5 Feb 2026 Kallum Josh REED · Prevention of Future Deaths report West London
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Concerns raised 1
Unacceptably long waits for ASD and ADHD referrals, assessments and diagnoses View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care West London 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
West London NHS Trust
Commission additional private-provider capacity for adult autism diagnostic assessments.
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West London NHS Trust
Monitor delivery and waiting lists through robust monitoring and quality-assurance measures.
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West London NHS Trust
Streamline and improve internal adult autism assessment pathways.
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West London NHS Trust
Agree with commissioners that adult autism assessment capacity will be augmented.
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Department of Health and Social Care
Invest in training professionals in autism and ADHD diagnostic assessment.
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AI-generated summary
Kallum Josh REED · 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
Kallum Josh REED died after being found fully suspended during a police search following his disappearance on 11 February 2025. The report raises concerns about delays in autism spectrum disorder and ADHD referrals, assessments and diagnoses, and about crisis-care referral pathways and coordination between mental health services.
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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 Unacceptably long waits for ASD and ADHD referrals, assessments and diagnoses
Wider context from the report “(1) The first concern is the "unacceptably long wait" for referrals, assessments and diagnoses of ASD and ADHD . The court was told that demand is continuing to outstrip the services ability to cope ; services are outsourced to private providers but there are still unacceptable delays . This impacts the provision of care, the provision of appropriate medication, providing the individuals with insight and understanding of their own presentations and the provision of professional support. In Kallum's case this contributed to the factors that caused his death. I am therefore raising this concern with the Minister for the DHSC and the WLNHS Trust
” Source location Kallum Josh REED · 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 Commission additional private-provider capacity for adult autism diagnostic assessments.
Verbatim wording from the response “Having successfully obtained additional interim funding we have commissioned a private partner provider to provide additional autism diagnostics capacity, and we are on schedule to reduce our waiting list to under twelve months by the end of March 2026 and to reduce this further to under six months by the summer of 2026. Robust monitoring and quality assurance measures are in place to track delivery and monitor waiting lists. In tandem with this we are working on our internal pathways, to ensure that these are more streamlined and productive. Finally, whilst we have received non-recurrent resources, we” Source location 2026-0061 - Response from West London 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 Monitor delivery and waiting lists through robust monitoring and quality-assurance measures.
Verbatim wording from the response “Having successfully obtained additional interim funding we have commissioned a private partner provider to provide additional autism diagnostics capacity, and we are on schedule to reduce our waiting list to under twelve months by the end of March 2026 and to reduce this further to under six months by the summer of 2026. Robust monitoring and quality assurance measures are in place to track delivery and monitor waiting lists. In tandem with this we are working on our internal pathways, to ensure that these are more streamlined and productive. Finally, whilst we have received non-recurrent resources, we” Source location 2026-0061 - Response from West London NHS 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 Streamline and improve internal adult autism assessment pathways.
Verbatim wording from the response “Having successfully obtained additional interim funding we have commissioned a private partner provider to provide additional autism diagnostics capacity, and we are on schedule to reduce our waiting list to under twelve months by the end of March 2026 and to reduce this further to under six months by the summer of 2026. Robust monitoring and quality assurance measures are in place to track delivery and monitor waiting lists. In tandem with this we are working on our internal pathways, to ensure that these are more streamlined and productive. Finally, whilst we have received non-recurrent resources, we” Source location 2026-0061 - Response from West London 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 Agree with commissioners that adult autism assessment capacity will be augmented.
Verbatim wording from the response “have also now agreed with commissioners that the previously commissioned service was insufficient and will be augmented. The commitment of our commissioners to expand the service will be critical if we are to deliver shorter waiting times on a sustainable footing.” Source location 2026-0061 - Response from West London NHS 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 Invest in training professionals in autism and ADHD diagnostic assessment.
Verbatim wording from the response “While I acknowledge that there is still more to do, I can report that waiting times for assessment for potential autism in adults have fallen in the past twelve months nationally across ICB catchment areas. We believe that this progress has been aided by the ‘Right to Choose’ pathway provided by ICBs which gives patients in England the right to choose which NHS-commissioned provider they are referred to for a first outpatient appointment for ASD (and ADHD) diagnostic assessment, allowing people to access providers offering shorter waiting times. Over the last 2 years NHSE has also invested in training a range of professionals in diagnostic assessment.” Source location 2026-0061 - Response from Department of Health and Social Care
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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 Adult ADHD assessments are outside the Trust’s commissioned remit, so it cannot respond on this matter.
Verbatim wording from the response “The Trust is not the commissioned provider for adult ADHD assessments in any of our boroughs and therefore cannot respond on this matter. This would best be addressed to the NW London Integrated Care Board as the commissioner.” Source location 2026-0061 - Response from West London NHS 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 Responsibility for adult ADHD assessments rests with the North West London Integrated Care Board as commissioner.
