Recurring concern

Failure to manage sleep deprivation risks to mental health and suicide

First to latest report 5 Jun 2017 — 27 Jun 2022

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
1

What this concern includes

Includes failures of controls specifically intended to identify, communicate, refer or otherwise manage sleep deprivation or significant sleep problems where the reported safety relevance is deterioration in mental health or suicide risk, including information sharing about those risks and referral of insomnia to appropriate sleep services.

What is not included
  • Excludes generic mental-health information-sharing failures where sleep deprivation or a significant sleep problem is not the bounded safety concern.
  • Excludes routine sleep advice, sleep hygiene or insomnia services where no mental-health or suicide-related safety risk is identified.
  • Excludes unrelated mental-health referral, treatment or suicide-prevention failures that do not materially concern sleep deprivation or significant sleep problems.
  • Excludes factual descriptions of poor sleep or insomnia without an identified failure of a dedicated recognition, communication, referral or management control.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East Riding and Hull

    AI-generated summary

    Jessica Louise LAVERACK “Jessie” · 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

    Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.

    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 information sharing about sleep deprivation risks and impacts on mental health and suicide

    Wider context from the report

    “(11) To consider better information sharing about the risks of sleep deprivation and its impact on mental health and suicide. ”

    Source location

    Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    The Department for Health and Social Care will respond separately on information sharing about sleep deprivation, mental health and suicide risks.

    Verbatim wording from the response

    “The Department for Health and Social Care will respond separately on better information sharing about the risks of sleep deprivation and its impact on mental health and suicide.”

    Source location

    Response from Home Office (2)
    Page 2 · response
    Published 3 November 2022

    Open published response

  2. Manchester South

    AI-generated summary

    David Ian Hamilton · 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 Ian Hamilton developed insomnia in October 2016, sought help from healthcare services, and was prescribed mirtazapine. He became increasingly anxious and reported thoughts of self-harm before being found dead at home on 7 February 2017; the investigation concluded that the death was suicide. Concerns included limited information-sharing between health professionals, unclear referral and escalation processes, lack of referral to sleep clinic services, and insufficient documentation of therapy selection.

    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 make referrals to sleep clinic services for insomnia

    Wider context from the report

    “4. Referrals were not made to sleep clinic services to assist with insomnia ”

    Source location

    David Ian Hamilton · 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

    Escalated the lack of local insomnia sleep-clinic provision and referral support to the Tameside and Glossop CCG mental health lead.

    Verbatim wording from the response

    “Based on the information that the RAID team is advising patients to ask for sleep clinic referrals and their letter to us advising us to refer, we have since found out that there is no sleep clinic for insomnia within Manchester. The nearest sleep clinic for insomnia is Blackpool and there is a 20 week waiting list. The Choose and Book referral system also offered sleep clinic in Sherwood, Nottingham, and the waiting list is 20 days. There is no other therapy being offered within Manchester for Insomnia. It would therefore be helpful in informing the RAID team of the lack of this service within Manchester area, if they are already not aware, so that patients can be guided appropriately by them.”

    Source location

    2017-0180-Response-by-Grosvenor-Medical-Centre
    Page 2 · response
    Published 4 August 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

    Local insomnia sleep-clinic provision is unavailable, so referrals require distant services with substantial waiting times.

    Verbatim wording from the response

    “Based on the information that the RAID team is advising patients to ask for sleep clinic referrals and their letter to us advising us to refer, we have since found out that there is no sleep clinic for insomnia within Manchester. The nearest sleep clinic for insomnia is Blackpool and there is a 20 week waiting list. The Choose and Book referral system also offered sleep clinic in Sherwood, Nottingham, and the waiting list is 20 days. There is no other therapy being offered within Manchester for Insomnia. It would therefore be helpful in informing the RAID team of the lack of this service within Manchester area, if they are already not aware, so that patients can be guided appropriately by them.”

    Source location

    2017-0180-Response-by-Grosvenor-Medical-Centre
    Page 2 · response
    Published 4 August 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026