6 Jul 2023 Mr Oleg Khala · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Inadequate recording of patients' mental health history by CATT View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
West London NHS Trust
Deploy enhanced documentation practices to support coordinated care.
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AI-generated summary
Mr Oleg Khala · 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 Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate recording of patients' mental health history by CATT
Wider context from the report “1. The generic, tick-box style of history recording by CATT which does not paint a full and proper picture of the mental health of the patient , especially compared to the assessments of psychiatric liaison, are such that risk may be unrecorded and under appreciated by CATT and patients thus be put at risk.
” Source location Mr Oleg Khala · Prevention of Future Deaths report
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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 Deploy enhanced documentation practices to support coordinated care.
Verbatim wording from the response “As part of the implementation of this we have developed and are deploying standardized protocols, enhanced documentation practices, and regular training sessions to promote effective coordinated care by any named clinician involved in patient care. These measures aim to mitigate potential risks and ensure that patients receive the highest quality of care in a coordinated manner.” Source location Response from West London NHS Trust
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19 Jun 2023 Nicholas LEGER · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Nicholas LEGER · 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
Nicholas Leger took his own life sometime between 7:30pm and 10:30pm on 20 February 2023, after learning via his solicitor that he had been charged. He had previously attempted to take his own life and had disclosed concerns about his mental health, but there had been no formal police assessment of his mental health or risk of suicide or self-harm for more than three months. The report identified a risk that people charged by Postal Charge Requisition could take their own lives where there was no formal mechanism to assess their mental health and risk at the time of charge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery
Wider context from the report “• That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC. There is no formal requirement for the OIC proactively to seek this information.
• That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR.
It is important to note the following:
• At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard.
• Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges.
• Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them.
• Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a police station for interview, once they have left the police station there are no such formal procedures (as above) , notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged.
• Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health.
It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm , there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm).
” Source location Nicholas LEGER · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a policy requiring supervised, documented risk assessments before issuing PCRs to recordable-offence suspects, including risk management and decisions on personal service.
Verbatim wording from the response “Following this Prevention of Future Deaths report, a proposal will be made for the implementation of a new policy requiring a risk assessment to be completed by the OIC, no earlier than fourteen days prior to issuing the PCR. This would build on the intelligence already gathered through the relationship between the OIC and the suspect, including any risk assessments completed at the time of their arrest/detention/voluntary interview under caution and by the Custody Sergeant upon release from custody. This would then form the basis of a decision as to whether to post or serve the PCR in person.” Source location Response from Metropolitan Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current pre-charge bail arrangements and guidance provide further opportunities to assess suicide risk, so additional assessment at postal charge requisition is not identified.
Verbatim wording from the response “Conclusion
It is unlikely that someone released on bail for sexual offences would now revert to RUI. This means that they would be recalled to custody for charge, where a pre-release risk assessment can be completed, for which there is full guidance. There is specific custody training aimed at reducing the risks of post detention suicides.” Source location Response from College of Policing
Open published response
8 Jun 2023 Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to consult medical notes and records during leave risk assessment View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Hilary Clare (Billy) Guedalla · 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
Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consult medical notes and records during leave risk assessment
Wider context from the report “6. The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment . Had that member of staff consulted the deceased’s medical notes and records, the serious suicide risk which they posed would have been evident .
” Source location Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.
Verbatim wording from the response “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.” Source location Response from East London NHS Foundation Trust
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26 May 2023 Paige Jeannette ALLEN · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to provide assessing practitioners with immediate and comprehensive access to relevant mental health records across localities View source
Linked response
Cwm Taf Morgannwg University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Cwm Taf Morgannwg University Local Health Board
Standardise management of required paper records.
View source
Cwm Taf Morgannwg University Local Health Board
Scope phasing out paper notes and maximise existing digital systems before implementing the single electronic record.
View source
Cwm Taf Morgannwg University Local Health Board
Review paper and electronic archives and systems and standardise approved inpatient and outpatient care-planning documentation.
View source
Cwm Taf Morgannwg University Local Health Board
Map information transfer between community and inpatient teams and share admission and discharge flow diagrams across the Care Group.
