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.

22 Dec2023
Surrey
Concerns raised1
1. Failure to gather relevant collateral history while respecting patient confidentiality
This report raised 7 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

Barbara Ann WOODMAN · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to gather relevant collateral history while respecting patient confidentiality
Wider context from the report
“ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████. The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. ”
Source location
Barbara Ann WOODMAN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Jul2023
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment
This report raised 7 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 6
1. Action
  Progress Triangle of Care accreditation from Star 2 toward Star 3.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progress
2. Action
  Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated planned
3. Action
  Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completed
1. Action
  Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completed
2. Action
  Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completed
3. Action
  Maintain an ongoing focus on improving engagement with families and carers using learning from this case.
  Stated by NHS Hampshire and Isle of Wight Integrated Care BoardStated in progress
AI-generated summary

Kirsty Clare TAYLOR · 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

Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment
Wider context from the report
“3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions. There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition. Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity. Unless all concerns are heard and considered and all available information is taken on board, holistically, there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed. In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded. ”
Source location
Kirsty Clare TAYLOR · 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
Progress Triangle of Care accreditation from Star 2 toward Star 3.

Verbatim wording from the response
“In June of this year we were delighted to be awarded Triangle of Care Star 2 accreditation and we are now working towards Star 3 to complete the process. In order for a mental health trust to achieve star 2 status, it must not only have completed the self-assessment for inpatient wards and crisis services, but also provision of support within community mental health services.”

Source location
Response from Southern Health NHS Foundation Trust
Page 5 · response
Published 11 December 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.

Verbatim wording from the response
“The introduction of Esther coaching this year will further enhance and reinforce the Triangle of Care principles. Esther Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous”

Source location
Response from Southern Health NHS Foundation Trust
Page 5 · response
Published 11 December 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.

Verbatim wording from the response
“There are 152 carer leads in teams across the Trust with an additional 63 honorary Carers Leads – influencers and ambassadors. These are members of the team with a responsibility to champion family and carer engagement as part of their wider clinical role. We have also employed 22 staff in the roles of Carer Support Workers across the Trust. These are paid roles exclusively for working with carers.”

Source location
Response from Southern Health NHS Foundation Trust
Page 6 · response
Published 11 December 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.

Verbatim wording from the response
“Policies and protocols with regards to information sharing (including the issue of capacity) are also in place. The Trust promotes the importance of both the 7th and 8th principles of the UK Caldicott Guardian Council in recognising the importance of the duty to share information being as important as the duty to protect patient confidentiality. They are included with our Triangle of Care work and information governance (IG) training. IG training is completed annually by every member of staff which will help to embed these principles further.”

Source location
Response from Southern Health NHS Foundation Trust
Page 6 · response
Published 11 December 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.

Verbatim wording from the response
“The Trust has increased the number of ways that people can give feedback and opportunities to share their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We have a number of carers groups across the Trust, as well as supporting external groups. Most recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton. Feedback and issues highlighted from these different platforms is reported to the Carers, Family and Friends group and the Patient Experience and Caring group as part of our business-as-usual reporting.”

Source location
Response from Southern Health NHS Foundation Trust
Page 7 · response
Published 11 December 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain an ongoing focus on improving engagement with families and carers using learning from this case.

Verbatim wording from the response
“Whilst there is more to be done to ensure that feedback from families and carers is heard and acted on and informs the delivery of care and decision-making for those in receipt of services, the trust has demonstrated its commitment to deliver continuous improvements in this area.”

Source location
Response from Hampshire and Isle of Wight
Page 3 · response
Published 11 December 2023
Open published response
28 Apr2023
East London
Concerns raised1
1. Failure to incorporate available clinical information into self-harm risk assessments
This report raised 14 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
  Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
  Stated by North East London NHS Foundation TrustStated planned
2. Action
  Audit compliance with live-record use and risk-assessment processes.
  Stated by North East London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Concerns about care provision and coordination are mainly for the NHS Trust to address.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Winbourne Gregory Charles · 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

Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to incorporate available clinical information into self-harm risk assessments
Wider context from the report
“1. A failure to adequately assess risk of harm - Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team (“MDT”) ward round on 6ᵗʰ April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion. ”
Source location
Winbourne Gregory Charles · 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 live RiO records for handovers, daily run-throughs and MDT ward rounds.

Verbatim wording from the response
“1. Risk assessment (lack of appropriate consideration of risks) – the Coroner found that poor | 1. | Handovers and daily run through to take place using live RiO | 1. Matrons, Ward Managers and Consultant Psychiatrists to be made aware that this needs to be in place”

Source location
NELFT NHS Foundation Trust Action Plan
Page 2 · response
Published 5 May 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit compliance with live-record use and risk-assessment processes.

