5 Jul 2022 Antony Christopher MCLELLAN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 1
Failure to incorporate autism into assessment and management of self-harm risk View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Antony Christopher MCLELLAN · 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
Antony Christopher McLellan was found unresponsive, hanging by a ligature in the garage at his home on 9 July 2021; his death was recognised that afternoon and the inquest concluded that he died by suicide. Concerns included that assessment and formulation of risks and safety did not fully explore the impact of his autism, including how he might communicate distress and risk, and that autism-informed support and services required significant improvement and expansion.
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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 autism into assessment and management of self-harm risk
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Source location Antony Christopher MCLELLAN · Prevention of Future Deaths report
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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 TEWV is responsible for delivering mental health services and making autism-related reasonable adjustments under its contract.
Verbatim wording from the response “The CCG (and now ICB) commission Tees, Esk, Wear Valley NHS Trust (TEWV) to provide the Mental Health provision to the residents of North Yorkshire. This would be the case whatever the Mental Health condition is and whether that is suspected, being assessed or diagnosed. The contract requires this provision of service. In addition to this where an individual with mental health conditions also has a diagnosis of autism, the contractual expectation would be that TEWV would make reasonable adjustments to their service to ensure that it is delivered to meet the needs of those individuals with autism and a mental health condition.” Source location Response from NHS England
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29 Jun 2022 Paul Alexander Meadows · Prevention of Future Deaths report Suffolk
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Concerns raised 3
Insufficient practitioner time to gather information and conduct triage and risk assessment View source Lack of thorough risk assessment and safety planning View source Insufficient professional curiosity around risk and suicidal ideation View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Alexander Meadows · 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
Paul Alexander Meadows was found dead at home on 4 August 2021 after taking a Codeine overdose, against a background of physical health difficulties and deteriorating mental health. The report identified concerns that his mental health crisis was not recognised by the First Response Service on 3 August 2021 and that there was no onward referral for urgent or emergency intervention. It also identified broader concerns about the time available to practitioners to gather information and properly triage and risk assess callers, linked to workload and recruitment pressures.
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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 Insufficient practitioner time to gather information and conduct triage and risk assessment
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess .
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess . Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Source location Paul Alexander Meadows · 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 Lack of thorough risk assessment and safety planning
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case . There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Source location Paul Alexander Meadows · 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 Insufficient professional curiosity around risk and suicidal ideation
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation .
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Source location Paul Alexander Meadows · 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 Repurposed the First Response Service and transitioned access to NHS 111 option 2 to refocus crisis response.
Verbatim wording from the response “• Suffolk and North East Essex Integrated Care System (ICS) and NSFT agreed to repurpose the FRS and transition to NHS111 option 2. This would refocus the service to revert to the ‘Crisis’ Response service that was initially planned. This change in April 2022, has seen a reduction in calls and abandonment rate and seen an improvement in call response times. It has also helped the team to spend more time with individuals who are accessing the service.” Source location Response from NHS Suffolk and North East Essex
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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 Continue working with NSFT to reduce team vacancies and improve the crisis-service offer in Suffolk.
Verbatim wording from the response “• The ICS will continue to work with NSFT to reduce the number of vacancies in the team and continue to improve the offer for people who are experiencing a mental health crisis in Suffolk.” Source location Response from NHS Suffolk and North East Essex
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 Expand and diversify the types of mental health workforce roles available.
Verbatim wording from the response “Turning to your matter of concern regarding staff vacancies, we are fully committed to attracting, training and recruiting the mental health workforce of the future. Through our plans set out in ‘Implementing the Five Year Forward View for Mental Health’ and ‘Stepping Forward to 2020/2021: The mental health workforce plan for England’, we have expanded and diversified the types of roles that are available.” Source location Response from Department of Health and Social Care
Open published response
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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 Invest £111 million in 2021/22 to grow the mental health workforce.
