21 Oct 2025 Steven Roy Davidson · Prevention of Future Deaths report Essex
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Concerns raised 1
Inability to navigate System One records to find previous incidents of self-harm in prison 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. 5
HCRG Care Group
Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
View source
HCRG Care Group
Require agency staff to confirm in writing that they understand how to navigate SystmOne clinical records and record confirmations.
View source
HCRG Care Group
Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
View source
HCRG Care Group
Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
View source
HCRG Care Group
Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
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Steven Roy Davidson · 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
Steven Roy Davidson died while in prison after a history of self-harm during a previous prison stay. The report identifies concerns that healthcare staff at HMP Chelmsford could not sufficiently navigate or search System One records, or did not sufficiently understand the importance of previous self-harm information when assessing his mental health and 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 Inability to navigate System One records to find previous incidents of self-harm in prison
Wider context from the report “(1) Health Care Staff at HMP Chelmsford say that they are:
(i) not able to navigate the System One records sufficiently well to find information about previous incidents of self- harm in prison ; and/ or
(ii) not sufficiently aware of the importance of searching the records made by clinicians during previous prison stays when conducting Reception Health Screens and/ or reviews of a prisoner’s mental health needs.
(iii) May not be sufficiently trained to understand and utilise System One records to find previous history, including incidents of self- harm in custody.
” Source location Steven Roy Davidson · 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 Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
Verbatim wording from the response “SystmOne is the NHS electronic patient record system used in prison and custodial healthcare settings across the country. NHS North of England Commissioning Support (NECS) provides training and technical support for users of SystmOne, including system navigation, search functions and information retrieval. HCRG has amended its training provision so that all new staff will now receive structured SystmOne training as part of their induction, provided by NECS and recorded in the mandatory training schedule. This will include guidance on locating clinical information that may be stored in different parts of the system (see further below). Refresher training will also be provided to existing staff within three months and recorded in their personal training record.” Source location Response from HCRG Care 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 Require agency staff to confirm in writing that they understand how to navigate SystmOne clinical records and record confirmations.
Verbatim wording from the response “All agency staff will be required to confirm in writing that they understand how to navigate clinical records held in SystmOne and this will be recorded in the ShareDrive. Any long-term agency staff will also complete the same structured training as permanent staff.” Source location Response from HCRG Care 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 Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
Verbatim wording from the response “All Practitioners conducting clinical assessments should, as part of good practice, review relevant patient history when undertaking reception screenings, mental health reviews or risk assessments. In this case, it appears that practitioners focused primarily on Mr Davidson's current presentation rather than reviewing earlier records in depth. HCRG will reinforce through clinical governance that risk-related history should be considered when assessing patients, and that in some cases this may involve searching beyond the default summary record view.” Source location Response from HCRG Care 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 Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
Verbatim wording from the response “To ensure that records are being reviewed appropriately, the existing monthly audit of clinical notes will now include specific checks as to whether practitioners have accessed relevant historic information when assessing risk. Findings from the audit will feed into governance meetings and quality and performance monitoring available to NHS England commissioners.” Source location Response from HCRG Care 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 Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
Verbatim wording from the response “HCRG’s Performance and Quality teams are embedding SystmOne training into existing governance and supervision processes to ensure consistent and safe use of the platform. Staff may also contact the Performance and Quality Lead if further clarification is needed, either directly or via their line manager.” Source location Response from HCRG Care Group
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10 Nov 2023 Christopher Richard ALLUM · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Failure to obtain and record previous methods of self-harm and suicide at referral and admission View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England The Langford Centre
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
The Langford Centre
Amend the initial referral form to require referrers to record previous suicide methods and self-harm methods, with explanations for incomplete information.
View source
The Langford Centre
Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.
View source
The Langford Centre
Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.
View source
NHS England
Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
View source See 1 more action
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AI-generated summary
Christopher Richard ALLUM · 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 Richard Allum had escalating mental health issues and a history of deliberate self-harm before being admitted to the Langford Centre on 14 May 2022. He was found unresponsive in his room on the evening of 15 May 2022, and death was confirmed at 23:01; the inquest concluded that he died as a result of suicide. The concerns identified included gaps in obtaining and recording previous methods of self-harm and relevant family information at referral and admission, and difficulties accessing NHS notes in private healthcare settings.
