Recurring concern

Failure to provide face-to-face clinical assessment when clinically indicated

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First reported 10 Oct 2013•Latest report 14 Jan 2026

Definition

What this concern includes

Includes failures in clinical assessment processes where face-to-face assessment is clinically indicated but is omitted, not offered, not required by policy, or replaced by remote contact without an adequate safety threshold; include the anchor and comparable primary-care or community-care assertions.

Not included

  • Excludes failures limited to telephone mental health assessment, which belong to the separately named mental-health telephone-assessment concern when that is the supported boundary.
  • Excludes remote consultations where the report does not identify a clinically indicated need for face-to-face assessment.
  • Excludes failures in treatment, referral, follow-up or diagnostic testing after an adequate face-to-face assessment has occurred.
  • Excludes generic access, staffing or communication deficiencies unless they directly result in failure to provide clinically indicated face-to-face assessment.
Reports
21

Distinct published reports

Individual concerns
21

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
24

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care7
NHS England2
NHS Greater Manchester Integrated Care Board2
49 Marine Avenue Surgery1
Ayurvedic Professionals Association1
Belmont Health Centre1
Berkshire Healthcare NHS Foundation Trust1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
East London NHS Foundation Trust1
General Medical Council1
General Pharmaceutical Council1
Greater Manchester Health and Social Care Partnership1
Herefordshire and Worcestershire Health and Care NHS Trust1
Kent and Medway Mental Health NHS Trust1

Concerns and responses across reports

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

  1. Inner North London

    AI-generated summary

    Seema Pravin HARIBHAI · 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

    Seema Haribhai, who had increasingly disabling psoriatic arthritis, took herbal remedies prescribed by an Ayurvedic practitioner and developed liver failure, dying some weeks later. The investigation determined that she died as a consequence of the administration of Ayurvedic medicines intended to treat psoriatic arthritis. Concerns included the practitioner’s failure to recognise the possible harm from the medicines or advise their immediate cessation, the lack of regulation and evidence of quality control, and shortcomings in the GP’s assessment and response to her symptoms and abnormal blood test.

    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 arrange an in-person physical examination

    Wider context from the report

    “However, the GP did not record the detail of the history, he did not record exactly when the yellow discolouration first appeared, and he did not record the absence of any other signs and symptoms. He did not ask for attendance at the surgery so that he could perform a physical examination. He did not advise immediate cessation of the Ayurvedic medicines. ”

    Source location

    Seema Pravin HARIBHAI · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  2. Manchester South

    AI-generated summary

    Alphonso Alexander Shearer · 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

    Alphonso Alexander Shearer, who had oesophageal cancer and poor swallowing, was discharged with a catheter after treatment for acute urinary retention. He developed symptoms consistent with a urinary tract infection, was prescribed antibiotics he could not swallow, and later collapsed and died while being transferred to an ambulance; post-mortem examination confirmed urosepsis. Concerns included the lack of a system to identify the need for liquid antibiotics, difficulties with the ASK MY GP communication system, and the absence of a face-to-face GP assessment before his deterioration was recognised.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide face-to-face GP assessment when deterioration may be present

    Wider context from the report

    “3. The inquest heard that he had not been seen face to face by a GP and that meant that the full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance. ”

    Source location

    Alphonso Alexander Shearer · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review systems for recording and prioritising consultation and home-visit requests.

    Verbatim wording from the response

    “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.”

    Source location

    Response from North Trafford Group Practice
    Page 4 · response
    Published 29 April 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind reception staff to record every home-visit request in the clinical system for clinician assessment.

    Verbatim wording from the response

    “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.”

    Source location

    Response from North Trafford Group Practice
    Page 4 · response
    Published 29 April 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Reinforce home-visit request recording requirements through reception staff orientation and training.

    Verbatim wording from the response

    “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.”

    Source location

    Response from North Trafford Group Practice
    Page 4 · response
    Published 29 April 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Progress the Greater Manchester access action plan to increase general-practice capacity and appointments, expand face-to-face GP access, reduce avoidable demand, and improve healthcare inequalities.

    Verbatim wording from the response

    “• Greater Manchester integrated care system has completed an action plan with further steps to support improved access and address healthcare inequalities. The plan includes how each of our 10 local systems will tackle variation in general practice, which is our utmost priority. This will continue to be progressed following the establishment of NHS Greater Manchester Integrated Care and the closure of local clinical commissioning groups on 1 July:”

    Source location

    Response from NHS Greater Manchester
    Page 3 · response
    Published 29 April 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the balance between remote and face-to-face consultations across Greater Manchester general practices.

