30 Nov 2018 Mr Bradley Fraser Brown · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Inadequate weekend mental health staffing and risk assessment for late prison transfers View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
HM Prison and Probation Service
Instruct Governors not to enter local agreements accepting transferred prisoners on Fridays.
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HM Prison and Probation Service
Strengthen first-night procedures by monitoring every new arrival for 72 hours, including random welfare checks during lock-up periods.
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HM Prison and Probation Service
Open a Challenge Support and Intervention Plan for new prisoners segregated before transfer.
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HM Prison and Probation Service
Require healthcare staff to notify the Orderly Officer when new arrivals miss appointments and record follow-up actions when prisoners refuse attendance.
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HM Prison and Probation Service
Issue HMP Haverigg staff a reminder to confirm transfers with Healthcare so medical records are promptly reassigned and available on arrival.
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Mr Bradley Fraser Brown · 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 Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate weekend mental health staffing and risk assessment for late prison transfers
Wider context from the report “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted . There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe . The same concern applies, in principle, to public/bank holidays.
There are different levels of healthcare at the weekends as compared to weekdays . This gives cause for concern given the inherent susceptibilities with which prisoners frequently present.
Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known).
By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities ) timely risk assessment is critical in the prevention of self-harm leading to death .
Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database.
There is no national guidance in relation to late transfers/cut-off points etc.
2. Commissioning of Mental Health/Healthcare Services:
As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.
These issues are not unique to the Prison involved in Mr Brown’s case.
” Source location Mr Bradley Fraser Brown · 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 Instruct Governors not to enter local agreements accepting transferred prisoners on Fridays.
Verbatim wording from the response “However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, a range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when they transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 hour period of monitoring, which includes randomly spaced welfare checks during lock up periods. A Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer.” Source location 2018-0374-Response-by-HM-Prison-and-Probation-Service
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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 Strengthen first-night procedures by monitoring every new arrival for 72 hours, including random welfare checks during lock-up periods.
Verbatim wording from the response “However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, a range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when they transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 hour period of monitoring, which includes randomly spaced welfare checks during lock up periods. A Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer.” Source location 2018-0374-Response-by-HM-Prison-and-Probation-Service
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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 Open a Challenge Support and Intervention Plan for new prisoners segregated before transfer.
Verbatim wording from the response “However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, a range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when they transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 hour period of monitoring, which includes randomly spaced welfare checks during lock up periods. A Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer.” Source location 2018-0374-Response-by-HM-Prison-and-Probation-Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require healthcare staff to notify the Orderly Officer when new arrivals miss appointments and record follow-up actions when prisoners refuse attendance.
Verbatim wording from the response “This provides for a period of monitoring to ensure that vulnerability or violence is managed appropriately. Healthcare staff have also been instructed to notify the Orderly Officer if any prisoner misses an appointment in the early days, so that reasons for non-attendance can be followed up. If a prisoner refuses to attend, Healthcare will be informed and the actions taken recorded by prison staff.” Source location 2018-0374-Response-by-HM-Prison-and-Probation-Service
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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 Issue HMP Haverigg staff a reminder to confirm transfers with Healthcare so medical records are promptly reassigned and available on arrival.
Verbatim wording from the response “Prior to any transfer there is a requirement for Healthcare staff at the sending establishment to assess each prisoner to ensure that any health concerns are recorded and communicated to the receiving prison and to confirm that the prisoner is medically fit to be moved. A notice has been issued to all staff at HMP Haverigg, which was the transferring prison in Mr Brown’s case, reminding them to confirm to Healthcare staff any transfer, so that medical records are reassigned promptly in order that they are immediately available when the prisoner arrives at the new establishment.” Source location 2018-0374-Response-by-HM-Prison-and-Probation-Service
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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 Existing weekday transfer schedules, advance warnings and exceptional weekend transfers are considered sufficient; removing Friday transfers would increase pressure and late arrivals.
Verbatim wording from the response “are located in the appropriate category of prison. Inter prison transfers currently take place from Monday and Friday in accordance with a schedule agreed with the Prison Escort Court Service (PECS). Removing Friday from the schedule would put undue pressure on the remaining four days and increase the risk of late arrivals on those days. Prisons are always given advance warning of these scheduled transfers and PECS notify establishments of their anticipated arrival times, so that arrangements can be made. In terms of weekends, whilst there is provision at a national level for inter prison transfers to be facilitated on a Saturday or Sunday, this will only be done under exceptional circumstances and is extremely rare. Transfers generally only take place over a weekend when an emergency at one prison necessitates a move of prisoners to a different establishment.” Source location 2018-0374-Response-by-HM-Prison-and-Probation-Service
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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 NHS England is responsible for responding directly to concerns about healthcare processes and mental healthcare provision.