Verbatim wording from the response
“2. To be audited to ensure compliance | DON/AMD | June 2023”

Source location
NELFT NHS Foundation Trust Action Plan
Page 2 · response
Published 5 May 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Concerns about care provision and coordination are mainly for the NHS Trust to address.

Verbatim wording from the response
“Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 5 May 2023
Open published response
14 Dec2021
Milton Keynes
Concerns raised2
1. Failure to discuss S. 136 Mental Health Act assessments with relevant police officers and other involved care professionals
2. Failure to ensure that S. 136 Mental Health Act assessments use full information held by relevant services
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

Hedley Frederick ROBINSON · 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

Hedley Frederick ROBINSON died on 14 April 2019 after sustaining multiple stab wounds inflicted in Newport Pagnell on 24 March 2019. The concern identified was that a Mental Health Act section 136 assessment was conducted without full information or discussion with relevant senior police officers and others involved in the assailant’s care, prompting concern about the operation of section 136 procedures in Milton Keynes.

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 discuss S. 136 Mental Health Act assessments with relevant police officers and other involved care professionals
Wider context from the report
“I am concerned that the S. 136 Mental Health Act assessment was conducted without full information held by CNWL or discussion with senior police officers and others who had been involved in the care of the deceased’s assailant. There needs to be an urgent review of the operation of S. 136 procedures in Milton Keynes. ”
Source location
Hedley Frederick ROBINSON · 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 ensure that S. 136 Mental Health Act assessments use full information held by relevant services
Wider context from the report
“I am concerned that the S. 136 Mental Health Act assessment was conducted without full information held by CNWL or discussion with senior police officers and others who had been involved in the care of the deceased’s assailant. There needs to be an urgent review of the operation of S. 136 procedures in Milton Keynes. ”
Source location
Hedley Frederick ROBINSON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Nov2021
Manchester North
Concerns raised1
1. Failure to incorporate relevant collateral information and community history in mental disorder assessments
This report raised 1 other concern. 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
  Introduce an inpatient–community interface meeting to improve discharge-planning information sharing and communication.
  Stated by Pennine Care NHS Foundation TrustStated completed
2. Action
  Introduce a process for arranging and facilitating discharge-planning and ward-round meetings.
  Stated by Pennine Care NHS Foundation TrustStated completed
3. Action
  Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
  Stated by Pennine Care NHS Foundation TrustStated planned
1. Action
  Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
  Stated by Pennine Care NHS Foundation TrustStated completed
2. Action
  Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
  Stated by Pennine Care NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
  Stated by Pennine Care NHS Foundation TrustDisputes the concern
AI-generated summary

Sarah McGarrigle · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to incorporate relevant collateral information and community history in mental disorder assessments
Wider context from the report
“(1) That the clinicians on Aspen Ward did not consider relevant information provided to the ward by the allocated social worker and the AMHP in the assessment of the Deceased’s mental disorder. The was an over-reliance on Sarah’s presentation on the ward and insufficient consideration given to the concerns that had been raised by community agencies, her psychiatric history and behaviours in the community setting. ”
Source location
Sarah McGarrigle · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

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

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

Source location
Response from NHS Pennine Care Foundation Trust
Page 2 · response
Published 6 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

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

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

Source location
Response from NHS Pennine Care Foundation Trust
Page 2 · response
Published 6 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

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

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

Source location
Response from NHS Pennine Care Foundation Trust
Page 2 · response
Published 6 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

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

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

Source location
Response from NHS Pennine Care Foundation Trust
Page 3 · response
Published 6 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

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

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

Source location
Response from NHS Pennine Care Foundation Trust
Page 4 · response
Published 6 October 2022
Open published response
Source evidence

How this respondent position was interpreted

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

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

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

Source location
Response from NHS Pennine Care Foundation Trust
Page 2 · response
Published 6 October 2022
Open published response
27 Aug2021
Manchester South
Concerns raised1
1. Failure to enable relevant family input during emergency mental health assessment
This report raised 2 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

Fadhia SEGULEH · 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

Fadhia Seguleh was receiving treatment for anxiety and depression when she was found unresponsive, attached to a ligature at her home on 24 February 2021. The concerns included fragmented care and inadequate information sharing between NHS mental health services, her GP and private therapy provider, telephone-only mental health assessments during Covid, and her attending A&E alone during a previous mental health crisis without family input.

