Recurring concern

Failure to obtain relevant collateral information from family and social supports

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First reported 10 Jan 2014•Latest report 5 Mar 2026

Definition

What this concern includes

Includes failures to identify, seek, obtain or use relevant collateral information from family, carers, social workers or other directly involved social supports when that information is material to patient assessment, risk management, support or care.

Not included

  • Excludes generic failures to gather information when no family or social-support collateral is involved.
  • Excludes failures concerning continuity of care, handover or referral unless the material deficiency is specifically failure to obtain or use collateral information from family or social supports.
  • Excludes unrelated failures to provide familial support or to balance confidentiality with family involvement where no failure to obtain relevant collateral information is asserted.
  • Excludes clinical-record retrieval or genetic-history investigation unless the report specifically frames it as collateral information from family or social supports.
Reports
37

Distinct published reports

Individual concerns
37

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
72

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.

NHS England7
Department of Health and Social Care3
East London NHS Foundation Trust3
Metropolitan Police Service3
Ministry of Justice3
Essex Partnership University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
North East London NHS Foundation Trust2
North London NHS Foundation Trust2
Recipient name withheld2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Browning Street Surgery1
Care Quality Commission1
Cornwall Partnership NHS Foundation Trust1
Cumbria, Northumberland, Tyne and Wear NHS Foundation 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. West Sussex, Brighton and Hove

    AI-generated summary

    Miles Ethan Hurley · 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

    Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.

    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

    Difficulty obtaining collateral mental health information from other services

    Wider context from the report

    “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite. a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care. b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody. c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody. c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment. d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody. d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present. e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality. ”

    Source location

    Miles Ethan Hurley · Prevention of Future Deaths report
    Page 7 · 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

    Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.

    Verbatim wording from the response

    “f) NHS Trust information sharing has also been raised as a concern by the NPCC in that the inability or refusal to share clinical records between criminal justice pathways adds risk to a detainees welfare.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 29 July 2024

    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

    Sussex Partnership Trust’s Mental Health Helpline is best placed to respond about family information not being shared with the commissioned Liaison and Diversion service.

    Verbatim wording from the response

    “7. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 29 July 2024

    Open published response
  2. Derby and Derbyshire

    AI-generated summary

    Sobia Tabasim Khan · 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

    Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.

    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 investigate culturally relevant family and community information

    Wider context from the report

    “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered. ”

    Source location

    Sobia Tabasim Khan · Prevention of Future Deaths report
    Page 4 · 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

    Deliver a rolling Unconscious Bias training programme to develop cultural competence.

    Verbatim wording from the response

    “With particular reference to the Coroner's concern, 5i, Derby City Council have introduced a rolling programme of Unconscious Bias training in relation to developing cultural competence.”

    Source location

    Response from Derby City Council
    Page 2 · response
    Published 22 February 2024

    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

    Revise Neighbourhood Profiles to capture cultural information, community groups, establishments, and significant community figures.

    Verbatim wording from the response

    “We have recently revised our Neighbourhood Profiles so that Safer Neighbourhood Teams can capture vital cultural information to enable them to understand the needs of the community and improve their engagement. The profiles outline the demographics of the area and identify key community groups and religious establishments, as well as identifying significant persons within them such as religious leaders, Councillors, headteachers and community workers.”

    Source location

    Response from Derbyshire Constabulary
    Page 3 · response
    Published 22 February 2024

    Open published response
  3. West London

    AI-generated summary

    Tom Sweeting · 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

    Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.

    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

    Inappropriate delegation of family collateral information gathering

    Wider context from the report

    “3. It was acknowledged that obtaining collateral information from the family is vital, but in this case was delegated to a very Junior member of the team who was in the early stages of her training. It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care. ”

    Source location

    Tom Sweeting · 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

    Introduce secondary induction training requiring demonstration, observation and supervised practice for collateral-information gathering.

