearest relative is informed. Further, family views were not sought regarding the decision to lift the section in any other way. At the inquest, staff remained unclear between themselves as to whose responsibility it was to inform the family. Whilst I was informed that a Policy has been drafted and is in the process of being ratified, it remained the case that there was no formal Policy in place covering contact with families in respect of the above decisions and/or in respect of inviting family members to MDTs more generally. I was further concerned that there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs and of any potential decision to remove a “section”. ”
Source location
David Richard Fowler · 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 inform families and seek their views about decisions to remove a Mental Health Act section
Wider context from the report
“In David’s case, no steps were taken to invite ████████ (or any other family member) to the MDT meeting on the 18th December 2018 when the decision was made by the Responsible Clinician to remove David from the confines of section 3 (and section 17) of the Mental Health Act 1983. It is a requirement of the Mental Health Act 1983 that the nearest relative is informed. Further, family views were not sought regarding the decision to lift the section in any other way. At the inquest, staff remained unclear between themselves as to whose responsibility it was to inform the family. Whilst I was informed that a Policy has been drafted and is in the process of being ratified, it remained the case that there was no formal Policy in place covering contact with families in respect of the above decisions and/or in respect of inviting family members to MDTs more generally. I was further concerned that there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs and of any potential decision to remove a “section”. ”
Source location
David Richard Fowler · 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
Revise and introduce the organisation-wide MH28 care planning and care coordination policy, including decision-making, communication, review, transition and discharge tools.

Verbatim wording from the response
“There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 1 · response
Published 6 January 2020
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
Provide further training to management teams on the revised care planning and care coordination policy.

Verbatim wording from the response
“There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 1 · response
Published 6 January 2020
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
Revise and implement MH12 Section 117 planning and MH10 family and external communication policies for people detained under the Mental Health Act.

Verbatim wording from the response
“I have also attached two revised policies specific to care planning policies for adults detained under the Mental Health Act most relevant to this regulation. These are the MH12 Section 117 planning policy and the MH10 Communicating to family and external parties’ policy for people under the Mental Health Act. These two policies outline specifically:”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 2 · response
Published 6 January 2020
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 an audit framework and conduct regular reviews to monitor compliance and service delivery across the revised care planning procedures.

Verbatim wording from the response
“I confirm there have been regular reviews of these procedures since the inquest and an audit framework has been devised to monitor continued compliance and service delivery in these areas including direct audit of the stages outlined in appendix 1.0 (care planning framework).”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 2 · response
Published 6 January 2020
Open published response
30 Sep2019
Liverpool and Wirral
Concerns raised1
1. Failure to consider and seek consent for family involvement in care planning
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Bring stakeholders together to scope routine electronic-record prompts for seeking consent to involve families in mental healthcare.
  Stated by NHS EnglandStated planned
2. Action
  Explore linking electronic-record consent prompts to national datasets to enable measurement and targeted improvement support.
  Stated by NHS EnglandStated planned
3. Action
  Continue linking with Health Education England on work to improve mental-health staff skills for family-engagement discussions and care planning.
  Stated by NHS EnglandStated in progress
1. Action
  Transform community mental-health care, including for young adults, through co-produced personalised care and support planning that centres carer and family involvement.
  Stated by NHS EnglandStated in progress
2. Action
  Develop information-sharing guidance and a consensus statement with Universities UK on when information can be shared without breaching confidentiality.
  Stated by NHS EnglandStated in progress
AI-generated summary

Ceara Marie Thacker · 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

Ceara Marie Thacker, a 19-year-old University of Liverpool student with a history of self-harm and contact with mental health services, was found deceased hanging on 11 May 2018. Concerns included the lack of discussion about involving her family in care planning and the absence of attempts to cut her down after she was found hanging; the first-aid training received by the person who found her did not cover hangings.

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 consider and seek consent for family involvement in care planning
Wider context from the report
“1. Throughout Ceara’s involvement with the medical professionals and therapists, whether Mersey Care, Mental Health Advisory team at the University or the GPs there is no evidence of any discussion around involving Ceara’s family in drawing up a plan or consideration of requesting consent from Ceara to discuss her situation with parents/family. It is accepted that Ceara was an adult and had full capacity, however, Ceara was a young adult, first time away from home who had history of mental health issues. It would have been helpful to have had these discussions so that if Ceara wanted that additional support from her family this could have been facilitated. That said it is unclear as to whether Ceara would have agreed to her family being involved, however, this line of enquiry would have been helpful. The general approach with young people appears to be to encourage them to discuss their issues with their parents/family rather than asking for consent for the professionals to discuss it with the parents/family. ”
Source location
Ceara Marie Thacker · 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
Bring stakeholders together to scope routine electronic-record prompts for seeking consent to involve families in mental healthcare.

