Recurring concern

Unsafe coordination and continuity during mental health service transfers

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First reported 17 Dec 2013•Latest report 6 May 2026

Definition

What this concern includes

Includes transfers between Trusts, areas or mental-health teams where planning, ownership, information exchange or continuity is deficient.

Not included

  • Ordinary clinical handover with no transfer of mental-health service responsibility
  • Discharge from mental-health care with no receiving service
  • Referral failures before a transfer is accepted
Reports
26

Distinct published reports

Individual concerns
33

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
39

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care4
Greater Manchester Mental Health NHS Foundation Trust3
Lancashire & South Cumbria NHS Foundation Trust3
NHS England3
Herefordshire and Worcestershire Health and Care NHS Trust2
North East London NHS Foundation Trust2
Pennine Care NHS Foundation Trust2
Arts University Bournemouth1
Avon and Wiltshire Mental Health Partnership NHS Trust1
Betsi Cadwaladr University LHB1
Birmingham Women'S and Children'S NHS Foundation Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Cheshire and Wirral Partnership NHS Foundation Trust1
Countess of Chester Hospital NHS Foundation Trust1
Coventry and Warwickshire Partnership NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester City

    AI-generated summary

    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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate and incomplete transfer and communication from inpatient care to the CMHT

    Wider context from the report

    “c. The transfer and communication process from inpatient care to the CMHT was inadequate and incomplete. ”

    Source location

    Jude Daryl Lloyd · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Address coordination of diabetes management at discharge through the diabetes steering group.

    Verbatim wording from the response

    “The HbA1c is a measurement of control of blood glucose (glycaemic control) over the weeks prior to the test being taken so the HbA1c of 135 suggested extremely poor glycaemic control in the community whilst Mr Lloyd was under the care of his GP prior to admission. We agree that sadly, the plan to ask the GP to follow this up on discharge was unlikely to have led to any improvement in glycaemic control and was not a robust plan to manage this. We will address discharge diabetes management coordination via the diabetes steering group.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 13 October 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing discharge CPA requirements in the CMHT procedure and clinical-record audits are relied upon to address discharge planning compliance.

    Verbatim wording from the response

    “The Trust’s investigation report detailed that Mr Lloyd’s Care Coordinator attended the discharge Care Programme Approach (CPA) meeting and participated in agreeing the discharge plan but did not complete a discharge CPA plan in line with Trust expectations when a patient is discharged from hospital. These expectations are already covered in the Trust CMHT Standard Operating Procedure and are monitored through audit of clinical records during management supervision of staff.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 13 October 2021

    Open published response

  2. Manchester City

    AI-generated summary

    Antony Declan Schofield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate transfer and communication from inpatient care to the HBTT

    Wider context from the report

    “1. a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care. b. The transfer and communication process from inpatient care to the HBTT appeared inadequate. b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated. c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it. d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this. e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile. f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”

    Source location

    Antony Declan Schofield · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.

    Verbatim wording from the response

    “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    HBTT staff reviewed the patient before discharge and considered that the information needed to support transfer had been shared verbally.

    Verbatim wording from the response

    “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    Open published response

  3. Manchester South

    AI-generated summary

    Steven Keith Marsland · 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 Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to allocate people moving between borough teams to a community psychiatrist

    Wider context from the report

    “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made; ”

    Source location

    Steven Keith Marsland · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. West Sussex

    AI-generated summary

    George Edward Rogers · 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

    George Edward Rogers had a diagnosis of body dysmorphic disorder and died on 28 August 2018 after causing a fatal laceration to his chest. Following his transfer between care teams, a Lead Practitioner was not appointed promptly, resulting in a period without treatment or ongoing risk assessment. The principal concern was that such transfer arrangements could delay treatment and leave patients unmonitored.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to appoint a Lead Practitioner when transferring patients between the CRHTT and ATS

    Wider context from the report

    “1. When transferring patients between the CRHTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment. ”

    Source location

    George Edward Rogers · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.