View source
Cwm Taf Morgannwg University Local Health Board
Develop and distribute user guides for accessing and using FACE and shared-drive records.
View source
Cwm Taf Morgannwg University Local Health Board
Use secure email inboxes for information sharing between RGH and Bridgend mental health teams.
View source
Cwm Taf Morgannwg University Local Health Board
Develop and distribute the Clinical Information Access and Recording Matrix and accompanying standard operating procedure across mental health clinical teams.
View source
Cwm Taf Morgannwg University Local Health Board
Develop and endorse a business case for a unified electronic record system.
View source
Cwm Taf Morgannwg University Local Health Board
Review the national Welsh Community Care Information System strategic programme with Digital Health and Care Wales and other health boards.
View source
Cwm Taf Morgannwg University Local Health Board
Plan the pre-implementation phase for transferring existing community mental health users to a Health Board Welsh Community Care Information System.
View source
Cwm Taf Morgannwg University Local Health Board
Review the unified-record business case using implementation lessons to determine required resources and approach.
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AI-generated summary
Paige Jeannette ALLEN · 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
Paige Jeannette Allen died after falling from Southerndown Cliffs in the early hours of 21 April 2021, following an emergency services rescue attempt. The concern was that mental health practitioners assessing patients in crisis across different Cwm Taf Morgannwg University Health Board localities might not have immediate access to relevant medical records, potentially increasing the risk of incomplete or insufficient assessments.
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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 assessing practitioners with immediate and comprehensive access to relevant mental health records across localities
Wider context from the report “Whilst I did not find that the matter of concern outlined below was directly causative of, nor contributory to, Miss Allen’s death, my concern broadly is that those patients who contact mental health services in Cwm Taf Morgannwg University Health Board (CTMUHB), especially at the time of crisis may be assessed without the assessing practitioner having immediate & comprehensive access to relevant and proximate medical records, notes & plans (such as WARRN assessments, & Care & Treatment Plans).
More particularly, the evidence indicated that should a patient present to mental health services in the Bridgend locality, but have their secondary mental health care managed in either the Merthyr/Cynon locality or the Rhondda/Taff/Ely locality or vice versa, the assessing practitioner will not immediately i.e. at the time of assessment, have access to that patient’s FACE records.
My concern is that this has the potential to deprive the assessing practitioner of pertinent and proximate material which may increase the risk of an incomplete or insufficient assessment.
That being potentially significant in informing the assessing practitioner of his/her action/planning for that individual in crisis.
Whilst I received evidence that CTMUHB has pledged to adopt a system, which it is believed will ameliorate the current situation, I am concerned that until such time as the same is available and immediately accessible across the three localities, the risk identified persists.
Interim measures may wish to be considered to mitigate the risk identified.
” Source location Paige Jeannette ALLEN · Prevention of Future Deaths report
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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 Standardise management of required paper records.
Verbatim wording from the response “Chaired by the Clinical Service Group manager for Merthyr and Cynon Locality, with a multidisciplinary group from across CTM, the HQCR has aligned this work with the recommendations and learning from recent external reviews most particularly the May 2022 Healthcare Inspectorate of Wales (HIW) Review of Discharge Arrangements for Adults from Inpatient Mental Health Services within CTMUHB. A programme of work is underway to:” Source location Response from Cwm Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scope phasing out paper notes and maximise existing digital systems before implementing the single electronic record.
Verbatim wording from the response “Chaired by the Clinical Service Group manager for Merthyr and Cynon Locality, with a multidisciplinary group from across CTM, the HQCR has aligned this work with the recommendations and learning from recent external reviews most particularly the May 2022 Healthcare Inspectorate of Wales (HIW) Review of Discharge Arrangements for Adults from Inpatient Mental Health Services within CTMUHB. A programme of work is underway to:” Source location Response from Cwm Taf Morgannwg University Health Board
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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 paper and electronic archives and systems and standardise approved inpatient and outpatient care-planning documentation.
