12 Aug 2025 Resmije Ahmetaj · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure to consider the risk of psychosis relapse View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Resmije Ahmetaj · 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
Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.
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 consider the risk of psychosis relapse
Wider context from the report “(3) There were issues around communication and escalation within the Trust mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and showed markedly subtherapeutic blood levels of antipsychotic medication. This subtherapeutic level was not acted upon and was contrary to:
a. Ms Ahmetaj insisting she was compliant with her medication
b. Ms Ahmetaj did not have any noted risks that would cause interference with her medication.
c. Ms Ahmetaj informed EPUT clinicians that:
i. On 24 June she thought her medication Clozapine was not working
ii. On 27 June she no longer wished to take her prescribed antipsychotic medication , and
iii. Did not agree she had Schizophrenia, and
iv. wanted to revert to a previous medication Quetiapine.
These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to continue her clozapine and wait for her appointment on 1 July and there was no consideration of the risk of relapse of psychosis .
” Source location Resmije Ahmetaj · Prevention of Future Deaths report
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 Take forward MDT learning on documenting and escalating inconsistencies between clozapine assays, adherence reports and clinical stability.
Verbatim wording from the response “On reflection, while the management of this case was consistent with current guidance, there are learning points regarding communication and escalation. Specifically, inconsistencies between assay findings, patient-reported adherence, and clinical stability should have been explicitly documented and escalated to the consultant psychiatrist at an earlier stage. Doing so would have provided additional assurance around risk management and strengthened the therapeutic dialogue with the patient. This learning is being taken forward by the MDT.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Clinical assessment and the already scheduled psychiatric review were considered sufficient; no earlier appointment was indicated without evidence of deterioration.
Verbatim wording from the response “National and local guidelines emphasise that Clozapine plasma levels are an adjunct to clinical decision-making and should not be used in isolation to guide practice. Clinical assessment of the patient remains the primary determinant of treatment intervention.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
1 Aug 2025 Sidi Chax Bojang · Prevention of Future Deaths report North London
View report summary
Concerns raised 1
Failure to account for recent self-harm, suicidal behaviour or suicidal thoughts when presentation appears improved View source
This report raised 2 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.
×
AI-generated summary
Sidi Chax Bojang · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.
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 account for recent self-harm, suicidal behaviour or suicidal thoughts when presentation appears improved
Wider context from the report “Where there is a significant change in presentation when assessed suggesting that the patient is now well , when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present .
That a psychiatrist did not review the person presenting before discharge.
The discharge of the person in these circumstances fell to a senior psychiatric nurse.
” Source location Sidi Chax Bojang · Prevention of Future Deaths report
Open source report
23 May 2025 George Kenneth Fraser · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to carry out robust risk assessments 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
North East London 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. 4
North East London NHS Foundation Trust
Use the MaST electronic system in Havering to monitor caseloads, documentation, engagement, risk and care-planning reviews.
View source
North East London NHS Foundation Trust
Implement the NICE-based risk-formulation approach through co-produced training, updated recording systems and team support.
View source
North East London NHS Foundation Trust
Recruit trainers to support delivery of the new risk-assessment and management training programme.
View source
North East London NHS Foundation Trust
Monitor compliance, patient and staff experience, and risk-formulation quality through supervision, meetings and the Risk Formulation Steering Group.
View source See 1 more action
×
AI-generated summary
George Kenneth Fraser · 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
George Kenneth Fraser, aged 37, was found deceased at his home after mental health services had been unable to contact him and his family had last contacted him several weeks earlier. The cause and date of death were uncertain. Concerns included the absence of a clear care plan and robust risk assessment, and inadequate action and communication following failed contact and concerns raised by a friend and family.
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 carry out robust risk assessments
Wider context from the report “(2) There was no robust risk assessment carried out by the Mental Health and Wellness team.
” Source location George Kenneth Fraser · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the MaST electronic system in Havering to monitor caseloads, documentation, engagement, risk and care-planning reviews.