    Verbatim wording from the response

    “The process for allocation of a Lead Practitioner is as follows; the CRHTT attends the weekly Multi-Professional ATS meeting (ATS - sometimes referred to as a Community Mental Health Team) to provide an update on each case and to request allocation, if needed, of a Lead Practitioner.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 1 · response
    Published 27 November 2019

    Open published response

    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 weekly patients transferred between teams who remain without an allocated Lead Practitioner.

    Verbatim wording from the response

    “Any patient not allocated a Lead Practitioner is monitored by the Team Leader on a weekly basis.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 2 · response
    Published 27 November 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.

    Verbatim wording from the response

    “I hope that the content of this letter and its enclosures addresses your concerns and provides you with assurance that there is no delay in a patient receiving access to treatment on transfer between CRHTT and the ATS, that there is a process in place to monitor patients who have been transferred and are receiving support with the Duty Worker whilst a Lead Practitioner is identified. However, if any further clarification is required or I can assist further in any way then please do not hesitate to contact me.”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 2 · response
    Published 27 November 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing monitoring and Duty Worker arrangements are sufficient while a Lead Practitioner is identified after transfer.

    Verbatim wording from the response

    “If the patient is already known to the team, the Lead Practitioner (ATS) will remain involved and work with the CRHTT throughout the episode of care. If the person is unknown to the ATS, the CRHTT and ATS will work together to plan onward care and support. Where a Lead Practitioner cannot be provided immediately by the ATS, an initial appointment will be offered within 7 days of transfer from the CRHTT and follow-up plans will be agreed. This may include care and support being offered by the ATS Duty Worker (a senior registered professional) who the patient will be able to contact for support. This support includes face to face contact on the same day if necessary and attendance at the ATS if”

    Source location

    Response from Sussex Partnership NHS Foundation Trust
    Page 1 · response
    Published 27 November 2019

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Daniel Hubert Collins · 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

    Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Transfer of necessary mental health care placing responsibility for initiating contact on patients

    Wider context from the report

    “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis. ”

    Source location

    Daniel Hubert Collins · Prevention of Future Deaths report
    Page 1 · concerns

    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 follow up with receiving services and patients after mental health care transfers

    Wider context from the report

    “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis. ”

    Source location

    Daniel Hubert Collins · Prevention of Future Deaths report
    Page 1 · concerns

    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 notify the receiving mental health service about care transfers

    Wider context from the report

    “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis. ”

    Source location

    Daniel Hubert Collins · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Inner West London

    AI-generated summary

    Paul Robert Allan · 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

    On 16 July 2017, Paul Robert Allan walked onto the track at Oxford Circus tube station and was struck by a westbound train. Concerns included his discharge from the Rochdale Community Mental Health Team without transfer to the corresponding team in Stoke, and a failure to consult or work with drug and alcohol advisory services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to transfer people between community mental health teams when they move

    Wider context from the report

    “1) The Rochdale Community Mental Health Team discharged Paul Robert Allan from their care instead of transferring him to the Community Mental Health Team in Stoke where Paul Robert Allan was moving to. ”

    Source location

    Paul Robert Allan · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Liverpool and the Wirral

    AI-generated summary

    Lee Joseph Hastings Swain · 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

    Lee Joseph Hastings-Swain, aged 28, was found deceased hanging from a bannister at his home on 30 November 2016. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included inadequate coordination and information-sharing between mental health services, delays in referral, poor clinical records, and insufficiently proactive engagement after his transfer between NHS trusts.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure effective information exchange during mental health service transfers

    Wider context from the report

    “A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP. This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services. In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation. ”

    Source location

    Lee Joseph Hastings Swain · Prevention of Future Deaths report
    Page 2 · concerns

    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 coordinated direct referrals and continuity of care during mental health service transfers

    Wider context from the report

    “A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP. This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services. In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation. ”

    Source location

    Lee Joseph Hastings Swain · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Amend the transfer policy to require timely, comprehensive handover of information for CPA and non-CPA service users.

    Verbatim wording from the response

    “Mersey Care NHS Foundation Trust (MCFT) response I have enclosed the key changes that have been made to policy following the Regulation 28 report at Appendix 1.”

    Source location

    2017-0196-Mersey-Care-NHS-Trust
    Page 2 · response
    Published 11 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Circulate the inquest outcome and transfer-policy changes through operational management meetings, consultant forums and a Quality Practice Alert.

