Concerns raised 1
Failure to achieve clear communication of key information with other agencies involved in patient care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
William Antony Northcott · 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 Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to achieve clear communication of key information with other agencies involved in patient care
Wider context from the report “It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been . I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team, and when dealing with its other agencies involved in a patient's care.
” Source location William Antony Northcott · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt SystmOne electronic patient records to enable consent-based information sharing between primary and secondary mental health services.
Verbatim wording from the response “There are a number of steps that Devon Partnership NHS Trust has adopted to ensure effective information sharing between those involved in the care of the patients.” Source location Response from Devon Partnership NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and implement a process for sharing annual clozapine health-check outcomes with mental health services.
Verbatim wording from the response “The practice would be happy to communicate the findings and results of the annual health checks with the Mental Health Services, providing that the patient has consented to this. We had considered involvement of the ICB and LMC to facilitate a streamlined approach. However, we have established that there is a Local Enhanced Service in place which we are currently reviewing and implementing a process to be able to share the outcomes and results from the annual review with Mental Health Services.” Source location Response from The Pembroke Medical Practice
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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 Clinical discussions with prescribers and care delivered by the Trust fall outside the regulator’s remit, so it cannot directly address them.
Verbatim wording from the response “We have considered the evidence provided and the circumstances leading to Mr Northcott’s death and acknowledge that most of your concerns relate to clinical discussions between a patient and their prescriber or via the clinical care delivered by the Trust. Unfortunately, the MHRA cannot directly address these points, as it is not within our remit to comment on the clinical care in specific cases.” Source location Response from Medicines and Healthcare Projects Regulation Authority
Open published response
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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 Devon Partnership NHS Trust is responsible for improving internal and cross-agency communication, so no direct response is provided.
Verbatim wording from the response “Concern 3:
Patients with treatment-resistant schizophrenia typically receive support from multiple teams and agencies. During the inquest, it became apparent that communication between professionals was, at times, suboptimal. The Coroner seeks assurance that Devon Partnership NHS Trust is working to improve internal and cross-agency communication.” Source location Response from Devon ICB
Open published response
20 Dec 2024 Antony Williamson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Inter-Trust communication channels failing between geographically proximate NHS Trusts View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Antony Williamson · 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
Antony Williamson experienced chronic pelvic pain and associated mental health difficulties, including increasing suicidal thoughts, before leaving home on 19 December 2023 and entering cold water. His body was found in the River Mersey on 17 March 2024, and the inquest concluded that he died from dry drowning and took his own life while experiencing hopelessness about the investigation and treatment of his pelvic pain. The report identified a lack of liaison and communication between the medical and mental health specialties involved in his care, with no formal framework to facilitate inter-specialty communication in complex cases.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inter-Trust communication channels failing between geographically proximate NHS Trusts
Wider context from the report “Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr Williamson’s care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others.
The inquest was told that there is a significant proportion of patients who are referred to the Pain Service who suffer poor mental health and who are therefore also under the care of mental health teams in the community.
The inquest heard that there is no formal framework (other than in cancer care and one specialist area of surgery) either locally or nationally to facilitate inter-specialty communication, particularly in complex and dynamic cases and further, that the existing channels of communication are more problematic between different NHS Trusts even within the same geographical area .
” Source location Antony Williamson · Prevention of Future Deaths report
Open source report
4 Nov 2024 Henry Joseph GRIERSON · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Failure to maintain communication between the college and external mental health support organisations View source
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AI-generated summary
Henry Joseph GRIERSON · 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
Henry Joseph Grierson was last seen at home on 20 April 2024 before leaving the address, later being found in a wooded area and pronounced dead by paramedics at 10:11 hours. The report raised concern that communication between Huddersfield New College, CAMHS and Recovery Steps was not maintained, leaving the college without awareness of his current mental health and his decision, with his family, to discontinue external support.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain communication between the college and external mental health support organisations
Wider context from the report “On the 13th November 2023 Henry Joseph Grierson with the consent of his Parents discontinued his referral and treatment from the organisation CAMHS, and on the 9th April 2024, Mr Grierson gave notice if his intention to discharge himself from the support organisation Recovery Steps.