Verbatim wording from the response “Mental Health and Wellness Teams in Havering have also started using an electronic system, the Management and Supervision Tool (MaST). This enables clinicians and managers to manage caseloads and to monitor the quality of documentation, levels of engagement, and how documentation reflects risk and the complexity of a patient’s needs. This also enables monitoring of DIALOG and care planning, allowing staff to clearly identify, where review of the patient is required.” Source location Response from North East London Foundation Trust
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 NICE-based risk-formulation approach through co-produced training, updated recording systems and team support.
Verbatim wording from the response “Since the publication of NICE Guidance NG225 on self-harm was published, focusing on assessment, management, and preventing recurrence, we have been working to change Trust practice in relation to the assessment and management of risk. In November 2023, NELFT's senior clinical leadership established a working group to plan for the full implementation of this” Source location Response from North East London Foundation Trust
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 Recruit trainers to support delivery of the new risk-assessment and management training programme.
Verbatim wording from the response “approach. The working group comprises staff from all professional groups, as well as service users and carers. To support implementation of this, new training has been developed, electronic recording systems reviewed and updated, trainers recruited, and team support designed to ensure that staff are equipped to embed this new way of working. This work programme has been co-produced with service users and carers, including involvement in training delivery, with every training day supported by a service user or carer to ensure their voice was heard throughout the process. This undertaking required considerable preparation before the rollout of the training began in 2024. The training programme has been delivered locality by locality, with three localities completed to date (July 2025).” Source location Response from North East London Foundation Trust
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 compliance, patient and staff experience, and risk-formulation quality through supervision, meetings and the Risk Formulation Steering Group.
Verbatim wording from the response “Compliance is monitored in teams through individual supervision, utilising the MaST tool, as well as team meetings and clinically focused groups, such as the team zoning meeting.” Source location Response from North East London Foundation Trust
Open published response
Concerns raised 1
Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Implement a national urgent clinical review process for suicide-related Category 3 calls, supported by dedicated NHS Pathways disposition coding.
View source
NHS England
Publish and reissue national operational guidance for assessing lethality and toxicity in overdose and suicidal ideation calls.
View source
NHS England
Provide substantial training information on assessing patients with mental health conditions.
View source
NHS England
Keep NHS Pathways clinical content under review as new evidence or guidance emerges.
View source See 1 more action
×
AI-generated summary
James Paul Michael Masheter · 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
James Paul Michael Masheter died by hanging at his home on 1 April 2024, after experiencing a significant mental health crisis and making calls for ambulance assistance. The report raises concerns that existing NHS Pathways mental health triage may not properly risk-assess serious crises involving a risk to life, and that categorisation as category 3 contributed to significant delays in ambulance attendance. Incorrect information about the expected waiting time was also provided to his friend, who believed the ambulance was arriving imminently and left him.
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 Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises
Wider context from the report “1. The NHS Pathways system is used for triage. This asks standard questions to ascertain the seriousness of the situation including whether the patient is awake and breathing and so on. The triage pathway includes some options for mental health situations but these are limited. Evidence was heard in the inquest that the North West Ambulance Service (NWAS) had liaised with NHS Pathways with a view to exploring how mental health calls are triaged. NHS Pathways declined to make any changes to mental health triage but offered advice to NWAS in how to triage mental health situations.
2. The evidence heard at the inquest was that notwithstanding the seriousness of the situation in which Mr Masheter presented, his appropriate categorisation was category 3. This led to significant delays in an ambulance attending. It is not clear to me whether it is possible for serious mental health crisis situations which present a risk to life are capable of being properly risk assessed on the basis of the NHS Pathways mental health triage which exists at present.
” Source location James Paul Michael Masheter · Prevention of Future Deaths report
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 national urgent clinical review process for suicide-related Category 3 calls, supported by dedicated NHS Pathways disposition coding.
Verbatim wording from the response “NHS England has led a number of national discussions regarding the management of suicidal calls. The NHS Pathways system has been adjusted to accommodate changes and the introduction of a national process. In this process, ambulance and NHS 111 providers facilitate an urgent clinical review for cases flagged as ‘Risk of Suicide’, which is further described below. These changes acknowledge that risks relating to suicidal intent are complex and may be multifactorial. Although non-clinical health advisers receive significant, structured training to use the NHS Pathways system, this system is organised to triage cases for further clinical input or assessment in most cases.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and reissue national operational guidance for assessing lethality and toxicity in overdose and suicidal ideation calls.