Verbatim wording from the response “The NHS Mental Health Implementation Plan 2019/20–2023/24 sets out the need for the mental health workforce to grow by over 27,000 during this time frame, to support the expansion and transformation of NHS mental health services and give an extra two million people the mental health support they need. We invested £111 million in 2021/22 to grow the mental health workforce to deliver these ambitious commitments. Further, Health Education England and NHS England have been working with Integrated Care Systems (ICSs) to confirm plans to 2024. The aim is for every ICS to look at everything they can do to meet the Implementation Plan ambition, including through innovative service models, increasing supply, and improving retention and recruitment.” Source location Response from Department of Health and Social Care
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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 Funding did not directly determine recruitment capacity, and the service was adequately funded initially.
Verbatim wording from the response “• Suffolk adequately funded the service from the outset but were not able to financially respond to the sudden increase caused by the request to make the service accessible to anyone with a mental health query. The Suffolk First Response Service was further advanced than the Norfolk equivalent service when the FRS went live in March 2020 and initially supported Norfolk calls too whilst the Norfolk service offer was further developed.” Source location Response from NHS Suffolk and North East Essex
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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 service could not financially respond to the sudden increase in demand caused by its expanded remit.
Verbatim wording from the response “• Suffolk adequately funded the service from the outset but were not able to financially respond to the sudden increase caused by the request to make the service accessible to anyone with a mental health query. The Suffolk First Response Service was further advanced than the Norfolk equivalent service when the FRS went live in March 2020 and initially supported Norfolk calls too whilst the Norfolk service offer was further developed.” Source location Response from NHS Suffolk and North East Essex
Open published response
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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 Local commissioners are responsible for deciding service provision and ensuring services meet local population needs.
Verbatim wording from the response “With regards to differences in funding available to Norfolk and to Suffolk, NHS England is responsible for determining allocations of financial resources to Integrated Care Boards from April 2022. The allocations process uses a statistical formula to make geographic distribution fair and objective, so that it more clearly reflects local healthcare need and helps to reduce health inequalities. Local commissioners are responsible for decisions about the provision of services in their area and ensuring that they meet the needs of the local population.” Source location Response from Department of Health and Social Care
Open published response
24 Jun 2022 ZSOLT KIRJAK · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Insufficient suicide risk assessment View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
ZSOLT KIRJAK · 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
ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.
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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 Insufficient suicide risk assessment
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide . The treatment plan prescribed did not manage the Patient’s risks.
” Source location ZSOLT KIRJAK · Prevention of Future Deaths report
Open source report
14 Jun 2022 Keith Andrew NOTTLE · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to ensure specialist mental health assessment of patients triaged by telephone workers View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Agree a standard operating procedure governing helpline referrals to the Crisis Team.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Ensure helpline workers and their team leader understand the referral standard operating procedure.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Agree a competency framework covering staff confidence in handling calls and escalating risk.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Review local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Review and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022. View source
Action
Introduce a digital telephony system that records calls and enables regular audit of call activity.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022. View source
Action
Introduce monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022. View source See 7 more actions
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AI-generated summary
Keith Andrew NOTTLE · 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
Keith Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals to mental health services.
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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 ensure specialist mental health assessment of patients triaged by telephone workers
Wider context from the report “Evidence was heard regarding the operation of a triage for patients who may be experiencing a mental health crisis. A practice had developed of bypassing specialist mental health assessment by means of telephone workers making their own judgments about the level of risk a person presents to themselves and others, and a judgment about whether or not they require urgent mental health assessment and / or treatment, based on a very limited criteria. This had the result of only a very small proportion of potentially unwell patients being considered by a person with qualifications to assess and treat mental health. This was a culture and practice which stood in conflict with the procedure the Trust had in writing for the role of the telephone workers.