No evidence has been presented to this Inquest as to the knowledge of these matters by the safeguarding team at Huddersfield New College.
No information concerning the current mental health issues of Mr Grierson had been provided to the College within a mitigation statement provided by him.
The evidence before the Court is that the latest communication concerning Mr Grierson's mental health provided by CAMHS was dated October 2023.
It is a matter of concern that communication between the college and CAMHS and Recovery Steps was not seemingly maintained to enable an awareness by the College of the current mental health of Mr Grierson in April 2024 and the decisions taken by himself and his family, to remove such external support .
” Source location Henry Joseph GRIERSON · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss multi-agency safeguarding communication with the NHS South West Yorkshire Partnership Foundation Trust.
Verbatim wording from the response “Notwithstanding our view that the discussion around multi-agency co-operation is not completely within our purview, representatives from the College have discussed the issue with their counterparts at the NHS South West Yorkshire Partnership Foundation Trust who have responsibility for CAMHS. In terms of steps that may be taken locally to improve the communication of information we can only act on matters within our control. We understand that the Trust have agreed in principle to write to you to set out the steps they will take as the provider of CAMHS services to address the concern you have raised.” Source location Response from Huddersfield New College
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and amend procedures for contacting external safeguarding agencies, including obtaining updates under Welfare Plans and during permanent exclusion.
Verbatim wording from the response “In terms of matters that are within our control, the College has reviewed and amended relevant policies and processes for contacting external agencies, particularly where a Welfare Plan has been created or when permanent exclusion is being implemented as a last resort. Included in this review of processes is College staff requesting and expecting updates from the external agencies involved in the safeguarding of a student, as identified and specified in their Welfare Plan. The College’s safeguarding team will remind external agencies of the responsibilities that they have to share safeguarding information, as detailed in ‘Keeping Children Safe in Education’ and ‘Working Together to Safeguard Children 2023’.” Source location Response from Huddersfield New College
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind external agencies of their safeguarding information-sharing responsibilities under applicable national guidance.
Verbatim wording from the response “In terms of matters that are within our control, the College has reviewed and amended relevant policies and processes for contacting external agencies, particularly where a Welfare Plan has been created or when permanent exclusion is being implemented as a last resort. Included in this review of processes is College staff requesting and expecting updates from the external agencies involved in the safeguarding of a student, as identified and specified in their Welfare Plan. The College’s safeguarding team will remind external agencies of the responsibilities that they have to share safeguarding information, as detailed in ‘Keeping Children Safe in Education’ and ‘Working Together to Safeguard Children 2023’.” Source location Response from Huddersfield New College
Open published response
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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 Implementing multi-agency communication changes is outside the College’s authority and requires discussion at a higher level.
Verbatim wording from the response “The College will always do anything we can to support our students, and we welcome the Coroner’s findings. We agree with the Coroner’s conclusion that steps need to be taken to enhance the communication from organisations such as CAMHS to schools and colleges, but consider this to be a conversation that needs to be had at a much higher level. Given that the College does not have the power to make and implement changes on behalf of other organisations, we have met with representatives of the Department for Education to explain the issues and to bring their attention to the challenges regarding multi-agency communication. The provision of clearer guidance about what triggers communication from such organisations would provide valuable clarity for the whole sector.” Source location Response from Huddersfield New College
Open published response
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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 NHS Trust responsible for CAMHS services is responsible for setting out steps to improve local information-sharing.
Verbatim wording from the response “Notwithstanding our view that the discussion around multi-agency co-operation is not completely within our purview, representatives from the College have discussed the issue with their counterparts at the NHS South West Yorkshire Partnership Foundation Trust who have responsibility for CAMHS. In terms of steps that may be taken locally to improve the communication of information we can only act on matters within our control. We understand that the Trust have agreed in principle to write to you to set out the steps they will take as the provider of CAMHS services to address the concern you have raised.” Source location Response from Huddersfield New College
Open published response
30 Oct 2024 Sebastian Benjamin OLIVER · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to seek clarification and communicate effectively with medical colleagues about fluctuating or lacking capacity View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
West Midlands Police
Require officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.
