21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid 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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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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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid
Wider context from the report “(7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP Cardiff
” Source location Alan Richard Miles Davies · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide basic life support, mental capacity and bespoke prison-nursing training, with the bespoke programme underway from May 2024.
Verbatim wording from the response “Since September 2021, there has been a shift in the Healthcare Team's skill mix, with the appointment of more nurses possessing general medical skills. These nurses are better equipped to identify and respond to patients at risk of deterioration. Training initiatives, including basic life support and mental capacity assessment, have been implemented, supported by a Practice Development Nurse. Additionally, a bespoke training program for Prison Nurses in Wales has commenced. in May 2024.” Source location Response from Cardiff and Vale University Health Board
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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 capacity assessment training to medical staff and plan annual refresher updates.
Verbatim wording from the response “Capacity Assessment has been imparted to medical staff, with plans for annual updates.” Source location Response from Cardiff and Vale University Health Board
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8 Feb 2024 Thomas GODDERIDGE · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure to account for variable and fluctuating capacity in capacity assessments View source
This report raised 1 other concern. 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. 4
Cumberland Council
Maintain a recurring Mental Capacity Act forum and reflective practice sessions addressing fluctuating capacity.
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Cumberland Council
Produce and circulate a seven-minute fluctuating-capacity briefing for managers to deliver in team meetings and staff supervision.
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Cumberland Council
Deliver rolling mandatory Mental Capacity Act training covering carers’ observations, executive capacity, fluctuating capacity and interpersonal influence.
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Cumberland Council
Deliver recurring legal briefings every six weeks addressing fluctuating capacity.
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Thomas GODDERIDGE · Prevention of Future Deaths report
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Report summary
Thomas Godderidge, aged 85, died from smoke inhalation after a fire broke out at his home on 16 February 2023. Concerns were raised about unreliable routine liaison between Adult Social Care and care providers when concerns arise about a service user's capacity, and about capacity assessments not consistently accounting for variable or fluctuating capacity.
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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 account for variable and fluctuating capacity in capacity assessments
Wider context from the report “(2) Mr Godderidge's carers also reported to me that in their experience consideration of capacity by Adult Social Care does not always reflect the possibility that a person's capacity may be variable and fluctuating . I am concerned that this gives rise to a risk of future deaths if a person is considered on a 'good day' without understanding that their presentation fluctuates substantially over time .
” Source location Thomas GODDERIDGE · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a recurring Mental Capacity Act forum and reflective practice sessions addressing fluctuating capacity.
Verbatim wording from the response “2. The council have a Mental Capacity Act forum in place which is open to social care and health practitioners across Adults and Childrens services. The last two forums have explored the topic of fluctuating capacity. On the 13th December 2023 the forum focused on Executive Dysfunction and was delivered by Dr Paul Russell (Consultant Clinical Psychologist), who spoke on practice experience of working with fluctuating capacity. A further forum took place on the 25th January 2024 and was a Community of Practice reflective practitioner session, with a focus on fluctuating capacity. The forum is a recurring event, providing a reflective workspace where key learning is shared, and practice is continually developed and improved.” Source location Response from Cumberland Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and circulate a seven-minute fluctuating-capacity briefing for managers to deliver in team meetings and staff supervision.
Verbatim wording from the response “3. The Adult Social Care Advanced Practice Lead team are producing a 7-minute briefing on fluctuating capacity for managers to deliver in team meetings and individual staff supervisions. This will remain available for continuous professional development for existing and any newly appointed staff in Adult Social Care. The target date for completion and circulation is 29th March 2024. The aim of this briefing is to raise and maintain awareness across all Adult Social Care teams, to improve practice and reduce the risk to our customer’s where fluctuating capacity is a factor in regards their care and support needs.” Source location Response from Cumberland Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver rolling mandatory Mental Capacity Act training covering carers’ observations, executive capacity, fluctuating capacity and interpersonal influence.