    Verbatim wording from the response

    “The Trust has reviewed this practice, and whilst the collating of collateral information will remain an important training task for junior members of staff, that there was a shortfall in supervision in this instance and improvements were required in the expectation of how the task should be undertaken. To aid with this, a secondary induction programme into the service has been introduced for new staff, which sets out how this task will be demonstrated, and observed before carried out independently with supervision. The service has commissioned a piece of co-development work with our Experts by Experience as Carers representatives to improve the practices further.”

    Source location

    Response from West London NHS Trust
    Page 3 · response
    Published 19 January 2024

    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

    Provide regular clinical supervision to monitor the quality of clinicians’ work.

    Verbatim wording from the response

    “The service governance structures in place to share learning through a Service Line Quality and Performance meeting into the borough team based Clinical Improvement Groups which are documented. A quarterly Mortality and Morbidity meeting has been introduced for liaison psychiatry teams to reflect on and learn from incidents. In addition, learning from our incidents is now fed into an annual team development programme, in the form of a thematic review of serious incidents, teaching and a complex case discussion forum. All clinicians receive regular clinical supervision which monitors the quality of work individual clinicians conduct.”

    Source location

    Response from West London NHS Trust
    Page 4 · response
    Published 19 January 2024

    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

    Delegating aspects of documentation and assessment to trainee doctors remains appropriate where the supervising consultant ensures adequate supervision.

    Verbatim wording from the response

    “The Trust shares your concern about the perceived mismatch between senior practitioners’ work practices and expectations of junior colleagues, and since this incident has confirmed that all members of staff received the same training and are expected to adhere to the same policies. Whilst it is normal practice in most healthcare settings for certain aspects of documentation and assessment to be delegated across the multidisciplinary team, including to trainee doctors, the supervising consultant retains responsibility for ensuring adequate supervision. Learning from this event has been incorporated into the teaching plan for future trainees rotating through LPS settings, and will be reflected upon by the senior practitioners involved in their monthly management meetings and annual appraisal.”

    Source location

    Response from West London NHS Trust
    Page 2 · response
    Published 19 January 2024

    Open published response
  4. Black Country

    AI-generated summary

    Karmchand Gulzar · 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

    Karmchand Gulzar was taken to Sandwell Hospital on 23 September 2022 with abdominal distension and pain and was diagnosed with acute intestinal obstruction. A CT scan and immediate surgical review were delayed; his condition deteriorated, urgent surgery took place during the evening and early morning, and he died during the operation in the early hours of 24 September 2022. Concerns included failure to follow the surgical registrar referral pathway, failure to undertake an urgent CT scan, and insufficient recognition of deterioration and concerns raised by carers and family about his condition.

    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 give adequate weight to concerns from carers and family familiar with a patient's presentation

    Wider context from the report

    “(3) The deterioration in Karmchand’s condition was not recognised due to difficulties in communication of pain due to his mental health condition. Concerns raised by his carers and family who knew him best and his presentation were not given adequate weight. A previous SI was reported to have raised this issue, but no action point or plan was provided in the current report to set out how staff could improve the assessment of patients with communication difficulties, by using observations and relying on people who better knew their demeanour and presentation. ”

    Source location

    Karmchand Gulzar · 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

    Trial a Carers Passport and supporting documentation prompting carers to describe patients’ individual needs and pain expressions.

    Verbatim wording from the response

    “In relation to the concerns regarding the recognition of deterioration not being recognised due to Mr Gulzar’s mental health condition and the concerns of his family/carers being ignored; there is considerable work being done by our Patient Experience team to support improvement in this area. Listening to and valuing the expertise that exists within carers and families is crucial to providing personalised care and treatment, and personalisation is a key-cornerstone of the Trust's Fundamentals of Care programme. Through this work a 'Carers Passport' with supporting patient documentation concentrating on the person, is being trialled in selected wards to understand the benefits this will reap for carers across the organisation. This trial will take place in April 2024, and we will then look to roll this out across the Trust.”

