Recurring concern

Unreliable Community Mental Health care access and discharge processes

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First reported 9 Dec 2015•Latest report 18 Nov 2025

Definition

What this concern includes

Includes failures in the named Community Mental Health care process involving access, allocation or provision of community mental-health support, appointments from allocated staff, and discharge planning or execution where unclear or inconsistent arrangements can interrupt care or leave risks unmanaged.

Not included

Excludes generic mental-health service capacity, staffing or communication deficiencies unless they directly impair Community Mental Health access or discharge processes.
Excludes failures confined to psychiatric appointments, urgent mental-health referrals or other separately named pathways when those processes are the more specific supported concern.
Excludes clinical treatment-quality failures after Community Mental Health care has been reliably accessed and discharge arrangements have been completed.
Excludes generic discharge failures outside Community Mental Health care.

Reports: 16
Individual concerns: 17
Date range: 2015–2025
Stated actions: 38

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.

Department of Health and Social Care4

NHS England4

Dorset Healthcare University NHS Foundation Trust2

Greater Manchester Mental Health NHS Foundation Trust2

Arts University Bournemouth1

Association Of British Neurologists1

Bournemouth, Christchurch and Poole Council1

College of Policing1

Cornwall Council1

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1

Devon Local Medical Committee1

Devon Partnership NHS Trust1

Dorset County Council1

Dorset Police1

Essex Partnership University NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

18 Nov2025
Staffordshire and Stoke-on-Trent
Concerns raised1
1. Failure to provide appointments from allocated Community Psychiatric Nurses and key workers
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 2
1. Action
  Issue and operationalize a Practice Note requiring SAF waiting-list contact, key-worker appointment dates, transition timescales, and clarification that SAF is not prerequisite to care.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated completed
2. Action
  Monitor adoption of the Practice Note and appointment timescales through multidisciplinary-team and assurance audits, including scheduled follow-up audits.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated in progress
AI-generated summary

Lynsey Ellen Dearden · 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

Mrs Lynsey Ellen Dearden was found deceased at her home on 11 March 2025. The inquest concluded with a short-form conclusion of suicide; the stated cause of death was asphyxiation, with anxiety and depression recorded in Part II. Concerns included failures to provide allocated Community Psychiatric Nurse appointments and to complete a standard assessment framework, alongside the absence of policies or guidance governing these 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 provide appointments from allocated Community Psychiatric Nurses and key workers
Wider context from the report
“1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place; ”
Source location
Lynsey Ellen Dearden · 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
Issue and operationalize a Practice Note requiring SAF waiting-list contact, key-worker appointment dates, transition timescales, and clarification that SAF is not prerequisite to care.

Verbatim wording from the response
“Immediate actions taken: In response to the PFD and our internal review, we have implemented the following: A Practice Note issued highlighting the following,”

Source location
Response from North Staffordshire Combined Healthcare NHS Trust
Page 2 · response
Published 21 November 2025
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
Monitor adoption of the Practice Note and appointment timescales through multidisciplinary-team and assurance audits, including scheduled follow-up audits.

Verbatim wording from the response
“The Practice Note already referenced has been issued to all relevant senior leads with an expectation that the improvements are immediately operational. Timeframes have been agreed and will be monitored via multidisciplinary team and assurance audits. Two initial audits have been undertaken, one prior to the Christmas 2025 and one during the second week of January 2026 to assess the adoption of the Practice Note and expected timescales. Results indicate good compliance across the Inpatient, CRHTT and CMHT services. A further audit is scheduled for 3 months’ time and 12-18 months to provide assurance that these processes have been embedded.”