Verbatim wording from the response “The Trust is not the commissioned provider for adult ADHD assessments in any of our boroughs and therefore cannot respond on this matter. This would best be addressed to the NW London Integrated Care Board as the commissioner.” Source location 2026-0061 - Response from West London NHS 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 Integrated care boards are responsible for providing appropriate local autism services in line with relevant NICE guidelines.
Verbatim wording from the response “It is the responsibility of integrated care boards (ICBs) to make available appropriate provision to meet the health and care needs of their local population, including provision of autism services, in line with relevant National Institute for Health and Care Excellence (NICE) guidelines.” Source location 2026-0061 - Response from Department of Health and Social Care
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20 Dec 2024 Oliver James WINSON · Prevention of Future Deaths report Norfolk
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Concerns raised 3
Failure to provide treatment to at-risk patients awaiting adult ADHD services View source Failure to monitor the condition of at-risk patients awaiting adult ADHD services View source Delays in access to adult ADHD services for at-risk patients 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. 3
NHS England
Explore opportunities with partners to expand ADHD pathways with pre-diagnostic or waiting-well support.
View source
NHS England
Operate the independent ADHD Taskforce to develop cross-sector understanding and improve joined-up access to early support.
View source
NHS England
Explore opportunities with partners to standardise ADHD pathways for greater consistency and transparency.
View source
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AI-generated summary
Oliver James WINSON · 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
Oliver James Winson, a 33-year-old man with a history of drug misuse and a referral for adult ADHD assessment, was found deceased at home on 10 June 2024. Toxicology confirmed cocaine use before death, and the medical cause of death was cocaine toxicity. The principal concern was that lengthy adult ADHD waiting lists left at-risk patients without treatment or monitoring, potentially allowing deterioration, harmful behaviour and death.
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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 provide treatment to at-risk patients awaiting adult ADHD services
Wider context from the report “Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provide details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time, as at the time of his death Mr Winson had been waiting for four years.
I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country.
It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment , their condition is not monitored and there is a risk as with Mr Winson, that their condition may deteriorate or lead to risk or harmful behaviour and death.
” Source location Oliver James WINSON · 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 monitor the condition of at-risk patients awaiting adult ADHD services
Wider context from the report “Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provide details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time, as at the time of his death Mr Winson had been waiting for four years.
I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country.
It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment, their condition is not monitored and there is a risk as with Mr Winson, that their condition may deteriorate or lead to risk or harmful behaviour and death.
” Source location Oliver James WINSON · 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 access to adult ADHD services for at-risk patients
Wider context from the report “Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provide details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time , as at the time of his death Mr Winson had been waiting for four years.
I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country.
It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment, their condition is not monitored and there is a risk as with Mr Winson, that their condition may deteriorate or lead to risk or harmful behaviour and death.
” Source location Oliver James WINSON · 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 Explore opportunities with partners to expand ADHD pathways with pre-diagnostic or waiting-well support.
Verbatim wording from the response “NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD, including exploring opportunities to:” Source location Response from NHS England
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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 Operate the independent ADHD Taskforce to develop cross-sector understanding and improve joined-up access to early support.
Verbatim wording from the response “Considering the challenges being reported about ADHD services, NHS England undertook a rapid review in December 2023. This identified several key areas of work in relation to ADHD which are now underway, including improving available data, developing resources to support commissioners in improving the quality and consistency of ADHD services nationally, and facilitating the sharing of information, innovation and good practice. NHS England has also convened the independent ADHD Taskforce, which works cross-sector to better understand more about the issues impacting those with ADHD and their families, and how service provision can be better joined up to meet people’s needs, including access to early support. It is increasingly recognised that ADHD is not solely a health concern, and that a cross-sector approach is needed to effect change.” Source location Response from NHS England
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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 Explore opportunities with partners to standardise ADHD pathways for greater consistency and transparency.
Verbatim wording from the response “NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD, including exploring opportunities to:” Source location Response from NHS England
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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 Local Integrated Care Boards commission ADHD services, including decisions on local pathways and provision.
Verbatim wording from the response “ADHD services are a complex landscape. They are commissioned locally by Integrated Care Boards (ICBs) with significant national variation existing in pathways and provision, including independent sector providers operating under the Right to Choose framework.” Source location Response from NHS England
Open published response
Concerns raised 2
Lack of commissioned adult ADHD assessment, diagnosis and treatment by CPT View source Failure to provide a practicable out-of-county ADHD treatment pathway with ongoing medication oversight and review View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
David Morley Sargeant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Morley Sargeant died on 16 June 2017 from the toxic effects of an intentional overdose of prescribed and controlled drugs, with suspension by a ligature around his neck also recorded. He had a history of chaotic illicit substance misuse and had been referred for assessment of possible ADHD, but specialist services in Cornwall or out of county were unable to diagnose and treat him. The principal concern was the lack of access to specialist ADHD assessment and treatment, including the absence of suitable ongoing medication oversight arrangements.