    Source location

    Response from Sandwell and West Birmingham NHS Trust
    Page 2 · response
    Published 3 January 2024

    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

    Deliver patient experience and communication education emphasizing carers’ involvement, expertise, and contribution to care and outcomes.

    Verbatim wording from the response

    “Additionally, we have identified training and education in patient experience and communication as Trust priorities. Every session delivered in the last year stresses the value of carer involvement, their specific expertise and knowledge and the benefits in experience and outcomes that these bring.”

    Source location

    Response from Sandwell and West Birmingham NHS Trust
    Page 2 · response
    Published 3 January 2024

    Open published response
  5. Surrey

    AI-generated summary

    Barbara Ann WOODMAN · 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

    Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.

    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 gather relevant collateral history while respecting patient confidentiality

    Wider context from the report

    “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████. The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. ”

    Source location

    Barbara Ann WOODMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. East Sussex

    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.

    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 seek and record relevant information from family 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
    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 initial medical and risk assessments to record consent, next-of-kin details, and information obtained from patients’ families.

    Verbatim wording from the response

    “b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.”

    Source location

    Response from Bramley Health
    Page 2 · response
    Published 14 November 2023

    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

    Require staff to obtain family contact information and speak with next of kin when agreed, recording the information provided.

    Verbatim wording from the response

    “If agreed, a qualified member of staff is subsequently tasked with reaching out to the family and recording vital information. The document includes a section to record the information provided by a family or relative. Obtaining contact information and speaking with the next of kin are now a mandatory task at Langford.”

    Source location

    Response from Bramley Health
    Page 3 · response
    Published 14 November 2023

    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

    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
    Page 3 · response
    Published 14 November 2023

    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

    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
    Page 2 · response
    Published 14 November 2023

    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

    Increase the role of family voice in the inpatient transformation programme.

    Verbatim wording from the response

    “In 2022, NHS England also established its Mental Health, Learning Disability and Autism Inpatient Transformation Programme to support cultural change and”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 November 2023

    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

    Obtaining information from an informal patient’s family depends on the patient’s consent.

    Verbatim wording from the response

    “b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.”

    Source location

    Response from Bramley Health
    Page 2 · response
    Published 14 November 2023

    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

    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
    Page 1 · response
    Published 14 November 2023

    Open published response
  7. North London

    AI-generated summary

    Sophie Gwen Williams · 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

    Sophie Gwen Williams died at home in the early hours of 20 May 2021 after taking a fatal overdose of prescription medications while in a psychotic or dissociative state. The report identifies concerns about the lack of assessment and management of her overdose and self-harm risk, continuity of care and crisis support, staff training and gender-affirming care, and coordination between mental health and gender-identity 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 of assessment protocols to require obtaining and considering the views of people close to patients

    Wider context from the report

    “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following: (A) by local NHS Trusts: (1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient; (2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on: (a) the needs of trans persons (b) gender-affirming care (c) dissociation and psychosis (3) Scrutiny of the delivery and implementation of such training, by way of quality assurance. (4) The absence from the assessment protocol of a provision to ensure that the full account is taken of: (a) any previous diagnosis and treatment (b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team (c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life (d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose (B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients): (1) a help-line, available when needed by patients (2) the direction of patients to specialist carers (3) provision of mental health care for those patients on waiting-lists (4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients (5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment ”

    Source location

    Sophie Gwen Williams · 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

    Require clinicians to invite family members, carers, supporters and advocates to assessments and record their contact details and involvement in Rio.

    Verbatim wording from the response

    “d. the views of those who are close to the patient, including the patient’s carers, family, and advocates (both formal and informal), who should be contacted, for that purpose.”

    Source location

    Response from Barnet, Enfield and Haringey Mental Health Trust
    Page 3 · response
    Published 10 March 2023

    Open published response
  8. Northamptonshire

    AI-generated summary

    Alfie Stone · 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

    Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.