” Source location Keith Andrew NOTTLE · 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 Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
Verbatim wording from the response “We have reviewed and refreshed the key factors in the role of the helpline (telephone) workers with colleagues in Nottinghamshire Healthcare Trust, including when and how referrals are escalated to the Crisis Team, training, supervision, monitoring and audit.” Source location Response from Turning Point
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 Agree a standard operating procedure governing helpline referrals to the Crisis Team.
Verbatim wording from the response “We have met with our colleagues from Nottinghamshire Healthcare Trust on a number of occasions and agreed a Standard Operating Procedure (SOP) for the flow of referrals from the helpline workers to the Crisis Team. This SOP is in line with the service specification and national guidance regarding access to mental health services.” Source location Response from Turning Point
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 Ensure helpline workers and their team leader understand the referral standard operating procedure.
Verbatim wording from the response “We have met with the team of helpline workers and their team leader and ensured that they are familiar with the detail of the SOP.” Source location Response from Turning Point
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 additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
Verbatim wording from the response “We have introduced additional monitoring and audits to ensure that all helpline workers are following the SOP and any variance is addressed in a timely way.” Source location Response from Turning Point
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 Agree a competency framework covering staff confidence in handling calls and escalating risk.
Verbatim wording from the response “We have also agreed a competency framework to provide assurance that our staff are confident in their ability to handle calls and the escalation process regarding risk, amongst other areas.” Source location Response from Turning Point
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 Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.
Verbatim wording from the response “The Recovery Workers also undertake a competency assessment to ensure they have a high level of competence in managing calls, using correct systems and utilising appropriate escalation protocols in relation to risk and safety management. The competency assessment has been updated in light of this inquest. The updated competency assessment is attached (Appendix 2).” Source location Response from NHS Nottinghamshire Healthcare
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 local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.
Verbatim wording from the response “We have been assured by Turning Point that in her evidence regarding transfers to CRHT the staff member was referring to June 2021 when the Urgent Access line was first set up, where there were some initial issues with the transfer of calls. The local guidance for the UK Mental Health Triage Scale has been reviewed with a more robust escalation process should there be any difficulty encountered in transfer of a call.” Source location Response from NHS Nottinghamshire Healthcare
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 and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.
Verbatim wording from the response “The Standard Operating Procedure (SOP) (Appendix 3) for the Urgent Access line has been reviewed and shared with all relevant staff via email and also during supervision and team meetings.” Source location Response from NHS Nottinghamshire Healthcare
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 a digital telephony system that records calls and enables regular audit of call activity.
Verbatim wording from the response “A new digital telephony system is being introduced into the Trust which will provide greater insight into call activity. All calls will be recorded which will enable the roll out of regular audit. It is anticipated that the telephony system will be operational by Mid-August 2022.” Source location Response from NHS Nottinghamshire Healthcare
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 monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.
Verbatim wording from the response “An audit system is being introduced whereby telephone recordings of a sample of telephone calls will be listened to monthly and utilised for audit and training purposes. This will include monitoring if the calls are being handled in accordance with the SOP and taking remedial action if needed.” Source location Response from NHS Nottinghamshire Healthcare
Open published response
15 Feb 2022 Mr Jason Lennon · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to assess mental state, relapse and risk of harm View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Jason Lennon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been considered.
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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 assess mental state, relapse and risk of harm
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” Source location Mr Jason Lennon · Prevention of Future Deaths report
Open source report
11 Feb 2022 Matthew McManus · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to assess and manage risk to self through a care plan View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Matthew McManus · 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
Matthew McManus, who had complex mental health and social care needs, died at the scene after sustaining multiple injuries on 9 November 2020. The report concluded suicide and identified a lack of coordinated care, information sharing, joint assessment and risk planning across the agencies supporting him. It raised concern that without a clear pathway for jointly assessing and coordinating care for adults with complex mental health and social care needs, future deaths may occur.
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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 assess and manage risk to self through a care plan
Wider context from the report “Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means.
████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself , and no real care plan was in place to manage that risk .
Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur.