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 enable relevant family input during emergency mental health assessment
Wider context from the report
“3. The inquest heard evidence that she had on a previous occasion been taken to A and E due to concerns that she would take her own life/self-harm. Due to Covid she had to go alone to A and E and was assessed alone without input from her family who were aware of the full picture. The experience of attending alone whilst experiencing mental health issues was deeply stressful for her and meant that she had been unsupported by her family at a time of crisis. In addition, the quality of information available was limited as a result of her being there alone. ”
Source location
Fadhia SEGULEH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 May2021
Manchester South
Concerns raised1
1. Failure to incorporate family information into care plans and risk assessments
This report raised 2 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 3
1. Action
  Update the Clinical Risk Assessment Policy to address confidentiality breaches where necessary to manage risks of serious harm.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Review and update Trust-wide clinical risk training to require gathering and corroborating risk information from family, friends and other professionals.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
3. Action
  Publish an updated Care Programme Approach Position Statement setting expectations for involving and supporting carers in care and support planning.
  Stated by NHS EnglandStated completed
AI-generated summary

Stephen Thurm · 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

Stephen Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to incorporate family information into care plans and risk assessments
Wider context from the report
“1. The inquest heard that information regarding the risk of self-harm to Stephen was passed by his family to his treating clinicians and his care coordinator but this was not taken into account as Stephen denied a recent attempt to take his own life. What steps could be taken to ensure family information is taken into account in the relevant care plan and risk assessments. ”
Source location
Stephen Thurm · 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
Update the Clinical Risk Assessment Policy to address confidentiality breaches where necessary to manage risks of serious harm.

Verbatim wording from the response
“GMMH Trust Clinical Risk Assessment Policy has been updated in March 2021 to include circumstances when staff may be required to breach someone’s confidentiality in respect of risk to self or others.”

Source location
2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 18 May 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and update Trust-wide clinical risk training to require gathering and corroborating risk information from family, friends and other professionals.

Verbatim wording from the response
“Alongside the updated Clinical Risk Policy the Trust wide clinical risk training has also been reviewed and updated in March 2021 to include the need for staff to gather information from other sources and not just the service user when undertaking assessment of risk. The use of professional curiosity is raised within the training and the need not to take things at face value but to corroborate information with other professionals, friends and family. The training makes it clear to staff that you do not require consent from a service user to receive information from others.”

Source location
2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 18 May 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish an updated Care Programme Approach Position Statement setting expectations for involving and supporting carers in care and support planning.

Verbatim wording from the response
“Carers are often vital in supporting people with severe mental health problems in the community. There was existing national CPA guidance which sets clear expectations around carer involvement, however, there was a need to bring this guidance (although helpful) up to date. As part of the newly published Care Programme Approach Position Statement, NHS England and NHS Improvement has set out clear expectations for systems to provide support for carers of people with severe mental health problems and to better involve carers in care and support planning from April 2021. Specifically, to use Long Term Plan funding to develop and implement plans to improve the lives of carers of people with severe mental health problems and also to look at specific inequalities’ carers may face.”

Source location
2021-0155-Response-from-NHS-Improvement_Published
Page 2 · response
Published 18 May 2021
Open published response
26 Jun2020
Inner South London
Concerns raised1
1. Failure to contact relevant corroborative sources during Mental Health Act assessment
This report raised 8 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
  Share the PFD report and response with all doctors, particularly psychiatry trainees.
  Stated by Oxleas NHS Foundation TrustStated planned
2. Action
  Discuss the case learning at the Section 12 and Approved Clinician refresher course for doctors.
  Stated by Oxleas NHS Foundation TrustStated planned
3. Action
  Develop the Support Network Engagement Tool to help clinicians identify and engage families, carers and other support networks.
  Stated by Oxleas NHS Foundation TrustStated completed
1. Action
  Audit care plans monthly for evidence that patients’ support networks, especially families and carers, are involved.
  Stated by Oxleas NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  The Mental Health Act does not require assessing doctors to obtain collateral information or consult others during an assessment.
  Stated by Oxleas NHS Foundation TrustDisputes the concern
AI-generated summary

Gary Etherington · 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

Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.

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 relevant corroborative sources during Mental Health Act assessment
Wider context from the report
“The coroner found that there were two failures in medical care, namely 1. The failure to contact ████████ at the Mental Health Act assessment in April 2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP. ”
Source location
Gary Etherington · 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
Share the PFD report and response with all doctors, particularly psychiatry trainees.

