Recurring concern

Unreliable gathering and use of collateral information in mental health assessments

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First reported 16 Jan 2014•Latest report 11 May 2026

Definition

What this concern includes

Includes failures of the mental health assessment process involving obtaining, sharing, accessing, evaluating or using relevant collateral information from families, carers, community professionals, other services or available records, including inappropriate delegation of that dedicated information-gathering function.

Not included

Excludes generic staff training, supervision, delegation or documentation failures that are not specifically tied to obtaining or using collateral information in mental health assessment.
Excludes failures concerning clinical assessment or risk assessment that do not involve collateral or externally sourced information.
Excludes general communication or information-sharing failures unrelated to mental health assessment collateral information.

Reports: 28
Individual concerns: 35
Date range: 2014–2026
Stated actions: 77

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England5

Department of Health and Social Care4

Greater Manchester Mental Health NHS Foundation Trust3

North East London NHS Foundation Trust3

East London NHS Foundation Trust2

Hampshire and Isle of Wight Healthcare NHS Foundation Trust2

Metropolitan Police Service2

Midlands Partnership University NHS Foundation Trust2

Avon and Wiltshire Mental Health Partnership NHS Trust1

Berkshire Healthcare NHS Foundation Trust1

Central and North West London NHS Foundation Trust1

Essex Partnership University NHS Foundation Trust1

Essex Police1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Integrated Care Partnership1

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.

21 Jun2018
Leicester City and South Leicestershire
Concerns raised1
1. Failure to routinely involve carers and families in the care of mentally unwell patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Complete supervision sessions for Mental Health Triage staff focused on family and carer involvement in assessment and improved working practice.
  Stated by Leicestershire Partnership NHS TrustStated planned
2. Action
  Provide Mental Health Triage and Crisis staff with NICE guidance on family and carer involvement.
  Stated by Leicestershire Partnership NHS TrustStated completed
3. Action
  Distribute a Whole Family Approach Bulletin to staff every two months to share family and carer involvement learning and good practice.
  Stated by Leicestershire Partnership NHS TrustStated completed
1. Action
  Expand family and carer content in record-keeping audits and monitor compliance through weekly audits and monthly clinical governance.
  Stated by Leicestershire Partnership NHS TrustStated in progress
AI-generated summary

John Charles Hazlewood · 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 Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to routinely involve carers and families in the care of mentally unwell patients
Wider context from the report
“2. Mr Hazlewood’s partner was repeatedly expressed to be his main or only protective factor from self-harm. She was not approached for information regarding his overdose, or her concerns regarding his escalating behavior and this missed an opportunity for the fuller picture to be captured when considering care planning and mental health assessment. This is an issue that I have raised with the Leicester Partnership Trust before in the matter of ████████ and it appears that carers/families are still not being routinely involved in the care of mentally unwell patients. This can create intolerable pressures upon families and leads to poor outcomes such as in these 2 cases. LPT are urged to consider how this matter can be embedded in training and practice. ”
Source location
John Charles Hazlewood · 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
Complete supervision sessions for Mental Health Triage staff focused on family and carer involvement in assessment and improved working practice.

Verbatim wording from the response
“Staff in our Assessment and Triage Team endeavor to elicit carers’ and families’ views regarding the care and treatment of patients, this enables us to gain an understanding of the whole person. However, this is clearly not always as effective as we would like. Although we implemented a number of actions in 2015 in response to the death of Mr. Abel, it is clear we need to continue to reinforce the importance of effective communication with families/carers. With this in mind, our senior Matron will complete work with the teams to ensure all staff in our Mental Health Triage team have a supervision session with the focus on family and carer involvement in the assessment process and discuss ways in which they can improve this within their working practice. This will be completed by October 2018.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 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
Provide Mental Health Triage and Crisis staff with NICE guidance on family and carer involvement.

Verbatim wording from the response
“We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 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
Distribute a Whole Family Approach Bulletin to staff every two months to share family and carer involvement learning and good practice.

Verbatim wording from the response
“We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 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
Expand family and carer content in record-keeping audits and monitor compliance through weekly audits and monthly clinical governance.

Verbatim wording from the response
“We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.”