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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 obtain and record previous methods of self-harm and suicide at referral and admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide . There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” Source location Christopher Richard ALLUM · 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 Amend the initial referral form to require referrers to record previous suicide methods and self-harm methods, with explanations for incomplete information.
Verbatim wording from the response “In order to address concerns relevant to The Langford Centre, we have been liaising with SPFT, and the following corrective measures have been agreed with our partners to be implemented from 1st January 2024;” Source location Response from Bramley Health
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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 Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.
Verbatim wording from the response “In order to further explore possible past suicide attempts and to ensure full capture of a patient’s self-harm history at the admission stage, both the initial medical assessment and formation of risk assessment, completed by the triaging doctor at Langford, include the same subsections.” Source location Response from Bramley Health
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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 Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.
Verbatim wording from the response “Finally, as there have been amendments to our initial processes, training updates have been rolled out company wide. This includes training to staff who triage our initial referral documents, medical doctors who conduct the initial assessments and consultants who oversee our ward rounds and MDT’s. All staff have been fully informed of the additional processes and the sensitivities surrounding the nature and detail of the information being requested.” Source location Response from Bramley Health
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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 Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
Verbatim wording from the response “Christopher’s case does highlight the importance of effective information sharing to support providing the best care possible where individuals are transferred between different care settings. That is why joined up partnership working is one of the four key principles underpinning NHS England’s guidance on Acute inpatient mental health care for adults and older adults that was published in July 2023. This document provides specific advice on good practice on information sharing as well as guidance on the holistic assessment that should take place when someone enters a new facility, including identifying any safeguarding or risk issues, including risk to self and others. This includes guidance on the key actions that should take place within 72 hours of admission which include:” Source location Response from NHS England
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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 Referring Trusts or bodies are responsible for completing previous suicide-method information in the initial referral form.
Verbatim wording from the response “a) Our initial referral form has been amended to include an additional field, entitled ‘Previous Suicide Methods’, which must be completed by the referrer. This field includes a supporting sub-section headed ‘Previous Suicide Methods Used,’ which is intended to record details of the self-harm methods.” Source location Response from Bramley Health
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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 Langford Centre, operated by an independent provider, is the appropriate organisation to respond to concerns about information collection and recording.
Verbatim wording from the response “The Langford Centre is operated by Bramley Healthcare, an independent Mental Health Care Provider providing services within the South of England. I note that you have also addressed your Report to the Centre, and they would be the appropriate organisation to respond to the above concerns. NHS England will carefully review and consider their response to you.” Source location Response from NHS England
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18 Apr 2023 Patrick Soames · Prevention of Future Deaths report South London
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Concerns raised 1
Lack of a national risk-flagging system for previous self-harm attendances View source
This report raised 3 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
Patrick Soames · 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
Patrick Soames died by suicide on 21 June 2021 after a final month involving repeated serious self-harm, including cutting, medication overdose and excessive alcohol misuse, with multiple hospital attendances. The principal concerns were that information about his risk was fragmented across NHS Trusts, police forces, local authorities and geographical areas, with no effective system to consolidate or flag his recent self-harm history nationally.
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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 a national risk-flagging system for previous self-harm attendances
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system : for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up .
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history .
” Source location Patrick Soames · Prevention of Future Deaths report
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24 Jun 2022 ZSOLT KIRJAK · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Lack of enquiry into previous self-harm and associated injury 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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ZSOLT KIRJAK · 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
ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.
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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 enquiry into previous self-harm and associated injury
Wider context from the report “3. There was a lack of enquiry by any of the clinicians who had seen the patient into the Patient’s previous attempt to give himself a stroke and a subsequently acquired eye injury. It is very unusual for a patient to attempt to give oneself a stroke and would reasonably be expected to warrant a detailed assessment because it implies a high degree of harm and lethality.
” Source location ZSOLT KIRJAK · Prevention of Future Deaths report
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21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
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Concerns raised 1
Failure to identify documented suicide and deliberate self-harm risk information View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Central and North West London 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. 7
Central and North West London NHS Foundation Trust
Require reception-screening staff to complete modified training and confirm competence through induction sign-off and supervision.
View source
Central and North West London NHS Foundation Trust
Provide reception-screening nurses with a guide explaining how to register patients and access previous medical records.
View source
Central and North West London NHS Foundation Trust
Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
View source
Central and North West London NHS Foundation Trust
Distribute guidance and a standard process for reviewing, entering and linking diagnoses and problems in SystmOne.