Verbatim wording from the response “The immediate mitigating actions of the HQCR included the review of all paper and electronic archives and systems to ensure that there was a congruence of all care planning documentation for inpatients and outpatients. This ensures, through the use of only approved Inpatient Management Plan and Care and Treatment Plan (CTP), that all staff are clear on what documents should be available to them when seeking them out. In addition, governance measures were introduced to limit access to any patient information held on the W and T electronic drives, with senior level authorisation required in order to gain access,” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Map information transfer between community and inpatient teams and share admission and discharge flow diagrams across the Care Group.
Verbatim wording from the response “The HQCR group has undertaken process mapping regarding passing patient information between Community Mental Health Team (CMHT) and Inpatient for admission and discharge developing flow diagrams that have been shared across the Care Group. They have also developed a number of user guides on how to access and use FACE/w-drive when accessing RTE and M&C records. At present the Mental Health teams will continue to use email to share information between RGH and Bridgend but now a secure email inbox is used at all times to ensure confidentiality but also simplifying access and gathering of information.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 distribute user guides for accessing and using FACE and shared-drive records.
Verbatim wording from the response “The HQCR group has undertaken process mapping regarding passing patient information between Community Mental Health Team (CMHT) and Inpatient for admission and discharge developing flow diagrams that have been shared across the Care Group. They have also developed a number of user guides on how to access and use FACE/w-drive when accessing RTE and M&C records. At present the Mental Health teams will continue to use email to share information between RGH and Bridgend but now a secure email inbox is used at all times to ensure confidentiality but also simplifying access and gathering of information.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 secure email inboxes for information sharing between RGH and Bridgend mental health teams.
Verbatim wording from the response “The HQCR group has undertaken process mapping regarding passing patient information between Community Mental Health Team (CMHT) and Inpatient for admission and discharge developing flow diagrams that have been shared across the Care Group. They have also developed a number of user guides on how to access and use FACE/w-drive when accessing RTE and M&C records. At present the Mental Health teams will continue to use email to share information between RGH and Bridgend but now a secure email inbox is used at all times to ensure confidentiality but also simplifying access and gathering of information.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 distribute the Clinical Information Access and Recording Matrix and accompanying standard operating procedure across mental health clinical teams.
Verbatim wording from the response “As a mitigation for the multiple record system that are still in place across the CTM Mental Health service the HQCR Workstream has developed a Clinical Information Access and Recording matrix (CIARM) for clinical team /staff access (“who accesses what system for what purpose”) for all systems across the mental health service. This informs all clinical staff of how to access patient clinical risk and discharge planning information both in and out of hours and is the primary tool by which the care Group will mitigate the potential risks inherent with our present multiple systems.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 endorse a business case for a unified electronic record system.
Verbatim wording from the response “In relation to the longer term work to develop safe systems for sharing information, I would like to provide assurance that the Executive and Board are committed to the implementation of a unified electronic record system for the Mental Health and Learning Disabilities Care Group, which includes Child and Adolescent Mental Health Services.” Source location Response from Cwm Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the national Welsh Community Care Information System strategic programme with Digital Health and Care Wales and other health boards.
Verbatim wording from the response “A business case has been developed and endorsed by the Executive. There are however challenges with the preferred national system. The Health Board is working closely with Digital Health and Care Wales and other Health Boards as part of the review of the national strategic programme for the Welsh Community Care Information System. The outcome of this review will influence timescales for WCCIS implementation for the Health Board.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Plan the pre-implementation phase for transferring existing community mental health users to a Health Board Welsh Community Care Information System.
Verbatim wording from the response “Currently, planning is underway for a pre implementation phase to bring all existing users, mainly within the CMHT’s who currently use WCCIS via the local authorities, over to a Health Board WCCIS system. The timescale for this is approx. 6 months, however CTM will be meeting with Aneurin Bevan University Health Board on 27 July 2023 to capture lessons learnt from their implementation” Source location Response from Cwm Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the unified-record business case using implementation lessons to determine required resources and approach.
Verbatim wording from the response “The business case is in the process of review, with the lessons from Aneurin Bevan seen as key to fully understanding the resources and approach required to best move forward with minimal delay. In addition the Health Board is working in partnership with Health Education Improvement Wales to develop digital champion roles to influence and lead digital workforce transformation.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Implementation of the integrated electronic record was delayed by infrastructure and resource issues, while national programme review affected implementation timescales.