Source location
Response from North Staffordshire Combined Healthcare NHS Trust
Page 2 · response
Published 21 November 2025
Open published response
31 Jan2025
Dorset
Concerns raised1
1. Lack of responsible clinician involvement in discharge planning
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
  Add discharge-planning requirements to the Liaison Psychiatry standard operating procedure for consultant consideration of 48-hour follow-up and documentation of the rationale when follow-up is not required.
  Stated by Devon Partnership NHS TrustStated completed
2. Action
  Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.
  Stated by Dorset Healthcare University NHS Foundation TrustStated in progress
3. Action
  Provide discharge-planning feedback, including the Coroner’s concerns and the family’s experience, at relevant multidisciplinary team meetings.
  Stated by Dorset Healthcare University NHS Foundation TrustStated completed
1. Action
  Introduce Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.
  Stated by Dorset Healthcare University NHS Foundation TrustStated completed
2. Action
  Share specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.
  Stated by Dorset Healthcare University NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  Dorset HealthCare disputes involvement in the discharge planning concerned, stating it was only contacted to arrange a psychiatric outpatient appointment.
  Stated by Dorset Healthcare University NHS Foundation TrustDisputes the concern
1. Position
  Discharge arrangements are led by the team seeking to transfer care, assigning responsibility to the transferring NHS provider.
  Stated by Dorset Healthcare University NHS Foundation TrustRedirects responsibility
AI-generated summary

Alexander Channing · 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

Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of responsible clinician involvement in discharge planning
Wider context from the report
“iii. There was a lack of involvement of a responsible clinician in the process of discharge planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset Healthcare NHS Foundation Trust. ”
Source location
Alexander Channing · 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
Add discharge-planning requirements to the Liaison Psychiatry standard operating procedure for consultant consideration of 48-hour follow-up and documentation of the rationale when follow-up is not required.

Verbatim wording from the response
“In terms of discharge planning from Liaison Psychiatry, in relation to the planned discharge from the district hospital in Exeter, I can confirm that the following paragraph has been added to the Liaison Psychiatry Services Exeter, Torquay and Barnstaple Specialist Services Directorate Standard Operating Procedure. It gives detail on page 12 of the attached document.”

Source location
Response from Devon Partnership NHS Trust
Page 2 · response
Published 31 January 2025
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
Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.

Verbatim wording from the response
“Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.”

Source location
Response from Dorset Healthcare NHS
Page 1 · response
Published 31 January 2025
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 discharge-planning feedback, including the Coroner’s concerns and the family’s experience, at relevant multidisciplinary team meetings.

Verbatim wording from the response
“Following the conclusion of the inquest, feedback was provided at a local level at multi-disciplinary team meetings in the relevant area, this feedback included the concerns expressed by the Coroner and the experience of Alec's family.”

Source location
Response from Dorset Healthcare NHS
Page 2 · response
Published 31 January 2025
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 Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.

Verbatim wording from the response
“Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.”

Source location
Response from Dorset Healthcare NHS
Page 2 · response
Published 31 January 2025
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 specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.

Verbatim wording from the response
“Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.”

Source location
Response from Dorset Healthcare NHS
Page 2 · response
Published 31 January 2025
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
Dorset HealthCare disputes involvement in the discharge planning concerned, stating it was only contacted to arrange a psychiatric outpatient appointment.

Verbatim wording from the response
“Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.”

Source location
Response from Dorset Healthcare NHS
Page 1 · response
Published 31 January 2025
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
Discharge arrangements are led by the team seeking to transfer care, assigning responsibility to the transferring NHS provider.

Verbatim wording from the response
“Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.”

Source location
Response from Dorset Healthcare NHS
Page 1 · response
Published 31 January 2025
Open published response
25 Jul2024
East London
Concerns raised1
1. Lack of safety planning before discharge
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 7
1. Action
  Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
  Stated by The TrustStated completed
2. Action
  Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
  Stated by The TrustStated in progress
3. Action
  Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.
  Stated by The TrustStated completed
1. Action
  Provide Trust-wide community mental-health-team training on enhanced transition care planning.
  Stated by The TrustStated completed
2. Action
  Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.
  Stated by The TrustStated in progress
3. Action
  Re-share the clinical risk policy and provide ward posters on safe discharge steps.
  Stated by The TrustStated completed
4. Action
  Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
  Stated by The TrustStated in progress
AI-generated summary

Danny Jay Anderson · 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

Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of safety planning before discharge
Wider context from the report
“There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023. The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny. From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy). There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022). Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk. There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed. ”
Source location
Danny Jay Anderson · 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
Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.