View source
Central and North West London NHS Foundation Trust
Review use of SystmOne’s problem section through the annual medical-records audit and assign improvement actions where required.
View source
Central and North West London NHS Foundation Trust
Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
View source
Central and North West London NHS Foundation Trust
Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
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AI-generated summary
Andrew Goldstraw · 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
Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.
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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 identify documented suicide and deliberate self-harm risk information
Wider context from the report “A. The computer system used by CNWL is known as SystmOne. Healthcare staff working on Reception when Mr Goldstraw first arrived at the prison had access to his previous medical notes and history (around 240 pages in all) stored on SystmOne. The records contained numerous references to suicidal ideation and previous attempts at deliberate self-harm. Mr Goldstraw had attempted to take his own life on several previous occasions, the most recent of which was only three months prior to his arrival at the prison. However, despite a proliferation of entries making reference to his mental health history the mental health nurse who had access to SystmOne was seemingly unaware of the relevant entries . Had he been, he said he would have opened an ACCT.
” Source location Andrew Goldstraw · 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 Require reception-screening staff to complete modified training and confirm competence through induction sign-off and supervision.
Verbatim wording from the response “The Trust has modified its staff training to ensure this type of issue does not re-occur in the future. All staff are required to complete this training as part of their induction and to sign that they have completed the training and are competent to undertake reception screening. For existing staff this training and compliance issues will be discussed through management supervisions.” Source location 2020-0041-Response-from-Central-and-North-West-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 Provide reception-screening nurses with a guide explaining how to register patients and access previous medical records.
Verbatim wording from the response “A reception guide has been developed for all CNWL nursing staff undertaking reception screening. This includes clear guidance on how a staff member is able to access previous medical records when registering a patient within the prison. A patient must be registered with the prison by the nurse in the reception and then the records saved prior to the nursing staff having access to all the medical records. This is clearly outlined in the reception guidance document.” Source location 2020-0041-Response-from-Central-and-North-West-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 Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Verbatim wording from the response “The Trust has sent out guidance to all offender care sites in relation to the search function. Whilst this is a function owned by SystmOne CNWL has given staff directions on how to best utilise this function. For instance, when trying to get a history of suicide attempts rather than searching suicide the clinician should search ‘suic’ which will bring up results for suicide, suicidal, suicidal thoughts.” Source location 2020-0041-Response-from-Central-and-North-West-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 Distribute guidance and a standard process for reviewing, entering and linking diagnoses and problems in SystmOne.
Verbatim wording from the response “The usefulness of the “Problem section” is reliant on the information added to it by whichever establishment the patient is in. However, CNWL offender care have sent out a memo to all staff to inform them how to review problems which are on the SystmOne record. In addition, since this inquest, CNWL Offender Care have sent out the SystmOne guidance section in how to input diagnosis data and link it to consultations in a standard way across the service. This is referred to as “creating a problem”. To ensure this memo is acted upon, Offender Care will undertake a review of the use of problem section in conjunction with their annual medical records audit. This audit generates site specific action plans highlighting areas for improvement.” Source location 2020-0041-Response-from-Central-and-North-West-London-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 Review use of SystmOne’s problem section through the annual medical-records audit and assign improvement actions where required.