    Verbatim wording from the response

    “I can confirm that the outcome of the inquest hearing and the required changes to the policy have been circulated within MCFT through operational management meetings, consultant forums and via Quality Practice Alert (QPA). I can also confirm that the QPA was issued prior to the Inquest hearing on 16th March 2017 as part of the Trust’s processes of learning from this incident. This included clear guidance on what is expected of teams when a patient is being transferred from one organisation to another. The contents of the QPA included:-”

    Source location

    2017-0196-Mersey-Care-NHS-Trust
    Page 2 · response
    Published 11 August 2017

    Open published response

    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

    Consider including an audit of transfer processes in the Junior Doctor Audit programme.

    Verbatim wording from the response

    “An audit of transfer processes based on the amended policies will be considered for inclusion in each Trust’s Junior Doctor Audit programme.”

    Source location

    2017-0196-Mersey-Care-NHS-Trust
    Page 2 · response
    Published 11 August 2017

    Open published response

  8. City of London

    AI-generated summary

    Charlotte Anne Agnew · 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

    Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide timely assessment and treatment when transfer between teams is necessary

    Wider context from the report

    “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were: (1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge. (2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide. (3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge. (4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness. (5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016. I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance. Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise). Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised. In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives. ”

    Source location

    Charlotte Anne Agnew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Surrey

    AI-generated summary

    Daniel Maher · 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

    Daniel Maher was found hanging at his home on 26 May 2016, and efforts to resuscitate him were unsuccessful. The report raised concerns that significant information about vulnerable individuals may not be readily accessible when mental health services in West Sussex and Surrey are involved, including because of limited access to records and reliance on verbal referrals without routinely shared paperwork.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to routinely share clinical assessment records with receiving community mental health services outside the county

    Wider context from the report

    “During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SABP. The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under s.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some point thereafter, to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence I have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey. - The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county. As a result, they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours. - The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients being referred to community mental health services outside of the county. The court was told that key paperwork, such as the clinical record of the s.136 assessment, is not routinely shared on the making of such referrals. In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection. - As a result of the above I am concerned that significant information relating to the clinical history, presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of, mental health services in Surrey. Consideration should be given to whether any steps can be taken to address the above concerns. ”

    Source location

    Daniel Maher · Prevention of Future Deaths report
    Page 2 · concerns

    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 timely access to patient information held by mental health services in other counties

    Wider context from the report

    “During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SABP. The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under s.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some point thereafter, to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence I have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey. - The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county. As a result, they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours. - The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients being referred to community mental health services outside of the county. The court was told that key paperwork, such as the clinical record of the s.136 assessment, is not routinely shared on the making of such referrals. In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection. - As a result of the above I am concerned that significant information relating to the clinical history, presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of, mental health services in Surrey. Consideration should be given to whether any steps can be taken to address the above concerns. ”

    Source location

    Daniel Maher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Norfolk

    AI-generated summary

    CHRISTOPHER JONATHAN HIGGINS · 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 Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of escort policy and planning to address inter-service patient transfers

    Wider context from the report

    “(2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police. In particular, Mr Higgins who had been acting in an unpredictable, and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him. The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins; ”

    Source location

    CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen policy direction so staff accompany patients during transfers wherever possible, with safety-based decisions made with other involved services.

    Verbatim wording from the response

    “Your report reflected the fact that Mr Higgins was transferred in the Police van back to the Fermoy Unit without a member of mental health staff present. Accepting that in Mr Higgins’s case the travel time and distance was small (within the site), the Trust acknowledges how important this can be for the patient. Therefore the Trust will be strengthening its policy direction (the policy is further”

    Source location

    2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 24 December 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Mental health staff may be unable to accompany patient transfers in limited instances where safety makes accompaniment impossible.

    Verbatim wording from the response

    “referenced below) that staff should wherever possible, accompany the patient during the transfer. There may be some limited instances where this is not possible on the grounds of safety but decisions would be made in liaison with other service involved.”

    Source location

    2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 2 · response
    Published 24 December 2015

    Open published response
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Data last updated 7 September 2026