    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 ask parents whether the child had vomited

    Wider context from the report

    “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited. ”

    Source location

    Alfie Stone · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Suction was not required because the child did not vomit while the crew was present.

    Verbatim wording from the response

    “3. No suction attempted, and the question was not asked of the parents as to whether the child had vomited.”

    Source location

    2022-0013-Response-from-East-Midlands-Ambulance-Service_Published
    Page 3 · response
    Published 20 January 2022

    Open published response
  9. Manchester North

    AI-generated summary

    Sarah McGarrigle · Prevention of Future Deaths report

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

    Report summary

    Sarah McGarrigle, aged 23, was found deceased at home on 1 March 2020. She died from catastrophic internal haemorrhage caused by spontaneous rupture of oesophageal varices associated with chronic alcohol use, in the context of trauma, mental disorder and self-neglect. The principal concerns were that relevant information about her history and community behaviours was not properly considered on Aspen Ward, and that a requested assessment of her mental disorder and capacity did not take place.

    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 incorporate relevant collateral information and community history in mental disorder assessments

    Wider context from the report

    “(1) That the clinicians on Aspen Ward did not consider relevant information provided to the ward by the allocated social worker and the AMHP in the assessment of the Deceased’s mental disorder. The was an over-reliance on Sarah’s presentation on the ward and insufficient consideration given to the concerns that had been raised by community agencies, her psychiatric history and behaviours in the community setting. ”

    Source location

    Sarah McGarrigle · 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

    Introduce an inpatient–community interface meeting to improve discharge-planning information sharing and communication.

    Verbatim wording from the response

    “████████o reduce the likelihood of similar incidents occurring in the future, the PCFT Oldham Triumvirate Leadership Team have held several meetings to renew the discharge process on its inpatient adult acute mental health wards. A number of ████████tions to improve the quality of discharges have been taken, which include:”

    Source location

    Response from NHS Pennine Care Foundation Trust
    Page 2 · response
    Published 6 October 2022

    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

    Introduce a process for arranging and facilitating discharge-planning and ward-round meetings.

    Verbatim wording from the response

    “████████o reduce the likelihood of similar incidents occurring in the future, the PCFT Oldham Triumvirate Leadership Team have held several meetings to renew the discharge process on its inpatient adult acute mental health wards. A number of ████████tions to improve the quality of discharges have been taken, which include:”

    Source location

    Response from NHS Pennine Care Foundation Trust
    Page 2 · response
    Published 6 October 2022

    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

    Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.

    Verbatim wording from the response

    “• The concerns identified during the inquest have been reviewed by Professor Nihal Fernando, PCFT’s Executive Medical Director. Professor Fernando will share a copy of PCFT’s Regulation 28 response with the Aspen ward consultant Psychiatrists Responsible Officer, in his new Trust.”

    Source location

    Response from NHS Pennine Care Foundation Trust
    Page 2 · response
    Published 6 October 2022

    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

    Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.

    Verbatim wording from the response

    “• Oldham's mental health services now have a route to refer patients to the Oldham multi-agency Adults with Multiple Complex Needs Meeting. This ████████to support professionals to work with complex patients who present with high levels of risk but are assessed as having the mental capacity to make unwise decisions or do not engage with their care and treatment.”

    Source location

    Response from NHS Pennine Care Foundation Trust
    Page 3 · response
    Published 6 October 2022

    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

    Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.

    Verbatim wording from the response

    “• PCFT’s Head of Safeguarding and the Named Professional for Safeguarding Adults will make a recommendation to the Oldham Safeguarding Adult Partnership Board that a multi-agency protocol be developed. The recommended protocol would outline the roles and responsibilities of each agency when assessing mental capacity for complex patients with a mixture of health and social care needs. The guidance would also outline how multi-agency partners can request specialist mental health input for a mental capacity assessment.”