Verbatim wording from the response “You have expressed concerns about the transfer of prisoners between prisons on a Friday and at weekends and how this may impact on the level of care and support available to them, particularly in respect of Healthcare and Mental Health assessments. I understand that NHS England will also be responding directly to your concerns in terms of their healthcare processes and will explain that the new specification for the provision of healthcare at Buckley Hall will include access to mental healthcare 7 days a week.” Source location 2018-0374-Response-by-HM-Prison-and-Probation-Service
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29 Oct 2018 Rosario CORDERO-SANZ · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to obtain direct or supported assessment of a person when access is challenged by concerns about police uniforms View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Metropolitan Police Service
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Rosario CORDERO-SANZ · 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
Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.
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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 obtain direct or supported assessment of a person when access is challenged by concerns about police uniforms
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process.
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues.
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves , or call for the assistance of a plain clothes colleague , or suggest that they speak to the friend who was sitting inside with her .
- Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Source location Rosario CORDERO-SANZ · Prevention of Future Deaths report
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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 Suggested scene-assessment actions will not be made mandatory because they may be impracticable or inappropriate in some circumstances.
Verbatim wording from the response “It has been established that the MSC officers who attended the address were not provided with the full details of the call. The informants whom they spoke to did not indicate that Ms Cordero-Sanz was in immediate danger. However it is recognised that if they had obtained more information at the scene utilising Language Line they may have altered their risk assessment and seen her in person. Whilst the suggested considerations have merit, we would not seek to make them mandatory actions as they may not be appropriate or practicable in all circumstances. Had the MSC officers known Ms Cordero-Sanz was a high risk missing person, MPS policy would have required them to physically see her and ensure she was safe and of no danger to herself or others.” Source location 2018-0307-Response-by-Metropolitan-Police
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24 Oct 2018 Maximilien Conrad Kohler · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Over-reliance on questionnaires causing underestimation of self-harm risk View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Maximilien Conrad Kohler · 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
Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.
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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 Over-reliance on questionnaires causing underestimation of self-harm risk
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place, and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular .
” Source location Maximilien Conrad Kohler · Prevention of Future Deaths report
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4 Oct 2018 Michael William Cooper · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Insufficient Care Coordinator capacity to review patient histories and assess risk View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Michael William Cooper · 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
Michael William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in 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 Insufficient Care Coordinator capacity to review patient histories and assess risk
Wider context from the report “3. When Mr. Cooper was established on the Care Programme Approach, his Care Co-ordinator did not have the capacity to review his notes prior to her first visit and therefore did not have a clear understanding of his complex history . Care Co-ordinators within Birmingham and Solihull Mental Health Trust are currently carrying a caseload of more than 30 patients . The NICE guidelines for the Care Programme Approach advises that a Care Coordinator should have caseload of 15 patients. Without the time to familiarise themselves with their patients’ histories Care Co-ordinators cannot make informed assessments of their risk which puts lives at risk.
” Source location Michael William Cooper · 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 Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
Verbatim wording from the response “b. Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG will identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate. This will be undertaken by the CCG and providers at established monthly quality review meetings.” Source location NHS-England-Response.pdf
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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 Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Verbatim wording from the response “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.” Source location Birmingham-and-Solihull-CCG-Response
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3 Oct 2018 Simon Anthony Graham · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Use of unqualified support workers for suicide risk assessments View source Absence of a scoring system or guide for suicide risk assessments View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
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Simon Anthony Graham · 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
Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.
Read the report on judiciary.uk
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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 Use of unqualified support workers for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk assessments .
” Source location Simon Anthony Graham · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a scoring system or guide for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk assessments.