Verbatim wording from the response
“The Root Cause Analysis investigation concluded that the strained relationship between Mr and ████████ and the restraining order against Mr Etherington contributed to the failure to engage with ████████. To ensure learning from this incident, I will share the PFD report and this response with all doctors, especially trainees in psychiatry, and have asked that this is a topic of discussion at our Oxleas Section 12 and Approved Clinician refresher course for doctors.”

Source location
2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Page 2 · response
Published 14 September 2020
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
Discuss the case learning at the Section 12 and Approved Clinician refresher course for doctors.

Verbatim wording from the response
“The Root Cause Analysis investigation concluded that the strained relationship between Mr and ████████ and the restraining order against Mr Etherington contributed to the failure to engage with ████████. To ensure learning from this incident, I will share the PFD report and this response with all doctors, especially trainees in psychiatry, and have asked that this is a topic of discussion at our Oxleas Section 12 and Approved Clinician refresher course for doctors.”

Source location
2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Page 2 · response
Published 14 September 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop the Support Network Engagement Tool to help clinicians identify and engage families, carers and other support networks.

Verbatim wording from the response
“The involvement of families and carers is a Trust quality priority and the Trust has developed a Support Network Engagement Tool (SNET) to help clinicians identify key support networks and engage them in assessment and treatment. In addition, care plans are audited every month to check for evidence of involvement of each patient’s support network especially families and carers and whilst the results of these audits show improvement over the last few years but we recognise there is more to be done.”

Source location
2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Page 2 · response
Published 14 September 2020
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 care plans monthly for evidence that patients’ support networks, especially families and carers, are involved.

Verbatim wording from the response
“The involvement of families and carers is a Trust quality priority and the Trust has developed a Support Network Engagement Tool (SNET) to help clinicians identify key support networks and engage them in assessment and treatment. In addition, care plans are audited every month to check for evidence of involvement of each patient’s support network especially families and carers and whilst the results of these audits show improvement over the last few years but we recognise there is more to be done.”

Source location
2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Page 2 · response
Published 14 September 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
The Mental Health Act does not require assessing doctors to obtain collateral information or consult others during an assessment.

Verbatim wording from the response
“There is no requirement under the Mental Health Act for an assessing doctor to obtain any collateral information as part of their assessment. Section 12 of the Act requires that a doctor making a recommendation may only do so if they have personally examined the patient. There is no legal duty placed on doctors to consult each other, or anyone else. The European Courts have held that the medical assessment must be based on the actual state of mental health of the person concerned and not solely on past events (Varbanov v Bulgaria [2000] MHRR 263 para 47).”

Source location
2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Page 2 · response
Published 14 September 2020
Open published response
12 Mar2020
Manchester North
Concerns raised1
1. Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS
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 5
1. Action
  Assess the feasibility of electronic Force-to-Force data exchange between GMP and partner agencies including NWAS.
  Stated by Greater Manchester PoliceStated in progress
2. Action
  Consider the effectiveness of current information-sharing arrangements with partners and brief the Greater Manchester Health and Justice Board on the concerns raised.
  Stated by Greater Manchester PoliceStated planned
3. Action
  Develop and implement a common, documented GMP-wide procedure with partners for responding to mental-health-related risk to life presented to blue-light services.
  Stated by Greater Manchester PoliceStated in progress
1. Action
  Jointly chair a pan-Greater Manchester task and finish group improving risk assessment, management, inter-agency communications and procedures for mental health crisis responses.
  Stated by North West Ambulance Service NHS TrustStated in progress
2. Action
  Draw together a pan-Greater Manchester protocol defining roles, shared risk assessment, communication and escalation for mental-health-related risk-to-life incidents.
  Stated by North West Ambulance Service NHS TrustStated completed
Respondent positions 1
1. Position
  Police and other emergency services are expected to share pertinent information so ambulance clinicians can know about prior contacts and assessments.
  Stated by North West Ambulance Service NHS TrustRedirects responsibility
AI-generated summary

Jason Pendlebury · 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

Jason Pendlebury, a known cocaine user, fell from the roof of a block of flats on 29 September 2018 and died in hospital on 2 October 2018 after sustaining serious injuries. The principal concerns related to communication and information-sharing between Greater Manchester Police, North West Ambulance Service, the GP and mental health professionals about his potential mental health needs and 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 share relevant prior mental-health contacts and assessments between GMP and NWAS
Wider context from the report
“I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital. It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take. I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services. A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made. The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels. ”
Source location
Jason Pendlebury · 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
Assess the feasibility of electronic Force-to-Force data exchange between GMP and partner agencies including NWAS.