Verbatim wording from the response “In April 2021, NHS England in conjunction with the Association of Ambulance Chief Executives (AACE) published a new operational procedure for all ambulance services in England entitled ‘Category 3/999 Overdose and Suicidal Ideation Calls: Initial Assessment of Lethality/Toxicity Principles Document’. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes to ensure suicidal patients receive the correct clinical response. This review had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above.” Source location Response from NHS England
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 substantial training information on assessing patients with mental health conditions.
Verbatim wording from the response “NHS Pathways has additionally provided significant training information regarding the assessment of patients suffering from mental health conditions and has offered to advise North West Ambulance Service (NWAS) on how to triage mental health situations. Regional clinical quality colleagues for the North West have also been made aware of your Report for the appropriate assurance purposes.” Source location Response from NHS England
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 Keep NHS Pathways clinical content under review as new evidence or guidance emerges.
Verbatim wording from the response “Given the significant consideration nationally of the management of callers at risk of suicide in recent years, and the fact that this has resulted in system changes, national discussions and mandates, NHS England is not considering a further system change to NHS Pathways at this time, but (as with all clinical content) this will remain under review as and when new evidence or guidance emerges.” Source location Response from NHS England
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 NHS England is not considering further NHS Pathways system changes because national reviews, discussions and mandated changes have already addressed suicide-risk management.
Verbatim wording from the response “Given the significant consideration nationally of the management of callers at risk of suicide in recent years, and the fact that this has resulted in system changes, national discussions and mandates, NHS England is not considering a further system change to NHS Pathways at this time, but (as with all clinical content) this will remain under review as and when new evidence or guidance emerges.” Source location Response from NHS England
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 NHS Pathways triage system elicited the correct information and triggered the nationally approved ambulance response in this case.
Verbatim wording from the response “In this particular case, it appears from the Report that the NHS Pathways triage system did elicit the correct information which triggered the correct nationally approved ambulance response.” Source location Response from NHS England
Open published response
17 Mar 2025 DARREN NEIL TURNER · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure to appropriately update and document risk assessments View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
DARREN NEIL TURNER · 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
Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.
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 appropriately update and document risk assessments
Wider context from the report “(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Darren’s risk assessment consistent with Trust policy . Relevant passive and active risk factors were not formally reflected in his documented risk assessments . Evidence from his Responsible Consultant Psychiatrist and the discharging Psychiatrist confirmed that, had they been aware of a disclosure made by Darren to his key worker/nurse prior to discharge, the Section 2 detention would not have been rescinded, he would not have been discharged on the 17th October and, accordingly, it is likely that he would not have taken his own life the following day.
” Source location DARREN NEIL TURNER · Prevention of Future Deaths report
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 the unified NOVA electronic patient record to integrate systems and carry forward risk information.
Verbatim wording from the response “Essex Partnership University Trust and Mid and South Essex NHS Foundation Trust (MSEFT) are working together to implement ‘NOVA’, a new and single Electronic Patient Record (EPR) system across our services, which will pull through risk information which will negate need to repeat information.” Source location Response from Essex Partnership University NHS Foundation Trust
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 ward-wide digital clinical dashboards displaying quality, performance and risk-assessment information.