” Source location Simon Anthony Graham · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
Verbatim wording from the response “b. Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG will identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate. This will be undertaken by the CCG and providers at established monthly quality review meetings.” Source location NHS-England-Response.pdf
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25 May 2018 Robin Damien Richards · Prevention of Future Deaths report Somerset
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Concerns raised 1
Inadequate risk assessment and subsequent risk management View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Robin Damien Richards · 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
Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate risk assessment and subsequent risk management
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Source location Robin Damien Richards · Prevention of Future Deaths report
Open source report
12 Feb 2018 John William Sloan · Prevention of Future Deaths report London Inner (South)
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Concerns raised 1
Failure to ask about suicidal ideas or suicide plans View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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John William Sloan · 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
John William Sloan died by suicide on 16 August 2017 after hanging himself while alone at home. He had been receiving mental health care for anxiety, depression, sleeplessness and suicidal ideation. The principal concerns were that he was not asked about suicidal thoughts or plans at his last face-to-face contact, and that information from his daughter about his distress was not recorded or acted upon.
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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 ask about suicidal ideas or suicide plans
Wider context from the report “(1) With regard to the contact on the 8/8/17 I am concerned that the deceased was not asked whether he was experiencing suicidal ideas or had suicide plans . Whilst it is a matter of speculation as to whether he would have disclosed suicidal plans or ideas I consider that this was an error in the management of the deceased’s mental health condition and was a missed opportunity to put in place supportive measures if such thoughts had been disclosed.
” Source location John William Sloan · Prevention of Future Deaths report
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19 Jan 2018 William Myers · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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William Myers · 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
William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.
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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 undertake multidisciplinary case conference reassessment by a forensic psychiatrist
Wider context from the report “(2) A variety of incidents should have alerted the clinicians and others involved in his management to the need for a multi-disciplinary case conference reassessment by the Forensic Psychiatrist . Neither of these took place and in consequence warning signs of impending or actual violence were not recognised . Examples include being found by the Police in a public place in possession of a bladed article when under the influence of some illicit substance and admitting he was hearing voices commanding him to kill people.
” Source location William Myers · 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 Strengthen assessment and multidisciplinary discharge processes for service users who go absent without leave.
Verbatim wording from the response “GMMH has ensured careful consideration is being given to the management of service users who go AWOL and the risk assessment process to be carried out prior to a multidisciplinary team discharging them.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
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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 forensic in-reach support for high-risk community patients, including timely advice, risk management and second opinions.
Verbatim wording from the response “In addition we are working with colleagues in the Trust’s forensic services to develop in-reach forensic support in the management of high-risk/MoJ patients in the community, especially in areas such as Central West CMHT with a higher proportion of such patients. This will facilitate improved risk assessment and management, forensic opinion and case conferences.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
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Concerns raised 1
Subjective risk assessments without reference to defined risk criteria View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jeff David ANTWIS · 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
Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.
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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 Subjective risk assessments without reference to defined risk criteria
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider review.
” Source location Jeff David ANTWIS · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standardised validated clinical risk assessment tool and pathway for responding to changes in risk.
Verbatim wording from the response “• A single point of access to the service was implemented on 4th Dec 2017 to ensure that young people’s needs can be appropriately identified at the point of referral and an appropriate, timely response provided (point 1 and 7). Introduction of standardised validated clinical risk assessment tool with associated pathway to enable timely robust response to changes in risk level (Also points 2, 3, 5, 6 & 7)” Source location 2017-0392-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 Review practitioners’ caseloads and open cases to ensure appropriate care plans, risk assessments and recording of need levels.
Verbatim wording from the response “• We have commenced reviewing the caseloads of all practitioners within the service to ensure that all young people within the service have appropriate care plans and risk assessments in place (points 2, 3, 5, 6 & 7) this will be completed by 31st March 2018.” Source location 2017-0392-Response
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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 Shropshire Community Health NHS Trust was responsible for investigating care because it provided CAMHS services in Shropshire at the relevant time.
Verbatim wording from the response “As identified in your letter South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not providing CAMHS services within Shropshire at the time of Jeff’s death therefore South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not in a position to have carried out an investigation into the care of Jeff prior to his death. The Serious Incident Investigation presented at the inquest was carried out by Shropshire Community Health NHS Trust who were providing CAMHS services in Shropshire in January 2017.” Source location 2017-0392-Response
Open published response
23 Oct 2017 Siân Louise WITHERIDGE · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to distinguish denial of a suicide plan from refusal to answer View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Siân Louise WITHERIDGE · 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
Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis 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 distinguish denial of a suicide plan from refusal to answer
Wider context from the report “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan .
False reassurance appeared to have been drawn from the latter . No arrangement was made for the crisis team to meet Ms Witheridge on 30 May.
” Source location Siân Louise WITHERIDGE · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.