Verbatim wording from the response
“There is clear existing guidance on the importance of seeking consent to involve family and friends.¹ Because of this we will focus our action to prevent future deaths on steps that would help ensure it is more reliably and consistently considered. This is potentially a complex undertaking, given the range of electronic patient record systems used in mental health services, and differing patient groups with different needs that need to be reflected within formats used to record information across a range of mental health services, and the need to work within the relevant legal frameworks, including giving due regard to information governance law, the Mental Capacity Act and the Mental Health Act. The NHS England & NHS Improvement mental health programme team will work with our partners in”

Source location
Response from NHS England
Page 1 · response
Published 4 June 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
Explore linking electronic-record consent prompts to national datasets to enable measurement and targeted improvement support.

Verbatim wording from the response
“NHSX and NHS Digital to bring together key stakeholders to scope whether it would be possible to routinely prompt seeking consent to involve families within electronic clinical record systems. We will also explore if the completion of those prompts can be directly linked to national datasets, as this would open the potential for measurement and for targeting improvement support where it is most needed.”

Source location
Response from NHS England
Page 2 · response
Published 4 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue linking with Health Education England on work to improve mental-health staff skills for family-engagement discussions and care planning.

Verbatim wording from the response
“We will also continue to link with Health Education England who deliver a range of workstreams focused on improving the skills of all staff working in mental health services,² as these skills underpin sensitive and challenging discussions with service users and care plans that genuinely engage family support. Our Long Term Plan work to transform community mental health care, including for young adults, has a specific focus on improving co-produced personalised care and support planning, in which carer and family involvement is central.”

Source location
Response from NHS England
Page 2 · response
Published 4 June 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
Transform community mental-health care, including for young adults, through co-produced personalised care and support planning that centres carer and family involvement.

Verbatim wording from the response
“We will also continue to link with Health Education England who deliver a range of workstreams focused on improving the skills of all staff working in mental health services,² as these skills underpin sensitive and challenging discussions with service users and care plans that genuinely engage family support. Our Long Term Plan work to transform community mental health care, including for young adults, has a specific focus on improving co-produced personalised care and support planning, in which carer and family involvement is central.”

Source location
Response from NHS England
Page 2 · response
Published 4 June 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
Develop information-sharing guidance and a consensus statement with Universities UK on when information can be shared without breaching confidentiality.

Verbatim wording from the response
“Increasingly universities are routinely asking for consent to contact students’ parents if support is felt to be needed, through registration questions phrased to ensure students understand the need for this. We are currently working with Universities UK to develop information sharing guidance and a consensus statement on when information can be shared without breaching confidentiality, and expect Universities UK to open consultation on draft guidance in the near future.”

Source location
Response from NHS England
Page 2 · response
Published 4 June 2025
Open published response
24 Jul2019
Manchester South
Concerns raised1
1. Failure of mental health trusts to communicate placement information with private providers and families
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Hannah Dolly Kaur Bharaj · 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

Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of mental health trusts to communicate placement information with private providers and families
Wider context from the report
“4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement. A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place; ”
Source location
Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
Page 3 · concerns
Open source report
9 Apr2019
Suffolk
Concerns raised1
1. Failure to involve the next of kin in care
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Evaluate next-of-kin processes, require corrective action, and monitor improvement through audit and quality and safety reviews.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
AI-generated summary

Anthony Hayward BUCKINGHAM · 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 Hayward BUCKINGHAM died at home on 13 March 2018 with a metal cable around his neck, after a previous suicide attempt and ongoing suicidal thoughts. The inquest highlighted concerns about the frequency of mental health visits, involvement of his father and practice nurse, a formal mental health assessment, and use of a care facility.

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 the next of kin in care
Wider context from the report
“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”
Source location
Anthony Hayward BUCKINGHAM · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Evaluate next-of-kin processes, require corrective action, and monitor improvement through audit and quality and safety reviews.

Verbatim wording from the response
“The Trust's internal investigation confirmed that the next of kin details were not obtained from Anthony, thereby impacting on their ability to engage his family. This was not picked up during the period of contact with the Home Treatment Team. A recommendation of work was made by the internal investigation resulting in the care team evaluating their processes. The clinical team leader monitors this taking action where required. The Trust obtains assurance of this improvement through means such as audit and its quality and safety reviews.”

