Recurring concern

Failure to obtain relevant collateral information from family and social supports

First to latest report 10 Jan 2014 — 5 Mar 2026

Reports that mention this concern
37
Times this concern has been raised
37
Stated actions linked to this concern
72

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.

What is 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 and published responses 37 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Lincolnshire

    AI-generated summary

    Toby Peter Edward Nieland · 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

    Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

    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 immediate family views on accommodation and treatment and care pathways

    Wider context from the report

    “1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care; ”

    Source location

    Toby Peter Edward Nieland · 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

    Reinforce family and carer involvement in care, including receiving carer information and sharing information with patient consent.

    Verbatim wording from the response

    “iv. To reinforce and further embed the important role of carers and family members in providing the right quality care to patients and to support carers in getting involved with their loved ones’ care, including receiving information from carers and sharing information with consent from patients. Lead: Service Manager for Carers and Peer Support – Ongoing”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 8 · response
    Published 26 October 2020

    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

    A police welfare check was not considered necessary based on the information available at the time.

    Verbatim wording from the response

    “The Trust was informed by the out of area inpatient unit that Mr Nieland had been discharged into the community. In accordance with Trust policy and national guidance, the Trust’s Crisis Resolution and Home Treatment Team offered timely follow-up appointments with Mr Nieland to assess his risk and care arrangements. Based upon the information available at the time, a clinical decision to request a police welfare check was not considered necessary. The Trust appreciate the importance of the views of family and carers has in formulating appropriate care arrangements for patients. With the benefit of hindsight, it is accepted that the knowledge and concerns of Mr Nieland’s family would have better informed assessment of risk. The Trust is continuing to support staff and to emphasise the importance of working and supporting patients to include family and carers in their care.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 5 · response
    Published 26 October 2020

    Open published response

  2. Gateshead and South Tyneside

    AI-generated summary

    MAUREEN WHARTON · 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

    Maureen Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or emergency 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 identify familial or social support for the patient

    Wider context from the report

    “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process. It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls. Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented. An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise. b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger. There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent. ”

    Source location

    MAUREEN WHARTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. East Sussex

    AI-generated summary

    Justin Peter Gallagher · 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

    Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database 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 involve family in obtaining important patient information

    Wider context from the report

    “(4) There was no involvement of the family and so a source of important information was missed. ”

    Source location

    Justin Peter Gallagher · Prevention of Future Deaths report
    Page 1 · 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

    Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.

    Verbatim wording from the response

    “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Gallagher and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 16 August 2019

    Open published response

  4. Inner South London

    AI-generated summary

    Mr Royston Kemp · 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

    Mr Royston Kemp, an 85-year-old care home resident with dementia and a history of fractures and falls, suffered an unwitnessed traumatic fracture of his left femur in February 2016. He was not referred to hospital until two days after signs of injury and died on 20 March 2016 from pneumonia, aspiration and advanced dementia, with the fracture-related immobility identified as a key contributor. Concerns included failure by a nurse to act on leg swelling and temperature differences, establish the care assistant’s concerns, measure vital signs, or escalate for medical assessment and referral.

    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 establish relevant care assistant concerns and their timing

    Wider context from the report

    “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was: 1) She found one leg more swollen than the other and of a different temperature but took no action 2) She failed to establish the care assistant’s concern or whether she had met the concern before or after her assessment 3) She failed to measure Vital Signs 4) She failed to escalate to medical care or refer, in the process failed to enable a diagnosis of fractured femur to be made. ”

    Source location

    Mr Royston Kemp · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Rosario CORDERO-SANZ · 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

    Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.

    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 use language support to obtain information from non-native English speakers

    Wider context from the report

    “2. In addition, the jury heard as follows. - The three police officers did not appear to have an in depth understanding of the misper process. - They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues. - They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices. - Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her. - Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else. I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars? ”

    Source location

    Rosario CORDERO-SANZ · 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

    Recirculate Language Line access instructions and information about its benefits to Metropolitan Special Constabulary officers.