Source location
2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Page 2 · response
Published 9 July 2018
Open published response
14 Aug2017
Essex
Concerns raised1
1. Failure of mental health assessors to seek family input in appropriate circumstances
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Reinforce to staff the importance of family involvement and ongoing communications.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Audit family involvement and communications through the staff supervision process.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
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
2 Dec2016
East London
Concerns raised1
1. Failure to obtain and communicate relevant police and family information during admission
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review and update s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.
  Stated by NELFT NHS NHS Foundation TrustStated planned
2. Action
  Create a generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.
  Stated by NELFT NHS NHS Foundation TrustStated planned
3. Action
  Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.
  Stated by Metropolitan Police ServiceStated completed
1. Action
  Design a bespoke handover form with NELFT for use at the 136 suite.
  Stated by Metropolitan Police ServiceStated in progress
2. Action
  Hold a progress-review meeting on the bespoke handover form.
  Stated by Metropolitan Police ServiceStated planned
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
13 Jun2016
Preston and West Lancashire
Concerns raised1
1. Failure of RMNs to read ACC T documentation for collateral information relevant to delusional-disorder diagnosis
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Andrew Gus PEEBLES · 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

The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.

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 RMNs to read ACC T documentation for collateral information relevant to delusional-disorder diagnosis
Wider context from the report
“(4) No reading by the RMN of the ACC T documentation for collateral information necessary to assist in the diagnosis of a delusional disorder ”
Source location
Andrew Gus PEEBLES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Jun2015
Wiltshire and Swindon
Concerns raised1
1. Failure to gather information from family and others involved in mental health assessments
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Deliver teaching sessions to improve communication with carers and patients and address barriers to family involvement.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated completed
2. Action
  Add space to the self-harm proforma to record next-of-kin details, relationship and the patient’s contact wishes.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated completed
3. Action
  Establish guidance and training requiring staff to involve service users, families and carers in CPA and risk assessments.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completed
1. Action
  Communicate triage, assessment and referral outcomes to referrers, service users, families, carers and relevant agencies.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completed
Respondent positions 2
1. Position
  Existing policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustExisting arrangements considered sufficient
1. Position
  Existing AMHP information-gathering guidance is clear, so no further action is proposed in that area.
  Stated by Approved Mental Health Professional/Social Work ServiceExisting arrangements considered sufficient
AI-generated summary

Elizabeth Godwin · 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

Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.

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 information from family and others involved in mental health assessments
Wider context from the report
“I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS: a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment. b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored. c) As to how that information is shared with other agencies involved in the care of that patient. d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it. e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail. I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns. ”
Source location
Elizabeth Godwin · 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
Deliver teaching sessions to improve communication with carers and patients and address barriers to family involvement.

Verbatim wording from the response
“The Emergency Department continues to raise awareness of the importance of family involvement and relatives’ valuable knowledge of the patient’s wider situation. Teaching sessions, including seven one hour sessions delivered by the clinical psychologist on removing the obstacles to communication with carers and patients, have been delivered.”

Source location
2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 19 June 2015
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
Add space to the self-harm proforma to record next-of-kin details, relationship and the patient’s contact wishes.

Verbatim wording from the response
“In addition, there is an allocated space on the self-harm proforma for information about the patient’s next of kin, their relationship and the patient’s wishes in relation to whether they should be contacted.”

Source location
2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 19 June 2015
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
Establish guidance and training requiring staff to involve service users, families and carers in CPA and risk assessments.

Verbatim wording from the response
“The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.”

Source location
2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 19 June 2015
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
Communicate triage, assessment and referral outcomes to referrers, service users, families, carers and relevant agencies.

Verbatim wording from the response
“The Trust CPA and Risk Policy outlines the requirement that referrals not requiring assessment will be returned to the referrer with referral outcome decision and recommendations for further intervention.”

Source location
2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 19 June 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.

Verbatim wording from the response
“The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.”

Source location
2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 19 June 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing AMHP information-gathering guidance is clear, so no further action is proposed in that area.

Verbatim wording from the response
“The guidance for AMHP’s in terms of information gathering is very clear and no action is proposed in this area. However, in terms of communication with other organisations, actions to be taken are covered in d) and e).”

Source location
2015-0233-Response-by-Wiltshire-Council
Page 3 · response
Published 19 June 2015
Open published response
11 May2015
Berkshire
Concerns raised1
1. Failure to obtain relevant history and treatment input from private clinicians
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Miss Chandni Nigam · 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

Miss Chandni Nigam, a 19-year-old woman with a history of depression and suicidal ideation, died after being struck by a train at Twyford Railway Station on 4 February 2014. The report raised concern that the NHS Mental Health Team did not obtain relevant history or input from her previous private clinicians when care transferred to the NHS.