Verbatim wording from the response
“One aspect of our ongoing IT Change Programme is the feasibility of an electronic Force to Force data exchange, which could potentially be used to share data electronically with agencies such as NWAS. It is anticipated that these advances in technology would improve the quality and efficiency of information sharing and is subject to ongoing review.”

Source location
2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Page 2 · response
Published 8 April 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Consider the effectiveness of current information-sharing arrangements with partners and brief the Greater Manchester Health and Justice Board on the concerns raised.

Verbatim wording from the response
“GMP’s Public Service Reform leads, Chief Supt. ████████ and DCI ████████ are to consider the effectiveness of the current arrangements regarding this type of information sharing with partners and the Greater Manchester Health and Justice Board will be briefed on the concerns raised here (additional information on this body is included in the Summary below).”

Source location
2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Page 3 · response
Published 8 April 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and implement a common, documented GMP-wide procedure with partners for responding to mental-health-related risk to life presented to blue-light services.

Verbatim wording from the response
“In 2019 The Greater Manchester Health and Justice Board oversaw work to develop and implement a common approach to people in mental health crisis. The involved a working group, Health and Justice Task and Finish Group, which included senior representatives form GMP and the North-West Ambulance Service, in addition to the mental health trusts serving Greater Manchester, local authority approved mental health practitioners and Greater Manchester Combined Authority.”

Source location
2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Page 5 · response
Published 8 April 2020
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
Jointly chair a pan-Greater Manchester task and finish group improving risk assessment, management, inter-agency communications and procedures for mental health crisis responses.

Verbatim wording from the response
“The Trust jointly chaired a task and finish group with GMP, which was set up last year in response to a Regulation 28 report issued by Ms Joanne Kearsley in December 2018 to Greater Manchester Health and Social Care Partnership, Greater Manchester Combined Authority, Greater Manchester Police, North West Ambulance Service and Pennine Care NHS Foundation Trust. It was agreed that enhancements to the response around concern for welfare, and particularly risk to life, must be applied on a pan-GM basis, therefore Greater Manchester Mental Health NHS Foundation Trust and North West Boroughs Healthcare NHS Foundation Trust are also partners, despite not being involved in the specific case in question.”

Source location
2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
Page 2 · response
Published 8 April 2020
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
Draw together a pan-Greater Manchester protocol defining roles, shared risk assessment, communication and escalation for mental-health-related risk-to-life incidents.

Verbatim wording from the response
“The task and finish group has drawn together a pan-GM protocol for responding to ‘risk to life’ where it presents as a result of mental health to blue light services to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk and to promote communication and escalation at the first point that a common understanding may falter.”

Source location
2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
Page 2 · response
Published 8 April 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
Police and other emergency services are expected to share pertinent information so ambulance clinicians can know about prior contacts and assessments.

Verbatim wording from the response
“When an NWAS mental health nurse carries out a telephone assessment, they would only be aware of a previous assessment by GMP or previous calls to GMP if this is communicated to NWAS by the police and documented by the call taker. GMP, and indeed any police force or emergency service, would be expected to share any information they felt to be pertinent. Once a clinician has completed an assessment, or returned the incident to dispatch if unable to carry out a triage, NWAS would not be made aware of any further updates from GMP as the clinicians no longer have sight of the incident.”

Source location
2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1
Page 1 · response
Published 8 April 2020
Open published response
2 Nov2018
Manchester West
Concerns raised1
1. Failure to obtain collateral histories during Mental Health Act assessments
This report raised 8 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

Karl Qolf Jamil Englemak Cassimjee · 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

Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.

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 collateral histories during Mental Health Act assessments
Wider context from the report
“1. Brief circumstances of matter of concern a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital); b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner; c. The assessment, as recorded by the Registrar was accepted to be sub-optimal; d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team. e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim). f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account. ”
Source location
Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to gather relevant collateral history while respecting patient confidentiality

Concerns raised1

Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment

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.6

Concerns raised1

Failure to incorporate available clinical information into self-harm risk 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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to discuss S. 136 Mental Health Act assessments with relevant police officers and other involved care professionals

Failure to ensure that S. 136 Mental Health Act assessments use full information held by relevant services

Concerns raised1

Failure to incorporate relevant collateral information and community history in mental disorder 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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to enable relevant family input during emergency mental health assessment

Concerns raised1

Failure to incorporate family information into care plans and risk 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.3

Actions described in response 6

Actions described in response 2

Respondent positions 1

Actions described in response 5

Respondent positions 1

Actions described in response 3