Verbatim wording from the response “4. A rolling programme of mandatory training regards the Mental Capacity Act is on the Training Plan and marked as ‘High Priority’. This will incorporate a specific focus around carers noting changes in presentation and how these are to be responded to. The program will also cover the main nuances such as executive capacity, fluctuating capacity and interpersonal influence on capacity. The Advanced Practice Lead team will utilise this training as the grounding from which Mental Capacity Act forums, Community of Practice forums, practice workshops” Source location Response from Cumberland Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver recurring legal briefings every six weeks addressing fluctuating capacity.
Verbatim wording from the response “5. Adult Social Care have planned legal briefings every 6 weeks, with the last briefing on the 20th March covering the matter of fluctuating capacity.” Source location Response from Cumberland Council
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31 Aug 2023 Donna Levy · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to undertake or consider a formal Mental Capacity Act assessment View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Donna Levy · 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
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.
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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 undertake or consider a formal Mental Capacity Act assessment
Wider context from the report “3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her.
4. No formal Mental Capacity Act assessment was ever undertaken or considered .
” Source location Donna Levy · Prevention of Future Deaths report
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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-capacity assessment training to all health and social care staff.
Verbatim wording from the response “• Provide mental capacity assessment training for all health and social care staff.” Source location Response from North East London Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete mental-capacity assessments in complex cases.
Verbatim wording from the response “• Complete mental capacity assessments in complex cases.” Source location Response from North East London Foundation Trust
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19 Feb 2023 Molly Ann Sergeant · Prevention of Future Deaths report Essex
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Concerns raised 1
Lack of appreciation of autism diagnosis and suicide risk in decision-making capacity 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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Molly Ann Sergeant · 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
Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.
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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 Lack of appreciation of autism diagnosis and suicide risk in decision-making capacity
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless.
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Source location Molly Ann Sergeant · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The acknowledged shortcomings were not causation or contributory factors in Molly’s death.
Verbatim wording from the response “It is not our view that these shortcomings, which we have fully acknowledged and have taken significant steps to ensure do not happen again, were causation factors or contributory factors which led to Molly’s very sad death.” Source location Response from Essex County Council
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1 Dec 2022 Mary Ebere Nwanyonyiri · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of assessment of patients’ capacity to refuse physical observations View source
This report raised 4 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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Mary Ebere Nwanyonyiri · 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
Mary Ebere Nwanyonyiri was admitted to Goodmayes Hospital after deterioration in her mental state and was found unresponsive on 19 April 2021; post-mortem investigations found that she died from Covid-19 infection. The report raised concerns about the absence of a written care plan and completed risk assessment, the lack of clear assessment of her capacity to refuse physical observations, and failures to recognise and respond urgently to the severity of her condition.
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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 Lack of assessment of patients’ capacity to refuse physical observations
Wider context from the report “1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved. The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery. Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations .
” Source location Mary Ebere Nwanyonyiri · Prevention of Future Deaths report
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23 Mar 2022 Emily Jane CALDICOTT · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Emily Jane CALDICOTT · 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 Jane Caldicott was admitted to hospital after an overdose and was later found unresponsive after tying a ligature around her neck. She died on 23 March 2020 from pneumonia and cerebral anoxia due to the application of a ligature. The principal concerns were that staff failed to adequately assess her capacity regarding Lorazepam, did not administer it in her best interests, and failed to remove the item used to make the ligature; the jury found these failures probably or possibly contributed to her death and identified a risk of future deaths.
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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 apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions
Wider context from the report “(6) Although staff on Holt Ward were undoubtedly having to deal with a very difficult situation in this case, I am concerned that if a such a decision has to be made in similar circumstances in the future, staff may not apply the correct test under the Mental Capacity Act 2005 , and there is therefore a risk of future deaths occurring.