Verbatim wording from the response
“The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.”

Source location
Response from Essex Partnership NHS
Page 1 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.

Verbatim wording from the response
“The Trust recognises that there was confusion around responsibilities of the named nurse, which includes risk assessment and formulating risks including plan at point of discharge. The Trust Quality Matron for Fundamentals of Care is leading on an improvement project looking at processes for the named nurse which aims to ensure there is consistent understanding of the named nurse role”

Source location
Response from Essex Partnership NHS
Page 1 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.

Verbatim wording from the response
“The Trust is on an ongoing journey for improved documentation, which has included training sessions and a specific focus on this within supervision reviews. Work has been undertaken to update the discharge letter template to include discharge planning prompts and the incorporation of carer involvement in the Care Programme Approach review documentation. Discharge letters have been reviewed by the Service User Network Group to review content and tone of correspondence.”

Source location
Response from Essex Partnership NHS
Page 2 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide Trust-wide community mental-health-team training on enhanced transition care planning.

Verbatim wording from the response
“Additional training has been undertaken Trust wide in Community Mental Health Teams to support enhanced transition care planning.”

Source location
Response from Essex Partnership NHS
Page 2 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.

Verbatim wording from the response
“and development of our staff with the new Skills Training on Risk Management (STORM) training. This is an evidence-based training methodology given to frontline team members who have the opportunity to practice, reflect, and give and receive feedback on skills in a safe and supportive learning environment. It uses the highest standard level of skills development, which includes filmed skills practice for the more advanced courses. The focus is on the person, collaboration, assessment, and safety planning, and they are joined by new skill sets including Suicide and self-harm – exploring the similarities and differences for assessment. We aim to have 60% of all registered practitioners across all urgent care pathways trained by end of 2024. Achievement of this training roll out is overseen by the Trust’s suicide prevention quality priority group.”

Source location
Response from Essex Partnership NHS
Page 4 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Re-share the clinical risk policy and provide ward posters on safe discharge steps.

Verbatim wording from the response
“In addition we have re-shared the clinical risk policy with staff supported with poster for wards on safety discharge steps”

Source location
Response from Essex Partnership NHS
Page 4 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.

Verbatim wording from the response
“Action is already underway as part of the Safety Action Plan to ensure there are clear documented actions agreed at discharge meetings and that the MDT outcome form is completed for each person clearly stating any actions and an overview of relapse signatures and recorded in the patient record.”

Source location
Response from Essex Partnership NHS
Page 4 · response
Published 1 August 2024
Open published response
14 May2024
Cornwall and Isles of Scilly
Concerns raised1
1. Discharging referrals without clinical triage of non-response
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.
Respondent positions 2
1. Position
  No further difficulties need to be overcome in the referral pathway into secondary mental health services.
  Stated by Cornwall CouncilNo action considered necessary
1. Position
  The Integrated Care Board is expected to respond to concerns about the specific care provided.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Sally Poynton · 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

Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.

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
Discharging referrals without clinical triage of non-response
Wider context from the report
“2) Community Mental Health Team i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain. I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly. ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice. iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances. iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge. I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above. ”
Source location
Sally Poynton · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
No further difficulties need to be overcome in the referral pathway into secondary mental health services.

Verbatim wording from the response
“• In terms of its function as a referral pathway I do not believe that there are any difficulties which need to be overcome.”

Source location
Response from Cornwall Council
Page 2 · response
Published 20 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Integrated Care Board is expected to respond to concerns about the specific care provided.

Verbatim wording from the response
“I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.”

Source location
2024-0267 Response from Department of Health and Social Care
Page 1 · response
Published 20 May 2024
Open published response
25 Sep2023
Manchester West
Concerns raised1
1. Failure to provide planned Care Coordinator or Community Psychiatric Nurse visits
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
  Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
3. Action
  Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
1. Action
  Audit the absence-cover process after three months to verify that it is embedded and being followed.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
AI-generated summary

Robert Leigh · 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

Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.