Verbatim wording from the response “A business case has been developed and endorsed by the Executive. There are however challenges with the preferred national system. The Health Board is working closely with Digital Health and Care Wales and other Health Boards as part of the review of the national strategic programme for the Welsh Community Care Information System. The outcome of this review will influence timescales for WCCIS implementation for the Health Board.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
28 Apr 2023 Winbourne Gregory Charles · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to incorporate available clinical information into self-harm risk assessments View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
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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
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15 Mar 2023 Jai SINGH · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Absence of a rolling risk assessment facility in SystemOne View source Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jai SINGH · 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
Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a rolling risk assessment facility in SystemOne
Wider context from the report “5. Other electronic health care records systems used in mental health settings have a rolling risk assessment document that clinicians are required to review and update at certain points in a patient's management. The risk assessment document provides a prompt to clinicians to formally consider risk and come to a reasoned, documented conclusion that then feeds into decision making. The record also provides a reliable, easily accessible source of risk history. No such facility is in use on SystemOne at HMP Birmingham . Further, the evidence given was that once a system is not being used routinely across mental health care within the prison estate and is not provided as standard on SystemOne. This creates an ongoing risk to life arising from under-estimation of risk as a result of clinicians not formally considering and assessing current risk levels, and salient risk history not being easily accessible . It is understood by Birmingham and Solihull Mental Health Trust that it should be possible to create a specific risk assessment record within SystemOne and this is being considered locally. However, the evidence given was that this issue should be highlighted nationally and that the developers and distributors of SystemOne should be involved so as to ensure the best available solution is identified.
” Source location Jai SINGH · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne
Wider context from the report “3. However, there are two features of the mental health care provided to Mr. Singh that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not include a psychiatrist; and
ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham .
” Source location Jai SINGH · Prevention of Future Deaths report
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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 an accessible risk-assessment document to SystemOne for Trust staff.
Verbatim wording from the response “The Trust is restricted to what it can change on SystemOne due to it being the national software used in prisons. We are however meeting with the software company on 27 April 2023 to discuss the concerns raised within the PFD. Any changes to be made at a national level by SystemOne may take some time. Consequently the Trust has looked to how it will be able introduce risk assessment documentation into the system and ensure that Trust staff complete this in the interim.” Source location Response from Birmingham and Solihull Mental Health
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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 the SystemOne risk-assessment process to clinical staff using a practice alert and Standard Operating Procedure.
Verbatim wording from the response “A risk assessment has been added to the System One software that is accessible for the Trust staff only. This will be rolled out to staff with a dissemination plan, which is attached. The plan includes a practice alert and a Standard Operating Procedure to be sent to all clinical staff. This has now taken place. This will set out the requirements for the risk assessments to be completed. This will ensure that going forward all patients will receive a risk assessment when one is necessary. The roll out of this will be complete by 20 May 2023.” Source location Response from Birmingham and Solihull Mental Health
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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 is restricted in changing the national prison software, and national SystemOne changes may take time.
Verbatim wording from the response “The Trust is restricted to what it can change on SystemOne due to it being the national software used in prisons. We are however meeting with the software company on 27 April 2023 to discuss the concerns raised within the PFD. Any changes to be made at a national level by SystemOne may take some time. Consequently the Trust has looked to how it will be able introduce risk assessment documentation into the system and ensure that Trust staff complete this in the interim.” Source location Response from Birmingham and Solihull Mental Health
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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 SystmOne is working correctly and safely from a system perspective.
Verbatim wording from the response “From a system perspective I am confident that SystmOne is working correctly and in a safe manner.” Source location Response from TPP
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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 system commissioner decides whether and how to use SystmOne templates, decision support, alerts, reminders and warnings.
Verbatim wording from the response “SystmOne provides our users with many tools to support patient care – the creation of data entry templates, the development of decision support for particular circumstances, and the ability to produce alerts, reminders and warnings as data is entered. The decision to use these, and how they should be used is in the hands of the commissioner of the system. Professor Powis’ report details how the system is used for mental health assessments.” Source location Response from TPP
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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 SystmOne record keeping are for Birmingham and Solihull Mental Health Foundation Trust to address locally.