View source
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AI-generated summary
Sebastian Benjamin OLIVER · 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
Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to seek clarification and communicate effectively with medical colleagues about fluctuating or lacking capacity
Wider context from the report “3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call).
4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check".
5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed.
6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres . It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue.
7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity.
” Source location Sebastian Benjamin OLIVER · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.
Verbatim wording from the response “(iii) Collaboration with partners: Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded utilising WMP systems and fed back to WMP supervisors and shared with the reporting partner agency. Whilst WMP can professionally challenge partners it is more appropriate to follow the process in the best interest of the public and inaccuracies be fed back within working groups such as Joint Strategic Operation Groups (JSOG) to aid future learning.” Source location Response from West Midlands Police
Open published response
3 Oct 2024 Mrs Gabrielle Sarah Anne Steel · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to leave or share written fire risk management plans with relevant recipients View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
London Fire Brigade
Review information-sharing processes, the data-protection impact assessment and third-party disclosure arrangements, consulting information-management specialists and the Information Commissioner.
View source
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AI-generated summary
Mrs Gabrielle Sarah Anne Steel · 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 Gabrielle Sarah Anne Steel, who was bed bound and known to smoke in bed and drink alcohol, died after a fire on her bed at her home on 17 October 2023. The fire investigation identified the likely cause as unsafe disposal of smoking materials, and the flame-retardant duvet cover was not on the bed. The principal concerns were poor communication of the fire safety assessment and the absence of a shared written fire risk management plan for those caring for her.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to leave or share written fire risk management plans with relevant recipients
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her.
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check .
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” Source location Mrs Gabrielle Sarah Anne Steel · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review information-sharing processes, the data-protection impact assessment and third-party disclosure arrangements, consulting information-management specialists and the Information Commissioner.
Verbatim wording from the response “Noting HM Coroner's observations, we have started to review our processes and have engaged with our Information Management Team to discuss the data protection issues around sharing information with third parties where the resident has full mental capacity. LFB are reviewing the data protection privacy impact assessment and consulting the Information Commissioner to fully scope how we can best meet this need while ensuring privacy for the resident.” Source location Response from London Fire Brigade
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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 Existing policy authorises sharing advice only with a resident who can understand and retain it, so staff followed the correct process.
Verbatim wording from the response “Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person. Providing staff are satisfied that the individual recipient is able to understand and retain the advice given, they share advice and observations face to face. During the booking of Mrs Steel's Home Fire Safety Visit it was confirmed that Mrs Steel was able to understand, process and retain the information provided – this was noted on our records and therefore the crews followed the correct process as outlined in the policy.” Source location Response from London Fire Brigade
Open published response
12 Aug 2024 Douglas ARMSTRONG · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to communicate the limits of responders' diagnostic ability to ambulance services View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Douglas ARMSTRONG · 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
Douglas ARMSTRONG had an unwitnessed fall at home on 16 December 2023 and sustained a fractured neck of femur that was not identified by care agency responders or a district nurse. His hospital arrival and likely surgery were delayed by around 18 hours, and he died in hospital on 5 January from aspiration pneumonia resulting from the injury. The principal concern was that responders may lack the skills, knowledge, training, or communication needed to identify such injuries or recognise when further assessment is required.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate the limits of responders' diagnostic ability to ambulance services
Wider context from the report “Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment.
Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation.
” Source location Douglas ARMSTRONG · Prevention of Future Deaths report
Open source report
12 Aug 2024 Mr David Thompson · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure of consultant-to-consultant communication across NHS and private care View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Pennine Care NHS Foundation Trust Priory Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Pennine Care NHS Foundation Trust
Send all doctors formal guidance on sharing correspondence when patients receive NHS and private-provider care.
View source
Pennine Care NHS Foundation Trust
Liaise with Medical Directors of Priory, Elysium and Cygnet to address communication failures collaboratively.
View source
Pennine Care NHS Foundation Trust
Provide five Band 7 Out of Area Practitioners to monitor private out-of-area placements, coordinate providers and support discharge planning.
View source
Priory Group
Remind clinicians to obtain and consider patients’ background history and involvement of other services at admission.
View source
Priory Group
Disseminate guidance on identifying and liaising with external care providers through network meetings, circulated minutes and a learning cascade.