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 history and treatment input from private clinicians
Wider context from the report
“(1) During the course of her on-going care, Miss Nigam was being seen by private psychiatrist and psychologist. When she reverted to NHS Mental Health Team Care she still had on-going sessions with the private psychologist. There was an opportunity to gain history and input from the private clinicians as to Miss Nigam’s history, previous treatment and what had been successful and less successful. No attempt to obtain that history or any input from the previous private clinicians appears to have been made. There was an opportunity to obtain helpful and effective historical information that may have assisted in the treatment of Miss Nigam by the Mental Health Team. ”
Source location
Miss Chandni Nigam · Prevention of Future Deaths report
Page 1 · concerns
Open source report
29 Apr2015
Inner North London
Concerns raised2
1. Delays in passing family information to the psychiatry liaison team
2. Failure to obtain collateral history from family members before concluding the interview
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Pilot the mental health assessment proforma and make it available to mental health colleagues.
  Stated by Whittington Health NHS TrustStated in progress
AI-generated summary

Finnulla Catherine MARTIN · 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

Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.

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
Delays in passing family information to the psychiatry liaison team
Wider context from the report
“8. The crisis team did not pass on information received from Ms Martin’s sister to the psychiatry liaison team with a sufficient degree of urgency to ensure that this was taken into consideration before the interview with Ms Martin was concluded. ”
Source location
Finnulla Catherine MARTIN · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to obtain collateral history from family members before concluding the interview
Wider context from the report
“6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms Martin. ”
Source location
Finnulla Catherine MARTIN · 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
Pilot the mental health assessment proforma and make it available to mental health colleagues.

Verbatim wording from the response
“b) To implement use of a mental health Proforma to improve the quality of assessments and ensure this is available to mental health colleagues”

Source location
2015-0173-Whittington-Health-NHS-Trust
Page 2 · response
Published 29 April 2015
Open published response
16 Jan2014
Sunderland
Concerns raised2
1. Failure to formally consult carers or partners in mental health welfare assessments
2. Failure to avoid discounting domestic abuse involving elderly people in mental health service assessments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

May Stokoe and James Henderson Stokoe · Prevention of Future Deaths report

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

Report summary

On 1 May 2013, May Stokoe was fatally attacked with a knife and James Henderson Stokoe inflicted fatal knife injuries on himself. The report raised concerns about the assessment and involvement of carers or partners in mental health services, including whether their information could better inform risk assessments and whether domestic abuse involving older people might be missed.

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 formally consult carers or partners in mental health welfare assessments
Wider context from the report
“I was also concerned about the possibility that carers or partners of individuals who are subject to the provision of Mental Health Services are not formally consulted about the welfare of the patient/service user. Although I was satisfied that domestic abuse awareness was an integral part of training for Mental Health staff, the circumstances of the deaths of Mr and Mrs Stokoe did raise for me concerns that more formal involvement of a carer/partner may allow them to make disclosures which might better inform the assessment process. For example, information from them may corroborate or verify that being provided by the service user/patient. In my view carers/partners may be a very valuable source of information which may not necessarily be disclosed or volunteered by the service user or patient. Carers/partners should have more visibility to the Mental Health Services and domestic abuse involving the elderly cannot be discounted and matters should be approached with an open mind. ”
Source location
May Stokoe and James Henderson Stokoe · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to avoid discounting domestic abuse involving elderly people in mental health service assessments
Wider context from the report
“I was also concerned about the possibility that carers or partners of individuals who are subject to the provision of Mental Health Services are not formally consulted about the welfare of the patient/service user. Although I was satisfied that domestic abuse awareness was an integral part of training for Mental Health staff, the circumstances of the deaths of Mr and Mrs Stokoe did raise for me concerns that more formal involvement of a carer/partner may allow them to make disclosures which might better inform the assessment process. For example, information from them may corroborate or verify that being provided by the service user/patient. In my view carers/partners may be a very valuable source of information which may not necessarily be disclosed or volunteered by the service user or patient. Carers/partners should have more visibility to the Mental Health Services and domestic abuse involving the elderly cannot be discounted and matters should be approached with an open mind. ”
Source location
May Stokoe and James Henderson Stokoe · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to routinely involve carers and families in the care of mentally unwell patients

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure of mental health assessors to seek family input in appropriate circumstances

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to obtain and communicate relevant police and family information during admission

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure of RMNs to read ACC T documentation for collateral information relevant to delusional-disorder diagnosis

Concerns raised1

Failure to gather information from family and others involved in mental health assessments

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to obtain relevant history and treatment input from private clinicians

Concerns raised2

Delays in passing family information to the psychiatry liaison team

Failure to obtain collateral history from family members before concluding the interview

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 4

Actions described in response 2

Actions described in response 5

Actions described in response 4

Respondent positions 2

Actions described in response 1