    Verbatim wording from the response

    “• In October 2021, NHS England set out a plan for improving access for patients and supporting general practice. This sets out how we will increase and optimise capacity, address variation, encourage good practice, and improve access, including face-to-face appointments with GPs.”

    Source location

    Response from NHS Greater Manchester
    Page 3 · response
    Published 29 April 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing digital systems provide clinician-triaged access to telephone, video, face-to-face consultations or home visits, with alternatives for patients unable to use them.

    Verbatim wording from the response

    “The adoption of AskmyGP during 2020 was planned as part of the NHS Long Term Plan to improve digital access for patients. This was expedited during the COVID-19 pandemic due to the advantages it offered in remote working. 70% of our practices in Trafford use this system which has enabled patients to access their practice without the need to physically attend on site which was encouraged during the pandemic where possible. The remaining 30% of our practices use similar digital systems with the same capabilities. These digital systems do not mean that that face to face appointments are not available. Each request on these systems are reviewed by a clinician and a decision is made on the method of consultation, which could be by telephone, email, video consultation, face to face or a home visit.”

    Source location

    Response from Tafford Clinical Commissioning Group
    Page 2 · response
    Published 29 April 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    CQC and NHS England will make required improvements across practices that do not meet patients’ reasonable needs.

    Verbatim wording from the response

    “Alongside this we are also working with the Care Quality Commission (CQC), which will work with NHS England to support systems in this process and to make the required improvements across those practices which are not meeting reasonable needs of patients. The CQC is rapidly developing an inspection methodology with a particular focus on access to GP services.”

    Source location

    Response from NHS Greater Manchester
    Page 4 · response
    Published 29 April 2022

    Open published response
  3. Leicester City and South Leicestershire

    AI-generated summary

    Jamie Francis O'Connor · 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

    Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of required face-to-face consultation before dispensing drugs

    Wider context from the report

    “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

    Source location

    Jamie Francis O'Connor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.

    Verbatim wording from the response

    “I appreciate that the events giving rise to this inquest date from several years ago. In late 2019 we launched a call for evidence in relation to remote consultations and prescribing. This explored whether our existing guidance, which was last updated in 2013 and which applied at the time of Mr O’Connor’s death, had kept pace with changes in practice and the use of technology.”

    Source location

    2021-0363-Response-from-GMC_Published
    Page 1 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.

    Verbatim wording from the response

    “Following this exercise, we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”

    Source location

    2021-0363-Response-from-GMC_Published
    Page 1 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.

    Verbatim wording from the response

    “Through our regulation of independent online primary medical services, CQC has identified gaps in the regulatory framework for independent online providers. We continue to have concerns about safety gaps, which generally align to those you have identified. We do however recognise there are benefits in the provision of online services, and for consultations and prescribing without the need for a face to face consultation where there are appropriate safeguards in place. These include history taking, engagement with the registered GP, and monitoring, as well as a risk assessing those medicines that are prescribed by a service. Our specific concerns are in the following areas:”

    Source location

    2021-0363-Response-from-CQC_Published
    Page 3 · response
    Published 4 November 2021

    Open published response
  4. Manchester South

    AI-generated summary

    Brian Fredrick Mottram · 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

    Brian Fredrick Mottram was found unresponsive at home on 15 November 2020 after feeling unwell for over a week. He had reported symptoms including shortness of breath, cough and a tight chest during a telephone GP consultation, but was not seen face to face. The concerns included the predominantly telephone-based appointment policy, the possible failure to identify Covid-19, and uncertainty about how high-risk patients were identified for additional assessment.

    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

    Predominant use of telephone appointments instead of face-to-face or video appointments

    Wider context from the report

    “1. The inquest heard that the GP surgery in common with surgeries across Tameside had a policy of predominantly using telephone appointments rather than face to face or video appointments. It was accepted at the inquest that Brian Mottram’s symptoms were consistent with Covid 19 but not there was no evidence before the Court that they were considered as such by the GP. A face to face appointment and testing in such a scenario may well have led to identification of Covid 19 and different treatment. ”

    Source location

    Brian Fredrick Mottram · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Encourage general practices to provide face-to-face consultations where clinically appropriate alongside remote triage.

    Verbatim wording from the response

    “The current national guidance states that practices should still triage all patients, and while Covid-19 is still a risk, a balance is still required to ensure the safety of staff in general practice, while ensuring that patients can still have consultations. This blended approach has seen more appointments in Tameside and Glossop taking place face to face than remotely.”

    Source location

    2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
    Page 2 · response
    Published 14 June 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    General practices were not predominantly using telephone appointments; over half of appointments were face to face, with additional home visits.