Verbatim wording from the response “Risk assessments are carried out in line with relevant National Institute for Health and Care Excellence (NICE) guidance for the mental health assessment of people in prison. There are templates available within SystmOne for this purpose. Any concern relating to record keeping within SystmOne, is for Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) to respond to locally as a separate matter.” Source location Response from NHS England
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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 NICE-aligned risk assessments, SystmOne templates and staff training provide sufficient arrangements for mental health assessment documentation.
Verbatim wording from the response “Risk assessments are carried out in line with relevant National Institute for Health and Care Excellence (NICE) guidance for the mental health assessment of people in prison. There are templates available within SystmOne for this purpose. Any concern relating to record keeping within SystmOne, is for Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) to respond to locally as a separate matter.” Source location Response from NHS England
Open published response
6 Mar 2023 Evelina Vilkiene · Prevention of Future Deaths report East London
View report summary
Concerns raised 2
Lack of detailed risk assessment during transition between mental health teams View source Lack of detailed risk assessment when weaning Clonazepam medication View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Evelina Vilkiene · 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
Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.
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 detailed risk assessment during transition between mental health teams
Wider context from the report “1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.
” Source location Evelina Vilkiene · Prevention of Future Deaths report
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 Lack of detailed risk assessment when weaning Clonazepam medication
Wider context from the report “2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
” Source location Evelina Vilkiene · Prevention of Future Deaths report
Open source report
27 Feb 2023 Sophie Gwen Williams · Prevention of Future Deaths report North London
View report summary
Concerns raised 1
Failure of assessment protocols to require consideration of dissociation and psychosis risks and effects View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sophie Gwen Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie Gwen Williams died at home in the early hours of 20 May 2021 after taking a fatal overdose of prescription medications while in a psychotic or dissociative state. The report identifies concerns about the lack of assessment and management of her overdose and self-harm risk, continuity of care and crisis support, staff training and gender-affirming care, and coordination between mental health and gender-identity 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 of assessment protocols to require consideration of dissociation and psychosis risks and effects
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” Source location Sophie Gwen Williams · Prevention of Future Deaths report
Open source report
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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 Require assessment of dissociation and psychosis, including consideration of self-harm and suicidality risks.
Verbatim wording from the response “c. the risks to (and effects on) patients with (or likely to develop) conditions of dissociation” Source location Response from Barnet, Enfield and Haringey Mental Health Trust
Open published response
27 Jan 2023 Jayden Andrew Booroff · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure of risk assessments to capture key risk information before ward observation levels are reduced View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Essex Partnership University NHS Foundation Trust
Revise observation recording documentation and add observation-level decision and audit requirements to assurance audits.
View source
Essex Partnership University NHS Foundation Trust
Introduce an Engagement and Observation Plan recording observation commencement, review, changes and discontinuation against patient risk.
View source
Essex Partnership University NHS Foundation Trust
Implement an electronic clinical dashboard showing recent clinical entries, current risk assessments and observation levels at handover.
View source
Essex Partnership University NHS Foundation Trust
Review the Trustwide Engagement and Supportive Observation Procedure to require MDT decisions informed by comprehensive risk assessment and documented care-plan rationale.
View source
Essex Partnership University NHS Foundation Trust
Configure risk-assessment documentation in Paris and Mobius to carry forward risk history while capturing newly identified risks.
View source
Essex Partnership University NHS Foundation Trust
Continue observation assurance monitoring through Tendable and observation-engagement audits, with weekly review of findings by the Inpatient Clinical Support Group.
View source
Essex Partnership University NHS Foundation Trust
Continue the adult inpatient record-keeping clinical audit covering current risk assessments, risk-management plans, MDT input, observation care plans and crisis plans.
View source See 4 more actions
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AI-generated summary
Jayden Andrew Booroff · 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
Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and emergency services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of risk assessments to capture key risk information before ward observation levels are reduced
Wider context from the report “(1) Essex Partnership NHS Foundation Trust risk assessments missed key risk information that led to a reduction in observations levels on the ward .