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 provide planned Care Coordinator or Community Psychiatric Nurse visits
Wider context from the report
“1. During the Inquest evidence was heard that: - i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL. iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments. iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences. ”
Source location
Robert Leigh · 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
Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.

Verbatim wording from the response
“Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is completed by the Care Coordinator prior to any planned absence, such as annual leave or a planned medical intervention. This ensures the Care Coordinator has considered any follow up for service users that is required during their period of absence and identifies who will carry out any planned interventions such as administration of depot medications, undertaking face to face visits, and making telephone contacts. If specific follow up is not required during the period of planned absence, the service user, and their families or carers will be provided with the contact details for the team, should they require additional support. The Team Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions required are undertaken by the team.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 2 · response
Published 28 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.

Verbatim wording from the response
“For unplanned absences such as sickness, it is expected that the Care Coordinator, at the point of contacting the Team Manager or Senior Practitioner to advise of their absence, will provide a detailed handover of any work that is required to be covered.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 2 · response
Published 28 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.

Verbatim wording from the response
“The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 3 · response
Published 28 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit the absence-cover process after three months to verify that it is embedded and being followed.

Verbatim wording from the response
“The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 3 · response
Published 28 November 2023
Open published response
12 May2023
North Northumberland and South Northumberland
Concerns raised2
1. Insufficient in-person engagement before discharge from the Community Treatment Team
2. Failure to hold a multidisciplinary pre-discharge meeting for future planning
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.

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

Odessa Carey · 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

Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient in-person engagement before discharge from the Community Treatment Team
Wider context from the report
“4. Discharge from the Community Treatment Team on 6 August 2018 There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning. A more assertive approach to engagement may have been appropriate. I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator. I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature. I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment. ”
Source location
Odessa Carey · 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 hold a multidisciplinary pre-discharge meeting for future planning
Wider context from the report
“4. Discharge from the Community Treatment Team on 6 August 2018 There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning. A more assertive approach to engagement may have been appropriate. I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator. I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature. I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment. ”
Source location
Odessa Carey · Prevention of Future Deaths report
Page 3 · concerns
Open source report
14 Apr2023
Staffordshire and Stoke on Trent
Concerns raised1
1. Failure to ensure access to GP and community mental health services for people released from prison
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 1
1. Action
  Work with health and social-care colleagues to link people released without accommodation to homeless healthcare, mental-health nursing and wider homelessness support services.
  Stated by Stoke-on-Trent City CouncilStated in progress
Respondent positions 1
1. Position
  The Council cannot directly address access to GP or community mental health services because it does not commission those services.
  Stated by Stoke-on-Trent City CouncilOutside remit
AI-generated summary

Mr Darren Clifford Docherty · Prevention of Future Deaths report

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

Report summary

Mr Darren Clifford Docherty was released from HMP Stoke Heath without accommodation and was subsequently found hanging from a tree on 10 August 2023. The report raised concern that people released from prison without accommodation may be unable to access GP and community mental health services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure access to GP and community mental health services for people released from prison
Wider context from the report
“1. That when people are released from prison they do so, on many occasions, with no accommodation. Those that need GP access and community mental health services are unable to access them in these circumstances. ”
Source location
Mr Darren Clifford Docherty · 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
Work with health and social-care colleagues to link people released without accommodation to homeless healthcare, mental-health nursing and wider homelessness support services.

Verbatim wording from the response
“4. We will continue to work with colleagues in health and social care to support individuals released from prison with no accommodation to access GP and community mental health services by ensuring they are aware of and linked into the existing Homeless Healthcare Service and Rough Sleeping Mental Health nurse and the wider support available through Hanley Connects, the City Council’s Homelessness Hub and the Rough Sleeper Outreach Service.”

Source location
Response from Stoke on Trent City Council
Page 6 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Council cannot directly address access to GP or community mental health services because it does not commission those services.