” Source location Emily Jane CALDICOTT · Prevention of Future Deaths report
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3 Dec 2021 TERENCE TALBOT · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Lack of formal mental capacity assessments for treatment decisions View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Kent and Medway Mental Health NHS Trust Maidstone and Tunbridge Wells NHS Trust
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
Kent and Medway Mental Health NHS Trust
Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
View source
Kent and Medway Mental Health NHS Trust
Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
View source
Maidstone and Tunbridge Wells NHS Trust
Commission and complete an audit of consent and mental capacity practices.
View source
Maidstone and Tunbridge Wells NHS Trust
Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.
View source
Maidstone and Tunbridge Wells NHS Trust
Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.
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TERENCE TALBOT · Prevention of Future Deaths report
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Report summary
Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.
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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 Lack of formal mental capacity assessments for treatment decisions
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Source location TERENCE TALBOT · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
Verbatim wording from the response “2) A robust monitoring of Mental Capacity Assessment of patients under our care is conducted via Mental Health Act Committee (led by the Chief Medical Officer and reporting to Trust Board) thereby ensuring the highest level of scrutiny around this. Assurance on this is provided via a Clinical Quality check (CLiQ check) process across all our services particularly the in-patient services. Since September 2021 we have implemented a streamlined process for Mental capacity assessment which was developed using Quality Improvement methodology by our Quality Improvement team. This has resulted in significant improvement in completion and documentation of Mental Capacity Assessments and Best Interest decisions where capacity is lacking.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
Verbatim wording from the response “3) The Mental Capacity Act (MCA) training for the organisation is closely monitored, again via the Mental Health Act Committee. MCA training is mandatory for all our clinical staff and we are currently at ninety percent completion rate for this training.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete an audit of consent and mental capacity practices.
Verbatim wording from the response “Response
The Court is respectfully advised that the Trust has commissioned an audit into its consent and capacity practices. The external Trust Auditor has found that the Trust is broadly performing well. The recommendations from this review have been discussed by the Directorate leads and taken forward as part of the DATIX action plan noted above.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.
Verbatim wording from the response “Further, the Trust has introduced a new clinical advisor role as the lead clinician on capacity. The Trust has also appointed a new Mental Capacity Act clinical practitioner who will be available to assist the wards in dealing with complex cases. These leads will strengthen our oversight in ensuring the appropriate considerations around capacity are comprehensively covered.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.
Verbatim wording from the response “Along with the above training, the Trust continues to provide tailored, bespoke training sessions to all staff regarding the vital importance of capacity assessments. Again, regular audit and monitoring is being applied Trust wide. Such training is mandatory for each clinical member of staff.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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19 Nov 2021 Sarah McGarrigle · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to conduct capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Pennine Care NHS Foundation Trust
Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
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Pennine Care NHS Foundation Trust
Commission Mental Capacity Act training for all clinicians.
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Pennine Care NHS Foundation Trust
Deliver mental-capacity lunch-and-learn sessions in Oldham.
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Pennine Care NHS Foundation Trust
Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
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Pennine Care NHS Foundation Trust
Design a Mental Capacity Act audit.
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Pennine Care NHS Foundation Trust
Implement PARIS across inpatient mental health wards, including a mental-capacity assessment documentation template.
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Pennine Care NHS Foundation Trust
Share inquest learning about longitudinal mental-capacity assessment with senior Oldham consultant psychiatrists.
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Pennine Care NHS Foundation Trust
Escalate the need for additional longitudinal mental-capacity education to the Safeguarding Team and Mental Health Law and Scrutiny Group.
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Pennine Care NHS Foundation Trust
Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
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Sarah McGarrigle · 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
Sarah McGarrigle, aged 23, was found deceased at home on 1 March 2020. She died from catastrophic internal haemorrhage caused by spontaneous rupture of oesophageal varices associated with chronic alcohol use, in the context of trauma, mental disorder and self-neglect. The principal concerns were that relevant information about her history and community behaviours was not properly considered on Aspen Ward, and that a requested assessment of her mental disorder and capacity did not take place.
