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. Inner North London

    AI-generated summary

    Emily VOUKELATOU · 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

    Emily Voukelatou left North Camden Crisis House after writing notes of intent, travelled to Beachy Head on 30 June 2016, and jumped from the cliff. Concerns included the lack of routine involvement of family members in care and Crisis House’s failure to return her sister’s repeated calls before and after her death.

    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 family members in patient care

    Wider context from the report

    “1. I heard evidence from the consultant psychiatrist responsible for Ms Voukelatou’s care at Crisis House that it is not routine for the crisis team to involve family members in the care of a patient. I wonder whether that is a policy that would benefit from reconsideration? Otherwise potentially helpful input may be lost. One of the mental health nurses said that families are sometimes invited to meetings, but nobody thought about this for Ms Voukelatou. Her family live in Greece, but she was close to her mother and twin sister, and arrangements might have been made, perhaps for a telephone meeting. ”

    Source location

    Emily VOUKELATOU · 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 updated mandatory risk-assessment training reinforcing the importance of working with families, with monthly delivery to clinical staff.

    Verbatim wording from the response

    “We have also reinforced the importance of working with families in our updated, risk assessment training which has been rolled out over the last 12 months. I have enclosed our updated risk assessment training for your information. Our risk assessment training is mandatory for all clinical staff. Our updated training has been implemented throughout the last year. It is run on a monthly basis, in partnership with Middlesex University. To date nearly 500 members of staff have been trained.”

    Source location

    2017-0004-Response-by-Camden-and-Islington-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Routine family-involvement assessment, patient consent considerations and mandatory training are considered sufficient without reconsidering the policy.

    Verbatim wording from the response

    “You heard evidence from the consultant psychiatrist responsible for Ms Voukelatou’s care that it is not routine practice for the crisis team to involve family members in a patient’s care. You have asked whether this policy would benefit from reconsideration to ensure that potentially helpful input from family members is not lost. You have also questioned whether arrangements might have been made for a telephone meeting with Ms Voukelatou’s family in Greece.”

    Source location

    2017-0004-Response-by-Camden-and-Islington-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    Open published response

  2. Leicester City and South Leicestershire

    AI-generated summary

    William Abel · 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

    William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would keep him safe.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate communication of professional concerns and safe-keeping expectations to family members

    Wider context from the report

    “2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night. ”

    Source location

    William Abel · 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

    Document family members’ presence, offer them opportunities to provide views and observations, and include this information in assessment outcomes.

    Verbatim wording from the response

    “Family members’ presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual. This information will be documented on the assessment form by the assessing professional and form part of the outcome of assessment.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    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

    Introduce an assessment-outcome and plan form providing patients and, with consent, accompanying carers or family members written advice and access information.

    Verbatim wording from the response

    “The service is introducing an outcome of assessment and plan record form to support the routine work of the Triage Car and Crisis Teams, ensuring that all patients come into contact with the Triage Car Mental Health Practitioner team are given key written information clarifying the immediate advice given, and where and how to access help should they need it. This will also be given to a carer, friend or family member if they are present at the assessment and the patient has consented to their involvement. We will implement this change for the Triage Car team by the end of December 2015 and the wider Crisis Team by the end of January 2015.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 3 · response
    Published 20 October 2015

    Open published response

  3. Surrey

    AI-generated summary

    Katherine Liana Bonaventura · Prevention of Future Deaths report

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

    Report summary

    Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment outcome.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a system for sufficiently thorough private consultation with family members or carers after inpatient leave

    Wider context from the report

    “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.” It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area. It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return. It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit. ”

    Source location

    Katherine Liana Bonaventura · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Black Country

    AI-generated summary

    Nadine Gillian THURMAN · 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

    Mrs Nadine Gillian Thurman was found hanging at home on 5 November 2012, following recent episodes of paracetamol and vodka misuse and hospital treatment. The concerns related to psychiatric assessment, including the exclusion of a relative from contributing and the reported practice of the crisis team refusing relatives' presence.

    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 a neutral approach to family involvement in psychiatric assessments

    Wider context from the report

    “My concerns relate to the psychiatric assessment of Mrs. Thurman. ████████ gave evidence to me that he was not allowed to contribute to the assessment. I was told that Mrs. Thurman was asked by a nurse if she was content to be seen on her own. That seems to me to be an approach that is suggestive of the answer and is likely to exclude relevant information. It seems to me that the approach to someone being assessed should be along the lines “Are you happy for your family to be involved in and make a contribution to the assessment”. I was also told by a hospital nurse that on contacting the crisis team to ask if a relative could be present, the crisis team always refuse. ”

    Source location

    Nadine Gillian THURMAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Inner South London

    AI-generated summary

    Kirabo Kiwanuka · 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

    Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

    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 in best-interests decisions for sectioned patients lacking capacity

    Wider context from the report

    “3. Where a patient lacks capacity and is under section, the involvement of the family in determining her best interests is required but here it was limited and yet they had concerns about the risks of treatment. The parents were not given the opportunity to contribute their views to the decision to administer Acuphase, but decisions had to be taken in situations of acute disturbance. What is the role of each of psychiatrists, physicians and next of kin in reaching critical care decisions for sectioned patients with acute medical and psychiatric problems? ”

    Source location

    Kirabo Kiwanuka · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Sunderland

    AI-generated summary

    May Stokoe and James Henderson Stokoe · 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 1 May 2013, May Stokoe was fatally attacked with a knife and James Henderson Stokoe inflicted fatal knife injuries on himself. The report raised concerns about the assessment and involvement of carers or partners in mental health services, including whether their information could better inform risk assessments and whether domestic abuse involving older people might be missed.

    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 formally consult carers or partners in mental health welfare assessments

    Wider context from the report

    “I was also concerned about the possibility that carers or partners of individuals who are subject to the provision of Mental Health Services are not formally consulted about the welfare of the patient/service user. Although I was satisfied that domestic abuse awareness was an integral part of training for Mental Health staff, the circumstances of the deaths of Mr and Mrs Stokoe did raise for me concerns that more formal involvement of a carer/partner may allow them to make disclosures which might better inform the assessment process. For example, information from them may corroborate or verify that being provided by the service user/patient. In my view carers/partners may be a very valuable source of information which may not necessarily be disclosed or volunteered by the service user or patient. Carers/partners should have more visibility to the Mental Health Services and domestic abuse involving the elderly cannot be discounted and matters should be approached with an open mind. ”

    Source location

    May Stokoe and James Henderson Stokoe · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026