Verbatim wording from the response
“Whilst the local authority does not commission GP or community mental health services and is therefore not in a position to directly address these concerns, it is aware that homelessness should not be a barrier to registration with a GP.”

Source location
Response from Stoke on Trent City Council
Page 3 · response
Published 29 April 2024
Open published response
21 Jul2022
Dorset
Concerns raised1
1. Ambiguity and inconsistency in access to Community Mental Health care processes
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 2
1. Action
  Continue implementing the CMHT/STWB interface and screening meetings through an updated standard operating procedure.
  Stated by Dorset Healthcare University NHS Foundation TrustStated completed
2. Action
  Participate in co-designing a new integrated community mental health operational model through the MHICC transformation programme.
  Stated by Dorset Healthcare University NHS Foundation TrustStated in progress
Respondent positions 4
1. Position
  The Trust disputes that staff misunderstand or face ambiguity about accessing community mental health services or discharging patients.
  Stated by Dorset Healthcare University NHS Foundation TrustDisputes the concern
1. Position
  The Trust maintains that the patient did not meet CMHT eligibility criteria at the identified discharge and assessment points.
  Stated by Dorset Healthcare University NHS Foundation TrustDisputes the concern
2. Position
  The Trust considers transformation work a more effective response than training staff on the existing CMHT access model.
  Stated by Dorset Healthcare University NHS Foundation TrustExisting arrangements considered sufficient
3. Position
  Existing national training, professional development and clinical guidance arrangements are relied upon to support community mental health practice and discharge planning.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Gaia Kima Pope-Sutherland · 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

Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report
“ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams. ”
Source location
Gaia Kima Pope-Sutherland · 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
Continue implementing the CMHT/STWB interface and screening meetings through an updated standard operating procedure.

Verbatim wording from the response
“In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.”

Source location
Response from NHS Dorset Healthcare University
Page 4 · response
Published 28 September 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
Participate in co-designing a new integrated community mental health operational model through the MHICC transformation programme.

Verbatim wording from the response
“It is our belief that the issues highlighted will be addressed through the transformation work that the Trust is closely engaged with, which was touched upon in the evidence of ████████. The NHS Long Term Plan and the Commissioning Framework for Community Mental Health sets out a new vision of mental health support provided by health, social care and voluntary, community and social enterprise (VCSE) organisations, beyond the model of CMHT care. In Dorset, the multi-agency, co-produced project to deliver this vision is known as the Mental Health Integrated Community Care (MHICC) programme. The programme has reached the stage where it is co-designing a new operational model of care, to begin implementation in 2023 / 2024.”

Source location
Response from NHS Dorset Healthcare University
Page 4 · response
Published 28 September 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust disputes that staff misunderstand or face ambiguity about accessing community mental health services or discharging patients.

Verbatim wording from the response
“I and my team note your concerns that you considered there to be “some ambiguity and inconsistency during the evidence regarding the content of the Integrated Community Mental Health Teams (ICMHT’s) operational policy, and the understanding and application of it”. The Trust team has considered carefully your recommendation that training be provided to all staff on access to Community Mental Health Services, including the process for discharge planning.”

Source location
Response from NHS Dorset Healthcare University
Page 3 · response
Published 28 September 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust maintains that the patient did not meet CMHT eligibility criteria at the identified discharge and assessment points.

Verbatim wording from the response
“In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.”

Source location
Response from NHS Dorset Healthcare University
Page 4 · response
Published 28 September 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust considers transformation work a more effective response than training staff on the existing CMHT access model.

Verbatim wording from the response
“For these reasons and the transformation work being carried out as described in this letter, the Trust does not consider that implementing an action to train Trust staff on the access to CMHT’s would resolve the issues raised.”

Source location
Response from NHS Dorset Healthcare University
Page 4 · response
Published 28 September 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing national training, professional development and clinical guidance arrangements are relied upon to support community mental health practice and discharge planning.