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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 Lack of commissioned adult ADHD assessment, diagnosis and treatment by CPT
Wider context from the report “In October 2016 Davy was referred by his GP to the community mental health team (CMHT), part of Cornwall Partnership NHS Foundation Trust (CPT) for assessment of possible ‘Attention deficit hyperactivity disorder’ (ADHD) which is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.
Davy was assessed in December 2016 by CMHT. However, Davy was discharged from CMHT without further diagnosis and treatment. This was because of the following reasons;-
1) CPT is not commissioned to assess, diagnose or treat adult ADHD.
2) Addaction Cornwall does not have access to a specialist psychiatrist with the skills to diagnose or treat ADHD.
3) Although the GP had the option to refer under Patient Choice for treatment out of county, the GPs previous experience indicated that this was impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication.
In summary, Davy could not be diagnosed and treated by specialist services either in Cornwall or out of county.
” Source location David Morley Sargeant · 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 provide a practicable out-of-county ADHD treatment pathway with ongoing medication oversight and review
Wider context from the report “In October 2016 Davy was referred by his GP to the community mental health team (CMHT), part of Cornwall Partnership NHS Foundation Trust (CPT) for assessment of possible ‘Attention deficit hyperactivity disorder’ (ADHD) which is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.
Davy was assessed in December 2016 by CMHT. However, Davy was discharged from CMHT without further diagnosis and treatment. This was because of the following reasons;-
1) CPT is not commissioned to assess, diagnose or treat adult ADHD.
2) Addaction Cornwall does not have access to a specialist psychiatrist with the skills to diagnose or treat ADHD.
3) Although the GP had the option to refer under Patient Choice for treatment out of county, the GPs previous experience indicated that this was impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication.
In summary, Davy could not be diagnosed and treated by specialist services either in Cornwall or out of county.
” Source location David Morley Sargeant · 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 Establish and operate a specialist adult ADHD assessment, diagnosis and treatment pathway in Cornwall.
Verbatim wording from the response “1) CFT is not commissioned to assess, diagnose or treat ADHD:
NHS Kernow Clinical Commissioning Group (CCG) has not historically commissioned a specialist adult ADHD service. However, in April 2018 it was acknowledged that this constituted a gap in service provision, and therefore an intention was set to develop and operate a pathway for adults (18 years and older) with ADHD. NHS Kernow identified and committed to a recurrent investment for CFT to co-design, develop and deliver the required level of intervention in line with the National Institute for Health and Care Excellence (NICE) guidance. The new service, due to be established in early 2019, will deliver an adult ADHD assessment, diagnosis and treatment pathway.” Source location 2018-0312-Response-by-Kernow-Clinical-Commissioning-Group
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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 Develop a shared-care agreement and prescribing guideline for pharmacological treatment of adult ADHD.
Verbatim wording from the response “A Shared Care Agreement and Guideline for the treatment of ADHD in adults will be developed by the NHS Kernow prescribing team to support the new commissioning model. This will support the prescribing of the evidence based pharmacological treatment, and is supported by an already identified budget within the prescribing team.” Source location 2018-0312-Response-by-Kernow-Clinical-Commissioning-Group
Open published response
16 Aug 2017 Christopher Ian Fairhurst · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Increased referral and treatment thresholds restricting access to specialist autism and ADHD/ADD services View source
This report raised 6 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
Christopher Ian Fairhurst · 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
Christopher Ian Fairhurst, aged 26, was found deceased on a footpath near Spotland Bridge, Rochdale, on 5 December 2016, with empty alcohol bottles and paracetamol packets nearby. The report identified concerns about shortages of GPs, lack of continuity and accessibility of care, inadequate appointment times and GP training, and increasing demand and referral thresholds for adult and children’s Autism and ADHD/ADD services.
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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 Increased referral and treatment thresholds restricting access to specialist autism and ADHD/ADD services
Wider context from the report “6. Both adult and children’s Autism and ADHD/ADD Psychiatric and Psychology services are currently struggling to cope with increasing demand for this area of mental health/neurodevelopmental care provision. The ‘threshold’ for referral and/or treatment has therefore been intentionally increased in order to try and address the problem. I am concerned that this is unsafe. It reduces patient accessibility to specialist diagnosis, care and treatment and places further burden upon GPs to care for patients with complex conditions.
” Source location Christopher Ian Fairhurst · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.