Verbatim wording from the response “The usefulness of the “Problem section” is reliant on the information added to it by whichever establishment the patient is in. However, CNWL offender care have sent out a memo to all staff to inform them how to review problems which are on the SystmOne record. In addition, since this inquest, CNWL Offender Care have sent out the SystmOne guidance section in how to input diagnosis data and link it to consultations in a standard way across the service. This is referred to as “creating a problem”. To ensure this memo is acted upon, Offender Care will undertake a review of the use of problem section in conjunction with their annual medical records audit. This audit generates site specific action plans highlighting areas for improvement.” Source location 2020-0041-Response-from-Central-and-North-West-London-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 Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Verbatim wording from the response “We will also remind staff that other organisations use SystmOne and that they may not enter data in an easy to view way. Staff have been advised to use search functionality to find data that may have not been entered properly by staff from other organisations.” Source location 2020-0041-Response-from-Central-and-North-West-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 Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
Verbatim wording from the response “Additionally, Offender Care is carrying out quarterly review of risk assessments. Mental Health risk assessments have been developed across CNWL offender care services and have been uploaded onto SystmOne. These risk assessments include a patient’s risk of harm to themselves and to others. These risk assessments should be updated whenever there is a recognised change in a patients risk and should form the basis of a care plan. Both risk assessments and the care plans they help formulate are audited every three months and also form part of the annual medical records audit to provide assurances that risks are being appropriately identified.” Source location 2020-0041-Response-from-Central-and-North-West-London-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 Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Verbatim wording from the response “Whilst the risk assessment template on SystmOne does ask pre-set questions the clinician is not reliant solely on the information disclosed during the assessment. When completing the risk assessment there is a section on the right hand side of the template with previous values that have been entered in relation to these questions. This allows the clinician to have an understanding of previous answers to these questions and gives them some context when considering a response to a question. For instance if a patient’s response contradicts a previous statement they have made the staff will be able to ascertain this and ask appropriate follow up. When the cursor is put in the box relating to risk incidents and triggers previous entries about this come up on the right hand section of the template.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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6 Dec 2018 John Michael KIRBY · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to obtain sufficient details of a reported suicide attempt View source
This report raised 10 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
John Michael KIRBY · 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
John Michael KIRBY took his own life, according to the conclusion of the inquest. The concerns included delays in his care, the handling of an ADHD diagnosis and Concerta prescribing, inadequate monitoring, and failures to respond appropriately to information about suicidal thoughts, a reported suicide attempt, substance use and an A&E admission.
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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 obtain sufficient details of a reported suicide attempt
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke ?
” Source location John Michael KIRBY · Prevention of Future Deaths report
Open source report
21 Jun 2017 Michael Folley · Prevention of Future Deaths report Central Hampshire
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Concerns raised 1
Failure to provide PER staff with relevant previous self-harm and suicide risk information 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
Michael Folley · 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
Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.
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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 provide PER staff with relevant previous self-harm and suicide risk information
Wider context from the report “b) Mr Folley was assessed as NCTS (no current thoughts of self-harm or suicide) and thus placed on the lowest observation rate of 60 minutes. However, access to previous data held on police (both internal and external) and other agency systems was not available to officers completing the PER and thus they could rely on current observations only . Despite this, it was essential to consider the risk of self-harm or suicide demonstrated and recorded over the previous months (July – September) not simply since detention on this occasion.
” Source location Michael Folley · 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 Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.
Verbatim wording from the response “Force Custody publishes a quarterly newsletter to all custody officers and detention officers. The next publication is due in September 2019 and will reinforce the issues addressed in this Regulation 28 Notice.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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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 Detention officers completing PERs had access to Hampshire Constabulary systems and the Police National Computer, but not other forces’ internal systems.
Verbatim wording from the response “1. Under Section 5, at paragraph 1(b) the report outlines that the officers completing the Prisoner Escort Record (PER) did not have access to the data held on Police (both internal and external) and other agency systems. The officers completing the PER did have access to Hampshire Constabulary internal systems and the Police National Computer but would not have had direct access to other police force internal crime or intelligence recording systems.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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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 Obtaining information from every external agency on every occasion is impracticable, so officers cannot routinely obtain all external data.
Verbatim wording from the response “Through the newsletter we will equally remind staff to consider the potential external sources of information available to them, including information held on other police force and agency systems when managing risks and completing PERs. This will be dependent on individual case by case circumstances as it is impracticable for data to be obtained from each outside agency on every occasion. Officers must rely on each force or agency adhering to its responsibilities to ensure relevant data is included on the national PNC system to which all forces have access.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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 Officers must rely on each police force or agency to place relevant information on the national Police National Computer.
Verbatim wording from the response “Through the newsletter we will equally remind staff to consider the potential external sources of information available to them, including information held on other police force and agency systems when managing risks and completing PERs. This will be dependent on individual case by case circumstances as it is impracticable for data to be obtained from each outside agency on every occasion. Officers must rely on each force or agency adhering to its responsibilities to ensure relevant data is included on the national PNC system to which all forces have access.” Source location 2019-0230-Response-by-Hampshire-Constabulary
Open published response
28 Jul 2014 Suzanne Cammell · Prevention of Future Deaths report Oxfordshire
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Concerns raised 1
Failure to make high-risk information available to responding officers 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. 1
Thames Valley Police
Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.