    Verbatim wording from the response

    “Between April 2020 to March 2021 Tameside and Glossop general practices have delivered over 1 million appointments, this includes 563 286 (or 51.6%) face to face appointment and 19,096 home visits.”

    Source location

    2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
    Page 2 · response
    Published 14 June 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    National and local guidance already required remote triage, risk stratification, oximetry and escalation pathways for potentially high-risk Covid-19 patients.

    Verbatim wording from the response

    “The General Practice in the Context of Coronavirus Standard Operating Procedure v3.4 stated that practices should be open for delivery of face to face care, whilst triaging patients remotely in advance where possible, using remote consultations where appropriate.”

    Source location

    2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
    Page 2 · response
    Published 14 June 2021

    Open published response
  5. Inner West London

    AI-generated summary

    Valeria Munoz Biggs · 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

    Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide early and ongoing in-person assessment by a fully qualified psychiatrist

    Wider context from the report

    “5. That patients should be assessed in person by a fully qualified psychiatrist early on and during a treatment phase of illness of this potential seriousness. ”

    Source location

    Valeria Munoz Biggs · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    Jamie Neil Elliott · 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

    Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide timely face-to-face psychiatric assessment after worsened-condition referral

    Wider context from the report

    “2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment. ”

    Source location

    Jamie Neil Elliott · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.

    Verbatim wording from the response

    “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

    Source location

    2017-0135-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide routine doctor review within 72 hours for Home Treatment referrals without prior professional assessment, with out-of-hours emergency review by on-call psychiatry.

    Verbatim wording from the response

    “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

    Source location

    2017-0135-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    Open published response
  7. West Yorkshire (Western)

    AI-generated summary

    Kirsty Childs · 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

    Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.

    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

    Remote diagnosis without face-to-face assessment

    Wider context from the report

    “3. Nurse Advisers within NHS Direct were reaching a diagnosis in Kirsty's case, without having the opportunity to undertake a face to face assessment, and there did not appear to be a lower threshold of recommending a face to face medical review ”

    Source location

    Kirsty Childs · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
  8. County Durham and Darlington

    AI-generated summary

    Jeffrey Gash · 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

    Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.

    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 obtain or require face-to-face assessment when clinically indicated

    Wider context from the report

    “4. Given that there was an insufficiency of enquiry into the deceased’s state of mind and in particular, a failure to further explore the issue of him claiming to hear voices, on inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had not agreed to it voluntarily, then there ought to have been a compulsory assessment. ”

    Source location

    Jeffrey Gash · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind staff to explore and use alternative venues for appointments.

    Verbatim wording from the response

    “I also acknowledge the conclusions from the inquest that further options may have been available in the absence of Mr Gash agreeing to see the crisis team at the hospital base, and indeed am aware of instances where staff have used alternative venues for appointments. Staff have been reminded of the need to explore and utilise alternative appointment venues.”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 3 · response
    Published 18 August 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Share recommendations with the crisis team and reinforce consultation with colleagues and medical staff for complex assessments.

    Verbatim wording from the response

    “Since Mr Gash's sad death, the individual nurse has critically reflected upon this at length with the team manager during her period of informal capability management described under point 1 above. I agree that more in-depth exploration of his reasons for not wishing to attend should have been undertaken. The Trust Did Not Attend policy does highlight that the nurse should have contacted the GP immediately to agree a management plan, in situations where high risks have potentially been identified. As noted above, the individual nurse has undergone a period of observed practice such that the Advanced Practitioner and Team Manager are now satisfied that she would now manage this situation differently, in that issues would be explored in more depth.”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 3 · response
    Published 18 August 2014

    Open published response
  9. Inner South London

    AI-generated summary

    Kirabo Kiwanuka · 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

    Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

    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

    Unavailability of timely physician assessment for acutely ill psychiatric-facility patients

    Wider context from the report

    “2. There is lack of clarity about whether acutely manic patients in a psychiatric facility with physical illness should receive domiciliary visits from physicians and medical care in the psychiatric facility or be transferred to a medical facility, where psychiatric staff attend and visit. She was not examined by a physician when she developed abnormal vital signs. At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion, although this is currently being explored by SLAM and KCH and is included in a draft protocol. When are patients best under the care of a medical and when a psychiatric ITU? How are Trusts to know what is the optimal model of care? ”

    Source location

    Kirabo Kiwanuka · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Worcestershire

    AI-generated summary

    Sean Christopher Seabourne · 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

    Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide timely face-to-face assessment of patients at high risk of concealed suicide

    Wider context from the report

    “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”

    Source location

    Sean Christopher Seabourne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026