A copy of the SSAB Safeguarding Adult Review can be found at this link
https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf
” Source location Matthew McManus · Prevention of Future Deaths report
Open source report
20 Oct 2021 Freeda GLAUSIUSZ · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to elicit clear risks during crisis-line conversations View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Freeda GLAUSIUSZ · 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
Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.
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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 elicit clear risks during crisis-line conversations
Wider context from the report “1. I was shocked when I listened to the recording of the call that █
████████ made to the crisis line the day before his daughter died.
The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation ; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis.
In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled.
The clinician then made no note of the call in the medical records, even retrospectively.
I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts.
• This is not the first time that I have made a PFD report to ELFT about its crisis line.
• Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record. He said that he had made a note on a piece of paper, but he did not now have that piece of paper.
• When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance.
” Source location Freeda GLAUSIUSZ · 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 Introduce standardised assessment and care-planning tools across the Crisis Pathway and specified linked services.
Verbatim wording from the response “Part of the transformation involves reviewing all job descriptions, operational policies and introducing a training programme tailored specifically to the needs of Crisis Practitioners. Standardised assessment and care planning tools will be introduced across the pathway, including the Psychiatric Liaison Team in the Emergency Department and the Crisis Café. A crisis hub will be established as an alternative to the Emergency Department. It is hoped staff will be able to work flexibly across the pathway in order to increase staffing in a specific area in the immediate demand becomes high. The Crisis Pathway services will work more closely with our voluntary sector colleagues to improve access to crisis services and care which is better focussed around the needs of specific communities.” Source location Response from East London NHS Foundation Trust
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14 Oct 2021 Paul Ashley Barton · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to account for fluctuating and contradictory suicidal intentions when assessing patient risk View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Paul Ashley Barton · 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
Paul Ashley Barton experienced significant distress, personality changes, dysfunctional behaviour, possible paranoid or delusional thoughts, and repeated suicidal thoughts and acts. He died by hanging on 28 November 2020. Concerns included the Crisis Resolution Home Treatment Team’s focus on avoiding inpatient admission, reliance on patients’ expressed intentions or denials despite fluctuating suicidal intentions, and shortcomings in the Trust’s investigation of his death.
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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 account for fluctuating and contradictory suicidal intentions when assessing patient risk
Wider context from the report “(2) This inquest was one of a number of inquests I have conducted where staff members from Nottinghamshire Healthcare NHS Foundation Trust have placed great reliance upon their interpretation of a patient’s intention and / or a patient’s denial of ongoing suicidal intention . This is so even where, as was the case for Mr Barton, there is a clear and established pattern of fluctuating and contradictory intentions and desires towards suicide.
” Source location Paul Ashley Barton · 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 Update the CRHTT operating procedure with broader assessment, safety-planning and risk-assessment guidance, then disseminate it through email, team meetings and supervision.
Verbatim wording from the response “As demonstrated, the expectations of a CRHTT assessment and plan are clear and require detailed information gathering and consideration of a wide variety of factors on which to base care planning and decision making. This should include whether a hospital admission is required but this cannot be the sole determining factor.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published
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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 and implement the approved Trust suicide-prevention training model, including tiered training, tailored team learning, reflective practice, clinical tools and ongoing evaluation.
Verbatim wording from the response “A priority of the Trust’s Towards Zero Suicide Strategy (2020–2023) was to review the Trust’s suicide prevention training offer and implement a new training model to bring this into line with the Trust’s Towards Zero Suicide approach (2020) and Health Education England’s Suicide Prevention Competencies. A paper to agree the proposed training, method of delivery and resource requirements was presented to the Trust’s Senior Leadership Team on 26 November 2021 for approval.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published
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27 Sep 2021 Antony Declan Schofield · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Lack of comprehensive pre-discharge risk review by staff with detailed knowledge of the patient 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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Each statement is shown once, even when linked to more than one concern.
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Antony Declan Schofield · 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
Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.