Source location
2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 18 June 2019
Open published response
5 Oct2018
North Yorkshire
Concerns raised1
1. Insufficient exploration of family support to provide mental health scaffolding during delays in professional help
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

ROBIN ANDREW JAMES MCEWAN · 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

On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family 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
Insufficient exploration of family support to provide mental health scaffolding during delays in professional help
Wider context from the report
“Within the contexts of a) Primary Care and b) acknowledgement that referral access to specialist mental health services is considerably delayed and c) recourse to private therapy was sought in the meantime pending any referral and d) there are resources that can be shared in the ‘waiting’ period then: (1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety; (2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”; (3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis; (4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available ”
Source location
ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jun2018
Leicester City and South Leicestershire
Concerns raised1
1. Failure to routinely involve carers and families in the care of mentally unwell patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Complete supervision sessions for Mental Health Triage staff focused on family and carer involvement in assessment and improved working practice.
  Stated by Leicestershire Partnership NHS TrustStated planned
2. Action
  Provide Mental Health Triage and Crisis staff with NICE guidance on family and carer involvement.
  Stated by Leicestershire Partnership NHS TrustStated completed
3. Action
  Distribute a Whole Family Approach Bulletin to staff every two months to share family and carer involvement learning and good practice.
  Stated by Leicestershire Partnership NHS TrustStated completed
1. Action
  Expand family and carer content in record-keeping audits and monitor compliance through weekly audits and monthly clinical governance.
  Stated by Leicestershire Partnership NHS TrustStated in progress
AI-generated summary

John Charles Hazlewood · Prevention of Future Deaths report

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

Report summary

John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.

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 routinely involve carers and families in the care of mentally unwell patients
Wider context from the report
“2. Mr Hazlewood’s partner was repeatedly expressed to be his main or only protective factor from self-harm. She was not approached for information regarding his overdose, or her concerns regarding his escalating behavior and this missed an opportunity for the fuller picture to be captured when considering care planning and mental health assessment. This is an issue that I have raised with the Leicester Partnership Trust before in the matter of ████████ and it appears that carers/families are still not being routinely involved in the care of mentally unwell patients. This can create intolerable pressures upon families and leads to poor outcomes such as in these 2 cases. LPT are urged to consider how this matter can be embedded in training and practice. ”
Source location
John Charles Hazlewood · 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
Complete supervision sessions for Mental Health Triage staff focused on family and carer involvement in assessment and improved working practice.

Verbatim wording from the response
“Staff in our Assessment and Triage Team endeavor to elicit carers’ and families’ views regarding the care and treatment of patients, this enables us to gain an understanding of the whole person. However, this is clearly not always as effective as we would like. Although we implemented a number of actions in 2015 in response to the death of Mr. Abel, it is clear we need to continue to reinforce the importance of effective communication with families/carers. With this in mind, our senior Matron will complete work with the teams to ensure all staff in our Mental Health Triage team have a supervision session with the focus on family and carer involvement in the assessment process and discuss ways in which they can improve this within their working practice. This will be completed by October 2018.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 2018
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
Provide Mental Health Triage and Crisis staff with NICE guidance on family and carer involvement.

Verbatim wording from the response
“We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 2018
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
Distribute a Whole Family Approach Bulletin to staff every two months to share family and carer involvement learning and good practice.

Verbatim wording from the response
“We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 2018
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
Expand family and carer content in record-keeping audits and monitor compliance through weekly audits and monthly clinical governance.

Verbatim wording from the response
“We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 2018
Open published response
3 May2018
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to involve and inform families in psychiatric care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Martin Glyn Baker · 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

Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.

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 and inform families in psychiatric care
Wider context from the report
“(1) It was accepted in evidence that there had been a lack of communication with the family. They had not been involved in any psychiatric reviews instead, on one occassion, a consultant was left to rely upon information provided by a junior healthcare assistant. At inquest I expressed my view that where a patient has signed a consent form authorising discussion of relevant events with the family, the default position should be that there will be involvement of the family in the absence of any good reason not to do so, for example, a patient’s subsequent express instruction not to share something with the family. In this case the family were unaware that Mr Baker had been discharged from psychiatric support and were unaware of what to do in the event of deterioration in Mr Baker’s condition. ”
Source location
Martin Glyn Baker · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Mar2018
Somerset
Concerns raised2
1. Failure to document discharge consultation and explicitly discuss risks with families
2. Failure to provide independent consultation with families on discharge to family care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Edward Arthur Lundy · 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

Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.

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 document discharge consultation and explicitly discuss risks with families
Wider context from the report
“1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. ”
Source location
Edward Arthur Lundy · Prevention of Future Deaths report
Page 1 · 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 independent consultation with families on discharge to family care
Wider context from the report
“1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. ”
Source location
Edward Arthur Lundy · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to involve patients’ carers as equal partners in the development and review of Section 117 after-care plans

Concerns raised2

Failure to heed family warnings about a patient’s fitness for discharge

Failure to involve family in section rescission decisions

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Failure to invite family members to relevant MDT meetings

Failure to inform families and seek their views about decisions to remove a Mental Health Act section

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

Concerns raised1

Failure to consider and seek consent for family involvement in care planning

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure of mental health trusts to communicate placement information with private providers and families

Concerns raised1

Failure to involve the next of kin in care

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Insufficient exploration of family support to provide mental health scaffolding during delays in professional help

Concerns raised1

Failure to routinely involve carers and families in the care of mentally unwell patients

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

Actions described in response 2

Actions described in response 4

Actions described in response 5

Actions described in response 1

Actions described in response 4