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AI-generated summary
Mr David Thompson · 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
Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of consultant-to-consultant communication across NHS and private care
Wider context from the report “1. There was a complete absence of any Consultant – Consultant discussions or communication , given this patient was receiving care from both the NHS and privately .
” Source location Mr David Thompson · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send all doctors formal guidance on sharing correspondence when patients receive NHS and private-provider care.
Verbatim wording from the response “In order to provide assurance that Pennine Care NHS Foundation Trust’s doctors are also adhering to this guidance formal communication has been sent to all doctors within the organisation from our Medical Director reminding them of this guidance and the GMC’s stipulation that all doctors must follow this. It also highlights this case and asks the doctors to take particular care if a patient is receiving treatment from both an NHS and private provider and that the private provider will also be copied into any correspondence.” Source location Response from Pennine Care NHS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise with Medical Directors of Priory, Elysium and Cygnet to address communication failures collaboratively.
Verbatim wording from the response “The organisation’s Medical Director will also liaise with the Medical Directors of all the private providers that Pennine Care patients are known to be placed. Contact will be made with the Priory, Elysium and Cygnet to raise the profile of this identified issue and to work collaboratively to ensure that this issue does not occur again.” Source location Response from Pennine Care NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide five Band 7 Out of Area Practitioners to monitor private out-of-area placements, coordinate providers and support discharge planning.
Verbatim wording from the response “To ensure the quality and consistency of the care of Pennine Care patients who are placed in an out of area private bed, an Out of Area Practitioner is responsible for monitoring the inpatient stay, linking in with the relevant providers and inpatient operational leads to ensure all patients receive support and discharge planning as required. The Out of Area Practitioner is a senior mental health practitioner (Band 7) who sits within the Patient Flow Team. They act as a case manager for that patient including attending ward rounds, keeping key professionals (including all Consultants) updated and involvement in repatriation and discharge planning. There are five of these practitioners within the organisation and each practitioner covers one of the five boroughs in which services are commissioned.” Source location Response from Pennine Care NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind clinicians to obtain and consider patients’ background history and involvement of other services at admission.
Verbatim wording from the response “Issue a reminder to all staff regarding the expectation that a patient’s background history is gained and understood at the point of admission.” Source location Response from Priory Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate guidance on identifying and liaising with external care providers through network meetings, circulated minutes and a learning cascade.
Verbatim wording from the response “To ensure this learning point is reiterated to all consultants across Priory, the importance of identification and liaison (where appropriate) with external organisations involved in the care and treatment of a patient was raised at:” Source location Response from Priory Group
Open published response
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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 organisation disputes that Consultant-to-Consultant communication failed through its omission, stating it was unaware of the private outpatient appointment.
Verbatim wording from the response “The organisation was not aware that David attended an outpatient appointment with ████████ at the Priory Hospital, Altrincham and therefore the opportunity for Consultant to Consultant communication to take place did not happen. The organisation’s expectation is for ████████ to copy the organisation into David’s clinic letter as per the section of ‘Contributing to continuity of care’ within the General Medical Council’s (GMC) ‘Good Medical Practice.’ The guidance states:” Source location Response from Pennine Care NHS
Open published response
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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 doctor who sees the patient, rather than the GP, is responsible for sharing clinic correspondence with other care providers.
Verbatim wording from the response “It was ████████’s evidence that the clinic letter was shared with David’s GP and he expected the GP to then share this information with all other care providers. This is not the responsibility of the GP but the responsibility of the doctor who has seen the patient. This evidence was factually incorrect and it is the view of the organisation’s Medical Director, ████████, that this is in breach of the GMC’s Good Medical Practice, which all doctors must follow.” Source location Response from Pennine Care NHS
Open published response
23 Jul 2024 Neil Woodley · Prevention of Future Deaths report South London
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Concerns raised 1
Failures in communication during welfare-check responses View source
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AI-generated summary
Neil Woodley · 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 Woodley was found ████████ at 7.25 am on 4 January 2024, and evidence from suicide notes suggested that he had killed himself overnight. A colleague called the police because he had not arrived at work, but an ambulance attended the following day after an alleged communication failure between Surrey Police and the Metropolitan Police. The concern was that failures in communication could result in avoidable fatalities in future cases, although the report states that earlier attendance would not have affected this outcome.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failures in communication during welfare-check responses
Wider context from the report “Mr Woodley’s brother and sister-in-law gave evidence at the hearing that a colleague of Mr Woodley called the police on the morning of 4 January concerned that he had not arrived at work. Their evidence was that an ambulance arrived to carry out a welfare check the following day (5 January) at around 1pm. They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police .