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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 conduct capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks
Wider context from the report “(2) That the Consultant Psychiatrists who reviewed the Deceased on Aspen Ward made the assumption that concern about the Deceased’s capacity was raised in the context of her withdrawal from alcohol . Consideration of the information that had been communicated to Aspen Ward (which included the specific limb of the capacity test that was in doubt) and a more longitudinal approach to the assessment would have shown that the concern related to the far more complex picture that the Deceased presented in the community and management of risks associated with self-neglect . This was not addressed by those responsible for assessing the Deceased on Aspen Ward .
” Source location Sarah McGarrigle · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
Verbatim wording from the response “• The concerns identified during the inquest have been reviewed by Professor Nihal Fernando, PCFT’s Executive Medical Director. Professor Fernando will share a copy of PCFT’s Regulation 28 response with the Aspen ward consultant Psychiatrists Responsible Officer, in his new Trust.” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission Mental Capacity Act training for all clinicians.
Verbatim wording from the response “There is evidence the Aspen Ward MDT considered Sarah’s mental capacity to make decisions about drinking alcohol, the risks associated with, however the Aspen Ward MDT did not complete and document a formal mental capacity assessment. This area of practice that required improvement had been identified in a PCFT investigation completed after Sarah’s death (but before Sarah’s inquest). Several actions have been taken since the time of Sarah’s admission to Aspen Ward which improve how inpatient wards consider and apply the mental capacity act in practice:” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mental-capacity lunch-and-learn sessions in Oldham.
Verbatim wording from the response “████████commissioned Mental Capacity Act training for all clinicians.
████████arding team have delivered lunch and learn sessions on mental capacity in Oldham.” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
Verbatim wording from the response “• Oldham's mental health services now have a route to refer patients to the Oldham multi-agency Adults with Multiple Complex Needs Meeting. This ████████to support professionals to work with complex patients who present with high levels of risk but are assessed as having the mental capacity to make unwise decisions or do not engage with their care and treatment.” Source location Response from NHS Pennine Care Foundation 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 Design a Mental Capacity Act audit.
Verbatim wording from the response “• The PCFT safeguarding team are designing a Mental Capacity Act audit.” Source location Response from NHS Pennine Care Foundation Trust
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 Implement PARIS across inpatient mental health wards, including a mental-capacity assessment documentation template.
Verbatim wording from the response “• PCFT has successfully implemented PARIS in all its inpatient mental health wards. This electronic patient record system includes a mental capacity assessment template that clinicians can use to document their assessments.” Source location Response from NHS Pennine Care Foundation 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 Share inquest learning about longitudinal mental-capacity assessment with senior Oldham consultant psychiatrists.
Verbatim wording from the response “• The learning from Sarah s Inquest regarding a potential missed opportunity for clinicians to consider a more longitudinal approach to assessing mental capacity assessments has been shared with senior Consultant Psychiatrists in Oldham. There was some agreement that additional education in this area could be beneficial. This will be escalated to the PCFT Safeguarding Team and the Mental Health Law and Scrutiny Group.” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate the need for additional longitudinal mental-capacity education to the Safeguarding Team and Mental Health Law and Scrutiny Group.