    Verbatim wording from the response

    “Language Line can be accessed via police Airwave radios at any time and full instructions on how to access this service is readily available on the MPS intranet. Instructions on how to use this and its benefits have been recirculated to the MSC via the duty sheet messaging system. The failures identified within this matter of concern represent individual failings which have been addressed directly with the officers concerned.”

    Source location

    2018-0307-Response-by-Metropolitan-Police
    Page 2 · response
    Published 17 February 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

    Suggested scene-assessment actions will not be made mandatory because they may be impracticable or inappropriate in some circumstances.

    Verbatim wording from the response

    “It has been established that the MSC officers who attended the address were not provided with the full details of the call. The informants whom they spoke to did not indicate that Ms Cordero-Sanz was in immediate danger. However it is recognised that if they had obtained more information at the scene utilising Language Line they may have altered their risk assessment and seen her in person. Whilst the suggested considerations have merit, we would not seek to make them mandatory actions as they may not be appropriate or practicable in all circumstances. Had the MSC officers known Ms Cordero-Sanz was a high risk missing person, MPS policy would have required them to physically see her and ensure she was safe and of no danger to herself or others.”

    Source location

    2018-0307-Response-by-Metropolitan-Police
    Page 3 · response
    Published 17 February 2019

    Open published response

  6. Oxfordshire

    AI-generated summary

    Liam Thomas · 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

    Liam Thomas died on 28 August 2016 after being found in a shower room at Littlemore Hospital with plastic bags over his head; he was pronounced dead at hospital, and the cause of death was asphyxiation. The principal concerns were access to plastic bags and other items posing a personal risk, the effectiveness of environmental safety checks, and communication between hospital staff and Liam’s family about information and elevated risk.

    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 obtain relevant information from family for staff

    Wider context from the report

    “The second area of concern is about communication with family. Again, I realise that this is not a straightforward matter because there are issues of consent and it is also the case that some families are not supportive or united. However, in Liam’s case, it is clear that his family were very supportive and united in terms of Liam’s health and wellbeing. A concern at inquest from the evidence was that there was a need for improved communication in terms of information provided by family to staff and also from the staff (particularly concerning elevated risk) to family members. This will enable family to be more watchful. ████████ in her evidence, referred to the “triangular approach” and recognised that there was more work to be done in this difficult area. She indicated that work was on going. It would be helpful if you could provide details about the current policy and practice concerning communications with family and if there is a programme in place, to improve it. ”

    Source location

    Liam Thomas · 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

    Employ a full-time Patient and Carer Experience lead to oversee carer and family experience surveys.

    Verbatim wording from the response

    “We have also employed a full time Patient and Carer Experience lead, who is overseeing the Carer and Family surveys which we co-designed with carers, and which provide direct feedback to wards and community teams about the experience of carers and families, and gives teams the opportunity to liaise directly with carers about the improvements they are making.”

    Source location

    2017-0347-Response-by-Oxford-Health-NHS-Trust
    Page 3 · response
    Published 5 February 2018

    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

    Use co-designed carer and family surveys to provide feedback to wards and community teams and support direct liaison with carers.

    Verbatim wording from the response

    “We have also employed a full time Patient and Carer Experience lead, who is overseeing the Carer and Family surveys which we co-designed with carers, and which provide direct feedback to wards and community teams about the experience of carers and families, and gives teams the opportunity to liaise directly with carers about the improvements they are making.”

    Source location

    2017-0347-Response-by-Oxford-Health-NHS-Trust
    Page 3 · response
    Published 5 February 2018

    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 IWantGreatCare across online and paper channels to collect patient and carer experience feedback.