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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 comprehensive pre-discharge risk review by staff with detailed knowledge of the patient
Wider context from the report “1.
a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit . This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Source location Antony Declan Schofield · 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 Update inpatient and HBTT procedures to require risk assessments at entry, discharge, identified intervals, and when risks change.
Verbatim wording from the response “During the period under review the Manchester services had recently changed to a new patient clinical record system, Paris, and were in the process of implementing the associated documents such as the Star V2 Risk Assessment which meant that there were some gaps in the services adhering to the Trust Policy.
The Standard Operating Procedures (SOP) for both the Inpatient wards and the HBTT have been updated to reflect the Trust Clinical Risk Policy and when staff should be completing a risk assessment. This includes on entry and discharge from a service as well as identified periods in between and in response to any changes to a person’s risks. The Safire SOP clearly outlines that a patient’s risk assessment should be reviewed and updated prior to discharge from the ward and that a crisis plan should be in place.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
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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 Introduce a discharge checklist requiring review and updating of the risk assessment before discharge.
Verbatim wording from the response “There is a discharge checklist that prompts the activities to be completed before and upon discharge that is scanned into the patient clinical record on completion. This checklist identifies that the Star V2 Risk Assessment should be reviewed and updated prior to discharge. The manager of the ward will undertake a quarterly audit on the checklists and discharge process to provide assurance that they are being completed and uploaded to the patient clinical record.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
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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 Conduct quarterly audits of discharge checklists and processes to verify completion and uploading to clinical records.
Verbatim wording from the response “There is a discharge checklist that prompts the activities to be completed before and upon discharge that is scanned into the patient clinical record on completion. This checklist identifies that the Star V2 Risk Assessment should be reviewed and updated prior to discharge. The manager of the ward will undertake a quarterly audit on the checklists and discharge process to provide assurance that they are being completed and uploaded to the patient clinical record.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
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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 Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.
Verbatim wording from the response “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
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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 Risk was explored and assessments were completed before discharge, although the assessment was not always updated.
Verbatim wording from the response “Mr Schofield was admitted to Safire Ward on 8 August 2019. He was discharged from Safire Ward on 20 August 2019. The GMMH risk assessment tool, Star V2 Risk Assessment was completed by Safire staff during Mr Schofield’s inpatient admission on 9, 11 and 19 August 2019. As the Trust’s Investigation Report identified that staff explored risk with Mr Schofield over the night of the 18th and the morning of 19 August 2019 although did not update the Star V2 Risk Assessment. During the review of his risk Mr Schofield confirmed that he had no thoughts of wanting to ████████ despite these matters being explored.
When Mr Schofield was discharged to the HBTT his risk was explored by staff with him although the Star V2 Risk Assessment was not updated.
GMMH Trust Clinical Risk Policy clearly sets out when a risk assessment should be undertaken.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
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27 Aug 2021 Fadhia SEGULEH · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Telephone-only GP assessments of mental health risk and need View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Fadhia SEGULEH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Fadhia Seguleh was receiving treatment for anxiety and depression when she was found unresponsive, attached to a ligature at her home on 24 February 2021. The concerns included fragmented care and inadequate information sharing between NHS mental health services, her GP and private therapy provider, telephone-only mental health assessments during Covid, and her attending A&E alone during a previous mental health crisis without family input.
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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 Telephone-only GP assessments of mental health risk and need
Wider context from the report “2. As a consequence of Covid all of the assessments of her by her GP in relation to her mental health were done via telephone . Prior to Covid it was likely that they would have been done face to face. It was accepted that assessments of mental health risk and understanding of need was far easier to assess face to face .
” Source location Fadhia SEGULEH · Prevention of Future Deaths report
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Includes deficiencies in the mental health risk-assessment process, including incomplete assessment, inadequate documentation or formulation, failure to gather relevant information, and reliance on insufficient indicators when assessing patients with mental health concerns.