” Source location Jayden Andrew Booroff · Prevention of Future Deaths report
Open source report
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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 Revise observation recording documentation and add observation-level decision and audit requirements to assurance audits.
Verbatim wording from the response “• The Trust engagement and supportive observation processes were reviewed. Following this review, the document in which observations are recorded on was revised to support recording of actual time for each observation. Policy revisions related to roles for decreasing observations and auditing of observations was also added to the Matrons Assurance Tendable audits.” Source location Response from Essex Partnership University
Open published response
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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 Engagement and Observation Plan recording observation commencement, review, changes and discontinuation against patient risk.
Verbatim wording from the response “An observation and engagement task and finish group was established to undertake a full review of processes and implemented a number of improvements including:” Source location Response from Essex Partnership University
Open published response
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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 an electronic clinical dashboard showing recent clinical entries, current risk assessments and observation levels at handover.
Verbatim wording from the response “• The Trust has implemented a new electronic clinical dashboard, which provides an overview of documentation for ward staff. This is used at handover, and allows staff to view the three most recent clinical entries for each patient, including up to date risk assessments and observation levels. Record keeping audits also take place to support assurance and monitoring processes.” Source location Response from Essex Partnership University
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Trustwide Engagement and Supportive Observation Procedure to require MDT decisions informed by comprehensive risk assessment and documented care-plan rationale.
Verbatim wording from the response “• In relation to the risk information which led to a reduction in the engagement and supportive observation levels; the Trustwide Engagement and Supportive Observation Procedure was further reviewed in January 2022 and outlines decisions about the level of observation should be made by the multi-disciplinary team (MDT). The procedure also references the requirement of considering a patient’s risk assessment in the decision discussion of observation levels. In particular, that a risk assessment is completed through interview with the patient and carers, careful study of the patient history, use of ratified risk assessment tools, and include assessments of other professionals. A patient’s care plan will contain the rationale for the observation level agreed, details of their risk assessment and how this is managed.” Source location Response from Essex Partnership University
Open published response
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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 Configure risk-assessment documentation in Paris and Mobius to carry forward risk history while capturing newly identified risks.
Verbatim wording from the response “• At present, risk assessment documentation within Paris and Mobius are “trending” which means they capture information from the previously typed risk assessment and pull this automatically into a new risk assessment form. This will ensure that risk history is included within one place, whilst new identified risk can be included to ensure the comprehensive nature of the assessment. The information can be considered when making clinical decisions with the patient and their family, and can be incorporated into their risk management plan.” Source location Response from Essex Partnership University
Open published response
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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 observation assurance monitoring through Tendable and observation-engagement audits, with weekly review of findings by the Inpatient Clinical Support Group.
Verbatim wording from the response “The Trust continues with observation assurance monitoring and has strengthened some of these processes. Key assurance monitoring includes:” Source location Response from Essex Partnership University
Open published response
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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 the adult inpatient record-keeping clinical audit covering current risk assessments, risk-management plans, MDT input, observation care plans and crisis plans.
Verbatim wording from the response “Clinical Audits:
Adult Inpatient Wards Record Keeping Audit continues to be part of the Trust Clinical Audit Programme. Clinical audit is a proven method of quality improvement and an important mechanism for providing assurance in relation to the provision of safe and effective patient care. It gives staff a systematic way of looking at their practice and making improvements.” Source location Response from Essex Partnership University
Open published response
25 Nov 2022 Philip John BATTLE · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Failure of ambulance triage to assess presenting mental-health and self-harm risks View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Philip John BATTLE · 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
Philip John Battle died by suicide on 8 July 2022 after contacting the ambulance service about an overdose and an attempted hanging. The report raised concerns that the ambulance triage process focused on physical health rather than immediate mental-health and self-harm risks, and that no attempt was made to contact someone who could check on his safety. It also identified limited coordination and shared mental-health crisis resources between ambulance, police and 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 of ambulance triage to assess presenting mental-health and self-harm risks
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” Source location Philip John BATTLE · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.