Verbatim wording from the response
“With regard to your concerns related to the availability of training on access to community mental health services, including discharge planning – you may wish to note that NHSE provides funding and resources for continuous professional development for community mental health practice, together with supporting good care in all settings. HEE, working in partnership, also provides a range of quality training and resources for health care professionals, at all stages of their career; this is intended to support good practice. The training and resources provided by HEE align with policy direction and legislative frameworks, together with national clinical guidance such as that published by NICE (Transition between inpatient mental health settings and community or care home settings^5), which acknowledges its starting point.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 28 September 2022
Open published response
9 Jun2022
East London
Concerns raised1
1. Failure to provide community mental health services to older patients
This report raised 9 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
  Expand NHS support in care homes and strengthen links with general practices and community services.
  Stated by Department of Health and Social CareStated planned
2. Action
  Increase the mental-health workforce, including staffing capacity for community mental-health services for older adults.
  Stated by Department of Health and Social CareStated completed
3. Action
  Introduce integrated community models giving adults and older adults with severe mental illness greater choice and control over care and support.
  Stated by Department of Health and Social CareStated planned
Respondent positions 1
1. Position
  There was no evidence that a lack of care contributed to the death.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Shirley Alice Moloney · 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

Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.

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 provide community mental health services to older patients
Wider context from the report
“(i) Mrs Moloney suffered from paranoid schizophrenia. There was evidence of her mental state deteriorating in the months leading up to her death. Her mental health deterioration is likely to have impacted upon her physical health deterioration, but she was not under the care of community mental health services in the last nine months of her life. ”
Source location
Shirley Alice Moloney · 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
Expand NHS support in care homes and strengthen links with general practices and community services.

Verbatim wording from the response
“Whilst there was no evidence that a lack of care contributed to Mrs Moloney’s death, we recognise the areas of concern you have identified that could contribute to future deaths. We are committed through the NHS Long Term Plan to offering more NHS support in care homes to ensure there are strong links between care homes, local general practices and community services.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 20 September 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
Increase the mental-health workforce, including staffing capacity for community mental-health services for older adults.

Verbatim wording from the response
“You have raised concerns around the resourcing of older age psychiatric teams. We recognise the need to increase capacity in NHS mental health services, including community mental health services for older adults, due to the increasing demand for services. The mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared with December 2020, and by over 11,800 compared to December 2010. However, we know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services for all ages. We therefore aim to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20).”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 20 September 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 integrated community models giving adults and older adults with severe mental illness greater choice and control over care and support.

Verbatim wording from the response
“Furthermore, through the NHS Long Term Plan, we are investing at least £2.3 billion additional funding a year to expand and transform mental health services in England by 2023/24. This will enable an extra two million people to be treated by NHS mental health services by 2023/24. This includes new integrated community models, giving 370,000 adults and older adults with severe mental illness greater choice and control over their care and support to live well in their communities by 2023/24.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 September 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
There was no evidence that a lack of care contributed to the death.

Verbatim wording from the response
“Whilst there was no evidence that a lack of care contributed to Mrs Moloney’s death, we recognise the areas of concern you have identified that could contribute to future deaths. We are committed through the NHS Long Term Plan to offering more NHS support in care homes to ensure there are strong links between care homes, local general practices and community services.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 20 September 2022
Open published response
23 Apr2020
Nottinghamshire
Concerns raised1
1. Insufficient clinical psychology staffing and access within Community Mental Health Teams
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
  Fund additional clinical psychology posts and other staff capacity to strengthen community mental health team delivery.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated completed
2. Action
  Work with Nottinghamshire Healthcare NHS Trust on a five-year community mental health transformation programme, including monthly transformation meetings.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated in progress
3. Action
  Provide planned annual investment to increase clinical psychology provision across Nottinghamshire Healthcare NHS Trust services.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated planned
1. Action
  Fund additional clinical psychology posts, alongside other posts, to increase community mental health team capacity and test new delivery models.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated completed
2. Action
  Invest in increased clinical psychology provision across Nottinghamshire Healthcare NHS Trust services to deliver Long Term Plan ambitions.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated planned
Respondent positions 3
1. Position
  The healthcare trust determines the exact community mental health team staffing resource required under the agreed service specification.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardRedirects responsibility
1. Position
  The agreed community mental health team specification and ongoing transformation programme are considered sufficient to address concerns about clinical psychology provision.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardExisting arrangements considered sufficient
2. Position
  Nottinghamshire Healthcare NHS Trust determines the staffing resource required to deliver the community mental health team specification.
  Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardRedirects responsibility
AI-generated summary