Verbatim wording from the response “The Trust has developed new digital clinical dashboards available in all wards which displays a range of ‘at a glance’ quality/performance information. This includes monitoring of risk assessments. All staff have access to this dashboard.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
13 Mar 2025 Mr Paul Timothy Dunne · Prevention of Future Deaths report South London
View report summary
Concerns raised 2
Failure to apply A&E risk assessment and staffing policies to mental health staff View source Failure to recognise high-risk mental health patients View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Mr Paul Timothy Dunne · 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 Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to apply A&E risk assessment and staffing policies to mental health staff
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” Source location Mr Paul Timothy Dunne · 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 Failure to recognise high-risk mental health patients
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk , despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Source location Mr Paul Timothy Dunne · Prevention of Future Deaths report
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 Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Verbatim wording from the response “1. We recognise the distress and concern these events have caused and acknowledge the importance of accountability where there are apparent shortfalls in professional conduct or decision-making. However, it is important to clarify that the Care Quality Commission’s regulatory remit, as established under the Health and Social Care Act (2008) and the associated Regulated Activities Regulations (2014), is focused on assessing and holding providers rather than individual staff accountable for meeting fundamental standards of care. While we do not have the authority to investigate or act against individual healthcare professionals, we expect providers to ensure that their staff are competent, appropriately trained, and supported to deliver safe and effective care.” Source location Response from Care Quality Commission
Open published response
17 Feb 2025 DAVID WAYNE BENNETT · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure of mental health liaison to undertake the mental health risk assessment View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Essex Partnership University NHS Foundation Trust Mid and South Essex 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. 4
Mid and South Essex NHS Foundation Trust
Commission and complete an independent safety review of the Mental Health Liaison service.
View source
Mid and South Essex NHS Foundation Trust
Devise an action plan to deliver improvements to the Mental Health Liaison service.
View source
Mid and South Essex NHS Foundation Trust
Develop a Mental Health Liaison service across all hospitals in partnership with the Integrated Care Board and EPUT.
View source
Essex Partnership University NHS Foundation Trust
Move towards a collaborative Safety Planning approach to keeping people safe.
View source See 1 more action
×
AI-generated summary
DAVID WAYNE BENNETT · 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
David Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of mental health liaison to undertake the mental health risk assessment
Wider context from the report “(7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health . This is the role and purpose of mental health liaison .
” Source location DAVID WAYNE BENNETT · Prevention of Future Deaths report
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 Commission and complete an independent safety review of the Mental Health Liaison service.
Verbatim wording from the response “Independent Mental Health Liaison Safety Review
In addition to the steps taken above, we have commissioned an independent review of the MHLT adult services supplied to us by EPUT. The review was finalised in January 2025 and several recommendations were made to improve the MHLT service.” Source location Response from Mid & South Essex NHS Trust
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 Devise an action plan to deliver improvements to the Mental Health Liaison service.
Verbatim wording from the response “Independent Mental Health Liaison Safety Review
In addition to the steps taken above, we have commissioned an independent review of the MHLT adult services supplied to us by EPUT. The review was finalised in January 2025 and several recommendations were made to improve the MHLT service.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Mental Health Liaison service across all hospitals in partnership with the Integrated Care Board and EPUT.
Verbatim wording from the response “We are working in partnership with the Mid and South Essex Integrated Care Board and EPUT to develop a Mental Health Liaison service in all of our hospitals that meets the needs of patients in mental health crisis whilst they await care and treatment in the appropriate mental health care setting.” Source location Response from Mid & South Essex NHS Trust
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 Move towards a collaborative Safety Planning approach to keeping people safe.
Verbatim wording from the response “In line with other Mental Health Trusts we are moving towards a “Safety Planning” approach to keeping people safe. This approach is welcomed and championed by those with mental health needs. This approach promotes a collaborative approach to keeping patient’s safe. It would be impractical and a failure of the use of learned and professional expertise to have mental health nurses only carrying out risk assessments. Again, mental health risk assessments is a joint responsibility.” Source location Response from Essex Partnership University NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.
Verbatim wording from the response “I understand from my colleagues in attendance at the Inquest hearing, that these matters of concern; points 1 – 5, do not relate to Mid and South Essex NHS Foundation Trust (MSEFT), and we have not identified any action to be taken in respect of these.” Source location Response from Mid & South Essex NHS Trust
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 No action was identified because the acute Trust nurse appropriately sought advice from the mental health liaison team for the risk assessment.
Verbatim wording from the response “(7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison.” Source location Response from Mid & South Essex NHS Trust
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 Mental health risk assessment is a joint responsibility, not exclusively the role of mental health liaison staff.