Verbatim wording from the response “• The learning from Sarah s Inquest regarding a potential missed opportunity for clinicians to consider a more longitudinal approach to assessing mental capacity assessments has been shared with senior Consultant Psychiatrists in Oldham. There was some agreement that additional education in this area could be beneficial. This will be escalated to the PCFT Safeguarding Team and the Mental Health Law and Scrutiny Group.” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
Verbatim wording from the response “• PCFT’s Head of Safeguarding and the Named Professional for Safeguarding Adults will make a recommendation to the Oldham Safeguarding Adult Partnership Board that a multi-agency protocol be developed. The recommended protocol would outline the roles and responsibilities of each agency when assessing mental capacity for complex patients with a mixture of health and social care needs. The guidance would also outline how multi-agency partners can request specialist mental health input for a mental capacity assessment.” Source location Response from NHS Pennine Care Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
Verbatim wording from the response “physical symptoms of withdrawal. On admission to Aspen Ward, she was not experiencing any alcohol-related behavioural issues. It is widely accepted that alcohol use can cause or increase symptoms of behavioural and/or mental illness. For some patients, when they stop alcohol, their symptoms can significantly improve or stop all together. Sarah’s overall presentation from the time she was assessed and detained under the MHA in the Royal Oldham Acute Hospital, compared to while an inpatient on Aspen was significantly better. Sarah appeared to improve in the time between being detained under Section 2 and being transferred to Aspen Ward (which was a period of several days). Sarah had been safely using leave off the medical wards for a cigarette break. While on Aspen Ward, she also used leave off the ward for cigarettes.” Source location Response from NHS Pennine Care Foundation Trust
Open published response
1 Nov 2021 Neil Peter Bastock · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to undertake a formalised mental capacity assessment before section rescission decisions View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
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Neil Peter Bastock · Prevention of Future Deaths report
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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.
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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 undertake a formalised mental capacity assessment before 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review medical staff training provision on mental capacity assessments.
Verbatim wording from the response “To support an improvement in relation to this area, the Trust’s Head of Mental Health Legislation, in conjunction with the Medical Director, will carry out a review of the current training provision for medical staff in relation to mental capacity assessments.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a Trust-wide audit of mental capacity assessments and best-interest decisions, including possible detention-rescission decisions.
Verbatim wording from the response “In January 2022, a Trust-wide audit relating to mental capacity assessments and best interest decisions will be undertaken. The Mental Health Legislation Team will review the audit tool to explore if the decision to rescind a detention can be incorporated within this audit.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss amending the Responsible Clinician form to prompt documentation of mental capacity assessments when rescinding detention.
Verbatim wording from the response “A discussion will be held through the Trust’s Mental Health Legislation Operational Steering Group to amend the form completed by the Responsible Clinician when a decision to rescind the section is made, which will include a prompt for the Responsible Clinician to ensure that a mental capacity assessment is documented.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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4 Oct 2021 Jude Daryl Lloyd · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to complete and properly record formal mental capacity assessments View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jude Daryl Lloyd · 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
Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.
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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 complete and properly record formal mental capacity assessments
Wider context from the report “b. No appropriate formal mental capacity assessments were made and properly recorded although this would also be relevant in managing his mental and physical conditions.
” Source location Jude Daryl Lloyd · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trigger formal Mental Capacity Assessments and Best Interest Meetings for inpatient concerns about capacity to consent to or refuse physical-health treatment, and disseminate the process.
Verbatim wording from the response “This was identified in the Trust’s investigation report under the sub-heading Summary of Inpatient Concerns and was addressed in recommendation 5 of the report. There are now clear processes in place in the inpatient service where any concerns raised in respect of a person’s capacity to consent to or refusal of physical health treatment would trigger a formal Mental Capacity Assessment and a Best Interest Meeting as part of the ward MDT meeting. This process has been shared at departmental meetings by the Lead Consultant for Salford Inpatients and the Salford Inpatient Operations Manager. In addition to this the Lead Consultant has introduced complex case meeting every 2 weeks. This is a medical peer group where cases can be brought for further discussion in respect of care planning.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver face-to-face Mental Capacity Act training to CMHT staff using case studies.
Verbatim wording from the response “The Trust expects all professionally qualified staff to undertake eLearning training in respect of the Mental Capacity Act (MCA). The current compliance with this training is; Salford inpatient wards 80-100% and CMHT 76%. In addition to the eLearning the social care lead for Central Manchester has developed and delivered 4 face to face sessions to CMHT staff regarding when MCA should be considered, using case studies to support learning. This delivery of these MCA training sessions is ongoing.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.