    Source location

    Response from NHS Pennine Care Foundation Trust
    Page 4 · response
    Published 6 October 2022

    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

    The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.

    Verbatim wording from the response

    “physical symptoms of withdrawal. On admission to Aspen Ward, she was not experiencing any alcohol-related behavioural issues. It is widely accepted that alcohol use can cause or increase symptoms of behavioural and/or mental illness. For some patients, when they stop alcohol, their symptoms can significantly improve or stop all together. Sarah’s overall presentation from the time she was assessed and detained under the MHA in the Royal Oldham Acute Hospital, compared to while an inpatient on Aspen was significantly better. Sarah appeared to improve in the time between being detained under Section 2 and being transferred to Aspen Ward (which was a period of several days). Sarah had been safely using leave off the medical wards for a cigarette break. While on Aspen Ward, she also used leave off the ward for cigarettes.”

    Source location

    Response from NHS Pennine Care Foundation Trust
    Page 2 · response
    Published 6 October 2022

    Open published response
  10. Manchester South

    AI-generated summary

    Carole Mitchell · 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

    Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.

    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 fully utilise information gathering from family due to misunderstanding of confidentiality

    Wider context from the report

    “3. It was accepted at the inquest that information gathering from family could be beneficial. However, there was a reluctance by health professionals to fully utilise information gathering due to concerns about breaching patient confidentiality. This appeared to stem from a misunderstanding between the concept of information sharing and information gathering and how they inter related with the principle of patient confidentiality. ”

    Source location

    Carole Mitchell · 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

    Develop an information-sharing and suicide-prevention consensus statement with leading mental health organisations.

    Verbatim wording from the response

    “Finally, in relation to the third matter of concern in your report and information sharing, the Department of Health and Social Care, with input from leading mental health organisations, developed an Information sharing and suicide prevention consensus statement⁴, to help address the concerns families have regarding mental health practitioners being reluctant to take information from families or to divulge information about a person’s suicide risk. Through its contract with the Department, the Zero Suicide Alliance is developing guidance for frontline staff on how to use the Consensus Statement and when and how to share information to help prevent suicide. Development of this resource is ongoing, with the guidance due to be published shortly. We will continue to promote this statement through our networks.”

    Source location

    2021-0037-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 3 · response
    Published 15 February 2021

    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

    Develop guidance for frontline staff on applying the consensus statement and sharing information to help prevent suicide.

    Verbatim wording from the response

    “Finally, in relation to the third matter of concern in your report and information sharing, the Department of Health and Social Care, with input from leading mental health organisations, developed an Information sharing and suicide prevention consensus statement⁴, to help address the concerns families have regarding mental health practitioners being reluctant to take information from families or to divulge information about a person’s suicide risk. Through its contract with the Department, the Zero Suicide Alliance is developing guidance for frontline staff on how to use the Consensus Statement and when and how to share information to help prevent suicide. Development of this resource is ongoing, with the guidance due to be published shortly. We will continue to promote this statement through our networks.”

    Source location

    2021-0037-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 3 · response
    Published 15 February 2021

    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

    Continue promoting the information-sharing and suicide-prevention consensus statement through departmental networks.

    Verbatim wording from the response

    “Finally, in relation to the third matter of concern in your report and information sharing, the Department of Health and Social Care, with input from leading mental health organisations, developed an Information sharing and suicide prevention consensus statement⁴, to help address the concerns families have regarding mental health practitioners being reluctant to take information from families or to divulge information about a person’s suicide risk. Through its contract with the Department, the Zero Suicide Alliance is developing guidance for frontline staff on how to use the Consensus Statement and when and how to share information to help prevent suicide. Development of this resource is ongoing, with the guidance due to be published shortly. We will continue to promote this statement through our networks.”

    Source location

    2021-0037-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 3 · response
    Published 15 February 2021

    Open published response
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Data last updated 7 September 2026