On the evidence before me, including that of Mr Woodley and his wife, I am satisfied that an earlier attendance would not have affected the outcome. However, I am concerned that failures in communication could result in avoidable fatalities in future cases .
” Source location Neil Woodley · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver learning to MPS staff and officers on district location sharing and compliance with relevant standard operating procedures.
Verbatim wording from the response “As an organisation, learning will be delivered to MPS staff and officers, highlighting the importance of district location sharing and compliance with standard operating procedures designed to protect front line policing and prevent correlation errors such as this incident.” Source location Response from Metropolitan Police
Open published response
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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 records do not show a communication failure between Surrey Police and the Metropolitan Police Service; both calls were handled correctly.
Verbatim wording from the response “Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.” Source location Response from Surrey Police
Open published response
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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 Existing procedures for transferring calls to other police forces were followed appropriately and ensured timely information transfer.
Verbatim wording from the response “Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.” Source location Response from Surrey Police
Open published response
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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 No communication failure between Surrey Police and the Metropolitan Police occurred because no record of a relevant 4 January call exists.
Verbatim wording from the response “The MPS have no records of Mr Woodley’s work colleague or SPS contacting the MPS regarding an incident concerning Mr Woodley on 4th January 2024.” Source location Response from Metropolitan Police
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3
Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to inform BSMHFT when missing patient investigations are closed View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association of Police and Crime Commissioners Birmingham and Solihull Mental Health NHS Foundation Trust Department of Health and Social Care Home Office National Police Chiefs’ Council NHS England West Midlands Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Birmingham and Solihull Mental Health NHS Foundation Trust
Circulate the RCRP escalation process to responsible clinicians, senior nurses and clinical staff, including its incorporation in the updated policy.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Continue updating and circulating the escalation process when contact details change.
View source
NHS England
Share information with health systems on establishing multi-agency governance, delivery structures, risk management, escalation and communication.
View source
NHS England
Issue guidance to health systems covering multi-agency governance, delivery structures and real-time and retrospective escalation processes.
View source
West Midlands Police
Maintain and disseminate the partner escalation process, including direct access to the Force Duty Manager for decision reviews.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Require police to notify the Trust in writing of decisions and reasoning when not deploying immediately after critical concern is communicated.
View source
West Midlands Police
Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
View source See 4 more actions
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AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” Source location Tcherno Bari · Prevention of Future Deaths report
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 Delays in communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” Source location Tcherno Bari · Prevention of Future Deaths report
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 BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” Source location Tcherno Bari · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the RCRP escalation process to responsible clinicians, senior nurses and clinical staff, including its incorporation in the updated policy.
Verbatim wording from the response “The updated policy sets out clearly the RCRP escalation process (challenge process) under Appendix K. This has been circulated to responsible clinicians and senior nurses within BSMHFT. As the escalation procedure contact details alter in the future, the process will continue to be updated and circulated to all senior clinicians in BSMHFT and will continue to be part of the missing persons policy.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue updating and circulating the escalation process when contact details change.
Verbatim wording from the response “The updated policy sets out clearly the RCRP escalation process (challenge process) under Appendix K. This has been circulated to responsible clinicians and senior nurses within BSMHFT. As the escalation procedure contact details alter in the future, the process will continue to be updated and circulated to all senior clinicians in BSMHFT and will continue to be part of the missing persons policy.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share information with health systems on establishing multi-agency governance, delivery structures, risk management, escalation and communication.
Verbatim wording from the response “To support implementation, NHS England has shared information with health systems about setting up multi-agency governance and delivery structures to oversee delivery, manage risks and escalations and enable open communication between local” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance to health systems covering multi-agency governance, delivery structures and real-time and retrospective escalation processes.