    Verbatim wording from the response

    “Earlier this year we introduced a new tool called IWantGreatCare which asks patients and carers a series of questions about their experience of the care they have received and give them opportunity to leave free text feedback. This is immediately received by team managers so they can respond dynamically to concerns raised. The tool is available online and on paper, and we rely on staff on wards and in community teams to ask patients and carers to give feedback, as well as posters and materials in wards and outpatient clinics advertising the feedback tool. In addition our patient and carer engagement lead regularly visits all services to work with managers to ensure plans are in place to address the feedback teams receive and hold open surgeries in wards and outpatient clinics encouraging patients and carers to give feedback.”

    Source location

    2017-0347-Response-by-Oxford-Health-NHS-Trust
    Page 3 · response
    Published 5 February 2018

    Open published response

  7. Essex

    AI-generated summary

    Terence Joseph Pimm · 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

    Terence Joseph Pimm died after leaping from the seventh floor of a car park on 26 August 2016, following recent threats to jump and contact with police, hospital and probation services. The substantive concerns included call handling and record-keeping, guidance and training, assessment of immediate risk, involvement of family members in mental health assessments, information sharing and coordination, and clinicians’ understanding of warrants.

    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 mental health assessors to seek family input in appropriate circumstances

    Wider context from the report

    “5). To mental health assessors as to the circumstances in which the input of family Members should be sought. ”

    Source location

    Terence Joseph Pimm · Prevention of Future Deaths report
    Page 1 · 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

    Reinforce to staff the importance of family involvement and ongoing communications.

    Verbatim wording from the response

    “The new Trust has taken steps to reinforce to staff the importance of family involvement and ongoing communications. A detailed debrief in this respect was undertaken with the staff involved in Mr Pimm’s care. Additionally, audits on this issue are being undertaken via the new Trust’s staff supervision process.”

    Source location

    2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
    Page 2 · response
    Published 25 September 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

    Audit family involvement and communications through the staff supervision process.

    Verbatim wording from the response

    “The new Trust has taken steps to reinforce to staff the importance of family involvement and ongoing communications. A detailed debrief in this respect was undertaken with the staff involved in Mr Pimm’s care. Additionally, audits on this issue are being undertaken via the new Trust’s staff supervision process.”

    Source location

    2017-0217-Response-by-Essex-Partnership-University-NHS-Trust_Redacted
    Page 2 · response
    Published 25 September 2017

    Open published response

  8. Inner North London

    AI-generated summary

    Fallon Alphonsine ABBY · 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

    Fallon Alphonsine ABBY died by suicide after jumping from the balcony of her sixth-floor bedroom on 18 February 2017, following recent hospital attendances and discharge to a home treatment team. The report raised concerns that the Roman Ward team did not contact her social worker, meaning potentially valuable information was not shared and social-work support was not available on discharge.

    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 contact social workers and obtain collateral history

    Wider context from the report

    “I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker. There was no protocol for this. If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel. The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made. It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge. This might be very important for another patient. ”

    Source location

    Fallon Alphonsine ABBY · 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

    Review the ward Operational Policy to include contacting the Leaving Care Team when a previously looked-after young person is admitted.

    Verbatim wording from the response

    “In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.”

    Source location

    2017-0288-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 6 December 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

    Work with admitted young people to negotiate their social worker’s involvement after informing the Leaving Care Team.

    Verbatim wording from the response

    “In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.”

    Source location

    2017-0288-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 6 December 2017

    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

    Planned training and policy changes are considered to have adequately addressed concerns about involving Leaving Care Team social workers.

    Verbatim wording from the response

    “In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.”

    Source location

    2017-0288-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 6 December 2017

    Open published response

  9. East London

    AI-generated summary

    Peter Daniel Usher · 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

    Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.

    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 obtain and communicate relevant police and family information during admission

    Wider context from the report

    “4. The police had received contact from family members whilst they were present at the hospital, confirming the concerns of family members due to the text received. This was not passed on to the hospital staff. It became apparent during the course of the Inquest that the police also had access to information which was relevant to the circumstances of the preceding events which would have been relevant to the mental state of the deceased. It would appear that inadequate questions were asked by the receiving hospital team in relation to the circumstances leading to admission. ”

    Source location

    Peter Daniel Usher · 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

    Review and update s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.

