Recurring concern

Insufficient frontline staff competence to recognise and explore substance-related mental-health risks

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First reported 28 Mar 2017•Latest report 16 May 2022

Definition

What this concern includes

Includes failures in the competence, training or practical experience of frontline staff who are expected to explore mental-health and substance-use issues or recognise substance-related dangers and presentations, including Phoenix Futures staff and healthcare staff in detained mental-health settings.

Not included

  • Excludes generic staff-training or staffing deficiencies where no direct substance-related mental-health recognition or exploration function is identified.
  • Excludes failures in specialist diagnosis, treatment or referral after appropriately competent frontline assessment has occurred.
  • Excludes generic mental-health, substance-misuse or clinical-service capacity problems that do not concern frontline staff competence.
  • Excludes competence concerns involving unrelated professional advice, records access or operational processes.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2017–2022

First to latest report issue date

Stated actions
0

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 England2
Care UK1
East London NHS Foundation Trust1
HM Prison and Probation Service1
Pentonville Prison1

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. Bedfordshire and Luton

    AI-generated summary

    Mr Thomas Antony Smith · 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 Thomas Antony Smith died in a drugs-related death after serious failings in his care on Coral Ward during the night of 29–30 December 2020. The principal concerns were inadequate staff knowledge about the dangers and presentation of drugs, insufficient observation and escalation after a positive drugs test and signs of deterioration, and weaknesses in the system for assessing risks associated with Section 17 leave.

    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

    Lack of staff knowledge and training about substance-related dangers and presentations in detained mental health settings

    Wider context from the report

    “1) Knowledge of the dangers of ████████ in detained mental health patient settings There was evidence of steps having been taken by the ELFT at a local level to remedy the apparent lack of knowledge amongst its staff regarding the dangers of ████████ and ████████ after Mr Smith’s death, including its own substance misuse training and inviting local substance misuse charities back onto its wards to work with its patients and staff as Covid restrictions lift. There was, however, various evidence which suggested a lack of knowledge from ELFT staff around ████████ and it’s potentially fatal effects, including that several witnesses: (i) Did not know what ████████ or ████████ could look like; (ii) Were unaware of how a person under the influence of ████████ or ████████ might present; and (iii) Had received no training on the dangers of ████████ or ████████ There was some evidence that this might be a wider issue of concern, both locally and nationally, than only with ELFT staff. In the event that is correct, this report is directed to NHS England and NHS Improvement. ”

    Source location

    Mr Thomas Antony Smith · 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

    Delivering education on the identified dangers is outside the commissioner’s remit.

    Verbatim wording from the response

    “NHS England acknowledge and share your concerns regarding knowledge of ████████ both locally and nationally, although it is not within NHS England’s remit to deliver this education as a commissioner. Provider organisations are responsible for providing staff with the relevant training, to ensure that they are aware of issues pertinent to their patient population. In this particular case, ELFT will be responsible for training and refreshing their employees on ████████ in detained mental health patient settings, and this is addressed further below.”

    Source location

    Responses from NHS England
    Page 1 · response
    Published 28 September 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

    Provider organisations, specifically ELFT, are responsible for training and refreshing staff on the identified dangers.

    Verbatim wording from the response

    “NHS England acknowledge and share your concerns regarding knowledge of ████████ both locally and nationally, although it is not within NHS England’s remit to deliver this education as a commissioner. Provider organisations are responsible for providing staff with the relevant training, to ensure that they are aware of issues pertinent to their patient population. In this particular case, ELFT will be responsible for training and refreshing their employees on ████████ in detained mental health patient settings, and this is addressed further below.”

    Source location

    Responses from NHS England
    Page 1 · response
    Published 28 September 2022

    Open published response

  2. Inner North London

    AI-generated summary

    John 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

    John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.

    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

    Insufficient training and experience to explore mental health and substance-use issues

    Wider context from the report

    “5. Mr Williams also told the member of Phoenix Futures who saw him that he felt cannabis gave him what the mental health team did not. However, the staff member felt he did not have the training or experience to explore either of these issues in greater depth. It may be that Phoenix Futures staff would benefit from additional training, perhaps alongside prison healthcare staff. ”

    Source location

    John WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026