Verbatim wording from the response “Concern 7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison.” Source location Response from Essex Partnership University NHS Trust
Open published response
31 Jan 2025 Kim Jeannette ROBINSON · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Failure to assess suicidal behaviour or thoughts in online consultations 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
Department of Health and Social Care
×
AI-generated summary
Kim Jeannette ROBINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kim Robinson died at home in Suffolk on 12 May 2024 after toxicological analysis identified a significantly toxic level of a medication obtained from an online pharmacy. The report identified concerns that the online prescriber could not access her GP records, the ordering process used incorrect details, and the medication was delivered in a quantity that gave her direct access to a fatal amount. The report stated that the online prescription system needed review.
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 assess suicidal behaviour or thoughts in online consultations
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Source location Kim Jeannette ROBINSON · Prevention of Future Deaths report
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 If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Verbatim wording from the response “In your report you suggest that all consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” On this point, the GPhC expects pharmacies to carry out a risk assessment for every part of the service they provide. If an appropriate organisation stated that this question should be included, then the GPhC would monitor this through its inspection processes.” Source location Response from DHSC
Open published response
20 Dec 2024 Haydar Jefferies · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to provide necessary clinical knowledge for overnight mental health 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.
×
AI-generated summary
Haydar Jefferies · 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
Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.
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 necessary clinical knowledge for overnight mental health risk assessment
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions .
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” Source location Haydar Jefferies · Prevention of Future Deaths report
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 re-commissioned prison healthcare services, including seven-day mental health provision, on-site attendance and out-of-hours urgent referral protocols.
Verbatim wording from the response “I would also like to inform you that since Haydar’s tragic death, the healthcare at HMP Coldingley, including mental health services, has been re-commissioned.” Source location Response from NHS England
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 Require relevant managers to consider out-of-hours mental-health support options, including NHS 111, when concerns are raised.
Verbatim wording from the response “The prison’s Safety Strategy also sets out that all managers, particularly night Orderly Officers and those in charge of the prison when healthcare colleagues are not available, must consider using out of hours options when concerns for a prisoner’s mental health have been raised. This includes phoning 111 – the NHS emergency non-life threatening phone number which now offers mental health crisis support.” Source location Response from HMPPS
Open published response
4 Dec 2024 Dean Martin Ford · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to carry out holistic formulations of risk to self View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Dean Martin Ford · 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
Dean Martin Ford died by suicide on 10 March 2024 after leaving home, buying a length of rope, and being found hanging in Bedfords Park, Romford. Concerns included failures by two mental health teams to carry out a holistic risk formulation, an incorrect assessment of his risk as low, and the absence of audits for risk assessments of people referred but not accepted by the mental health and wellbeing 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 Failure to carry out holistic formulations of risk to self
Wider context from the report “(1) Despite clear guidance from NICE in September 2022 relating to the need for a holistic formulation of risk to self, two NELFT teams involved in Mr Ford’s crisis care failed to carry out a holistic formulation of the risk he posed to himself .
(2) A clinical lead for the mental health and wellbeing team within NELFT, gave evidence at the inquest in December 2024 that Mr Ford’s risk was deemed to be low because “the main factor around risk is that he denied any risk to self and denied any suicidal thoughts”. This simplistic assessment of risk is not compliant with the NICE guidelines . It is of concern that a senior member - clinical lead - within the mental health and wellbeing team is not applying the correct risk formulation .
” Source location Dean Martin Ford · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and expand face-to-face risk-formulation training across acute, rehabilitation and borough-based staff, including new starters.
Verbatim wording from the response “We have undertaken a very thorough review of all policies, procedures and associated training and worked closely with our experts by experience. We launched our Risk Formulation training in September 2024 and have been delivering a day-long face-to-face training. The training utilises videos we made of experts by experience and carers talking about their experience of risk and suicide. We have now trained some 80% of our acute and rehabilitation colleagues, and moved to Borough based training in January 2025 and have started training colleagues in Barking and Dagenham.” Source location Response from North East London Foundation Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.