    Verbatim wording from the response

    “1, 2, 3, 4 | With emphasis on the requirement to comply with:”

    Source location

    2016-0428-Response-by-NELFT-NHS-Trust
    Page 2 · response
    Published 19 February 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

    Create a generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.

    Verbatim wording from the response

    “9 | To create a generic and secure nhs.net account for s136 suite, which would be monitored and used by the bleep holders to receive the collateral | OJ/VP/RK | 31.03.2017”

    Source location

    2016-0428-Response-by-NELFT-NHS-Trust
    Page 4 · response
    Published 19 February 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

    Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.

    Verbatim wording from the response

    “1.1 – The s136 paperwork completed by officers on the street is Form 434. The form has two particular areas that by their description can create ambiguity when completing them. The first is towards the top where it has the words “Friends/Family” and a space adjacent to it for the officer to fill out. I believe this needs to be more specific and should be changed to “Next of Kin.” This will give the officers more clarity when completing the form and eliminating the potential risk of important information being missed. The second is further down and reads “Name of person handing over” then as above there is a space adjacent for the officer to complete. This leaves some doubt as to whether the person accepting responsibility needs to sign. Under the s136 Pathway it clearly states that a signature is required.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 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

    Design a bespoke handover form with NELFT for use at the 136 suite.

    Verbatim wording from the response

    “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 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

    Hold a progress-review meeting on the bespoke handover form.

    Verbatim wording from the response

    “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 2017

    Open published response

  10. Exeter and Greater Devon

    AI-generated summary

    Matthew Llewellyn-Jones · 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

    Matthew Llewellyn-Jones, who had been detained under section 2 of the Mental Health Act after becoming acutely unwell with psychosis, left a locked hospital ward unaccompanied and was later found hanging by a ligature in the hospital grounds. The concerns included breaches of the ward’s locked door, predictable observations, inadequate collection of information from family and carers, insufficient assessment and observation, inadequate staff induction, and staffing levels that contributed to failings in his care and security.

    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 the admission recording system to make obtaining carer and family information mandatory

    Wider context from the report

    “(3) A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and/or family mandatory on admission. The importance of this information was readily acknowledged by the Trust in their internal inquiry and at inquest. The electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims in this respect. ”

    Source location

    Matthew Llewellyn-Jones · 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

    Use an active Care Notes care-planning field to record information sought from carers or family.

    Verbatim wording from the response

    “A copy of the Care Notes forms are attached, the specific changes that have been made are-”

    Source location

    2016-0385-Response-by-Devon-Partnership-NHS-Trust
    Page 2 · response
    Published 25 October 2016

    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

    Activate a Care Notes risk-assessment area recording carers’ and family members’ views.

    Verbatim wording from the response

    “• Risk Assessment (Specific area looking at carer/family views) – this is due to become active by the end of January 2017 (ref 2.2)”

    Source location

    2016-0385-Response-by-Devon-Partnership-NHS-Trust
    Page 2 · response
    Published 25 October 2016

    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

    A mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.

    Verbatim wording from the response

    “The introduction of a mandatory field has been considered by the Care Notes team and senior clinical colleagues. The decision has been made not to add as a mandatory field, it will continue to be recorded as a ‘free text’ field. The rational for this decision is that a mandatory field could be completed with a generic comment for example ‘have been unable to contact family at this time’, when audited as detailed below, this would be identified as completed. If the field is left ‘blank’ the audit will highlight this and allow individual review and follow up with the staff member concerned.”

    Source location

    2016-0385-Response-by-Devon-Partnership-NHS-Trust
    Page 2 · response
    Published 25 October 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026