View source
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AI-generated summary
Suzanne Cammell · 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
Suzanne Cammell died on 3 October 2013 after lying beneath the wheels of a lorry in a layby near Burford Golf Club; she sustained severe blunt head injuries when the lorry drove away. The principal concern was that high-risk information about the incident and a previous similar incident may not have been communicated by Thames Valley Police to Gloucestershire Constabulary or made available to the officer conducting a welfare check.
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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 make high-risk information available to responding officers
Wider context from the report “(1) There was also an incident on 23 September 2013 in Gloucestershire when Ms Cammell had been sectioned under Section 136 of the MHA because she had been seen placing her head under the wheels of a recycling lorry where she lived. She was seen by neighbours and/or the driver in time.
This information about the incident on 23 September 2013 was held on the Police National Database which, presumably, Gloucestershire control and ████████ would have had access to.
The concern therefore is in relation to communication between TVP and Gloucestershire Constabulary and, in turn, communication between Gloucestershire Control and its Officers. At Inquest, I did not have available to me details of the specific information passed by TVP control to Gloucestershire control in the early hours which subsequently led to ████████ and his colleague carrying out the welfare check at approximately 03.30. The evidence of ████████ at Inquest was that he did not know that she had been found lying underneath the wheels of the lorry earlier in the morning. He gave evidence that, if he had known this, he would have put in hand arrangements for a MHA assessment.
████████ also gave evidence that he did not know about the previous similar incident on 23 September despite the fact that it was on the PND and, furthermore, on Gloucestershire’s “Unified” Intelligence database.
The issue of concern therefore is the fact that specific information, of a high risk nature, was not or may not have been passed by TVP to Gloucestershire Constabulary or, if it was, it may not have been available to ████████ .
I appreciate that ████████ carried out a prompt welfare check and that Ms Cammell’s presentation was such that ████████ did not consider her to be at risk but it appears he did not have available crucial information .
” Source location Suzanne Cammell · 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 Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.
Verbatim wording from the response “████████ of our Professional Standards Department has carried out a thorough review of this matter, in the course of which he has consulted with senior colleagues from the Control Room & Enquiries Department, the Force Intelligence Bureau and the Partnership Team (which covers mental health).” Source location 2014-0579-Response-by-Thames-Valley-Police
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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 Gloucestershire Police addressed the concern about using the Police National Database in its own response.
Verbatim wording from the response “I understand that you posed to Gloucestershire a question in respect of the use of the Police National Database and that they have covered this in their response. Furthermore, I gather that at the Inquest you expressed concern in relation to a lack of information sharing between the Professional Standards Department and the officer who prepared the report for you. ████████ has put in place measures to address this. He has taken the liberty of making an appointment with you on 4 November 2014 to brief you on these measures and, of course, deal with any further questions you might have in respect of the case of Ms Cammell.” Source location 2014-0579-Response-by-Thames-Valley-Police
Open published response
2 Dec 2013 Michael James Meyler · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to attach existing Risk of Self-Harm / Suicide documents to ACCT documents 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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AI-generated summary
Michael James Meyler · 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
Michael James Meyler died in hospital on 1 January 2011 after being found hanging by the neck in his prison cell on 28 December 2010 and sustaining a hypoxic brain injury. The principal concerns were that information about his recent self-harm and suicide risk was not adequately circulated, read, or attached to his ACCT plan, limiting the ability of prison staff and healthcare personnel to make informed decisions about his welfare.
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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 attach existing Risk of Self-Harm / Suicide documents to ACCT documents
Wider context from the report “3. I am concerned that if an ACCT document is opened for any reason that if there should be a Risk of Self-Harm / Suicide document in existence for the prisoner, that it MUST be attached to the ACCT document . In this case the ACCT document was opened principally as an “instrument of support” where it was believed that the prisoner’s primary issues involved contact with his family and his children in particular. It was not known by those who opened the ACCT document and who conducted the various ACCT reviews that he had a history of self-harm which involved both taking an overdose and cutting his wrists on several occasions in the immediate months before he was committed to prison as a consequence of his distress over a long-term relationship breaking down. Furthermore, in the light of the information contained in the Risk of Self-Harm / Suicide document which came to their attention after the death of the deceased, all the Prison Officers involved indicated that they would have referred the deceased on for a Mental Health Inreach Assessment had they known of the details of his previous history. All the Prison Officers concerned felt that they had not been able to make “informed decisions” regarding the welfare of the prisoner concerned as they were not in possession of all the facts at the relevant times.
” Source location Michael James Meyler · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.