Verbatim wording from the response “partners, including to resolve any challenges. Information has also been shared on escalation protocols, including the need for local partners to set up real-time escalation processes (in response to a situation that is currently live) and retrospective escalation processes (to review situations that have occurred, learn lessons and agree changes going forward). This information will be included in guidance that NHS England will issue to health systems shortly.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and disseminate the partner escalation process, including direct access to the Force Duty Manager for decision reviews.
Verbatim wording from the response “HM Coroner was made aware of an escalation process that has also been put in place for our partner agencies during the inquest, should partners be concerned that a WMP colleague has not made the correct decision. The telephone number for contacting the most senior WMP officer on duty in the Force Contact Department has been shared (see Exhibit 1 below). This number allows partners to speak to the WMP Force Duty Manager directly, who will immediately seek a review of the decisions made.” Source location Response from West Midlands Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require police to notify the Trust in writing of decisions and reasoning when not deploying immediately after critical concern is communicated.
Verbatim wording from the response “Under the updated policy the police will formally notify BSMHFT in writing, with their decision and reasoning if they have decided not to deploy immediately, when critical concern is communicated to them by a mental health nurse in regard to a inpatient who is missing. This would enable the escalation process to be taken forward by senior clinicians as set out in Appendix K, if necessary.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
Verbatim wording from the response “BSMHFT and send an appropriate staff member, as required. The WMP missing persons policy will be updated to reflect this.” Source location Response from West Midlands Police
Open published response
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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 Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
Verbatim wording from the response “Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.” Source location Response from DHSC
Open published response
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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 Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
Verbatim wording from the response “As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.” Source location Response from the Home Office
Open published response
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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 Each Chief Constable decides whether and when to implement Right Care Right Person and which elements of the national framework to adopt.
Verbatim wording from the response “As Policing is operationally independent, each Chief Constable has to decide whether and when to implement Right Care Right Person and how much of the framework set out in the National Partnership Agreement and supporting guidance they wish to adopt.” Source location Response from the Home Office
Open published response
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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 Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.
Verbatim wording from the response “healthcare facilities. Missing Persons is not a part of this and existing police procedure regarding police involvement should continue to operate.” Source location Response from the Home Office
Open published response
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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 APCC cannot mandate its members to undertake actions in response to the identified safety concerns.
Verbatim wording from the response “As a membership body, the APCC cannot mandate actions upon its members. However, our role does include the provision of advice and recommendations to inform our members’ local activities, including the development of evidence-based guidance.” Source location Response from APCC
Open published response
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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 Operational implementation of Right Care, Right Person is assigned to Chief Constables rather than Police and Crime Commissioners.
Verbatim wording from the response “At a local policing level, PCCs are not responsible for making operational policing decisions, including the implementation of Right Care, Right Person, this is a decision for Chief Constables. Rather, PCCs are responsible for scrutinising their Chief Constables and holding them to account for the delivery of their duties. Additionally, PCCs have responsibilities to commission services, and where necessary, to bring partners together and work with them.” Source location Response from APCC
Open published response
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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 RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.
Verbatim wording from the response “The Missing persons framework is another distinct policy area which falls outside of RCRP when it is established that a persons whereabouts cannot be ascertained and all reasonable enquiries have been made by the informant to ascertain their whereabouts.” Source location Response from NPCC
Open published response
21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Failure to communicate relevant clinical information before transfer View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Alan Richard Miles Davies · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate relevant clinical information before transfer
Wider context from the report “(1) There was limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr Davies’ discharge . In particular, information that Mr Davies had commenced food refusal following the s 117 meeting and that it had not been possible to assess him physically prior to transfer was not clearly communicated to HMP Cardiff before the transfer occurred
” Source location Alan Richard Miles Davies · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Verbatim wording from the response “Regarding communication pathways, collaborative efforts with relevant parties have led to the development of a Standard Operating Procedure (SOP) for transferring individuals with mental/physical health needs into our care. This SOP delineates the necessary information required by HMP Cardiff to assess the individual's health needs and outlines a reliable route for sharing information across organisations to mitigate information-related risks. The protocol also identifies” Source location Response from Cardiff and Vale University Health Board
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.