Patricia Ferguson · 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

Patricia Ferguson had significant mental ill health and received secondary mental health services before her death by suicide. Clinicians considered that direct work with a clinical psychologist would benefit her, but no clinical psychologist was available; the report identified limited clinical psychology provision in community mental health teams as an ongoing risk of preventable future deaths.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient clinical psychology staffing and access within Community Mental Health Teams
Wider context from the report
“(1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular. (2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths. ”
Source location
Patricia Ferguson · 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
Fund additional clinical psychology posts and other staff capacity to strengthen community mental health team delivery.

Verbatim wording from the response
“The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models.”

Source location
2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
Page 1 · response
Published 20 October 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
Work with Nottinghamshire Healthcare NHS Trust on a five-year community mental health transformation programme, including monthly transformation meetings.

Verbatim wording from the response
“The BCCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years.”

Source location
2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
Page 1 · response
Published 20 October 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
Provide planned annual investment to increase clinical psychology provision across Nottinghamshire Healthcare NHS Trust services.

Verbatim wording from the response
“The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the BCCG and the Transformation plan is reviewed by NHS England on a monthly basis. BCCG have planned monthly transformation meetings with NHT commencing which were due to commence in March 2020. However, this has recently been impacted by the COVID-19 pandemic and has commenced week of 1st June 2020.”

Source location
2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
Page 2 · response
Published 20 October 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
Fund additional clinical psychology posts, alongside other posts, to increase community mental health team capacity and test new delivery models.

Verbatim wording from the response
“The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support test new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).”

Source location
2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
Page 2 · response
Published 20 October 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
Invest in increased clinical psychology provision across Nottinghamshire Healthcare NHS Trust services to deliver Long Term Plan ambitions.

Verbatim wording from the response
“The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment ████████ to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the CCG and the Transformation plan is reviewed by NHS England on a monthly basis. A Steering Group meets on a monthly basis to oversee the transformation of the Adult and Older Adult Community model. However, this has recently been impacted by the COVID-19 pandemic and will recommence in due course.”

Source location
2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
Page 2 · response
Published 20 October 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The healthcare trust determines the exact community mental health team staffing resource required under the agreed service specification.

Verbatim wording from the response
“Currently, there is an agreed specification for community mental health teams which Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.”

Source location
2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
Page 2 · response
Published 20 October 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The agreed community mental health team specification and ongoing transformation programme are considered sufficient to address concerns about clinical psychology provision.

Verbatim wording from the response
“The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support test new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).”

Source location
2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
Page 2 · response
Published 20 October 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Nottinghamshire Healthcare NHS Trust determines the staffing resource required to deliver the community mental health team specification.

Verbatim wording from the response
“Currently, there is an agreed specification for community mental health teams which outlines the aims, objectives and outcomes for the service. Nottinghamshire Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.”

Source location
2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
Page 2 · response
Published 20 October 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide appointments from allocated Community Psychiatric Nurses and key workers

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

Lack of responsible clinician involvement in discharge planning

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.2

Concerns raised1

Lack of safety planning before discharge

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.7

Concerns raised1

Discharging referrals without clinical triage of non-response

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 provide planned Care Coordinator or Community Psychiatric Nurse visits

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 raised2

Insufficient in-person engagement before discharge from the Community Treatment Team

Failure to hold a multidisciplinary pre-discharge meeting for future planning

Actions described in response 2

Actions described in response 5

Respondent positions 2

Actions described in response 7

Respondent positions 2

Actions described in response 4