27 May 2026 Abbigail Louise SMITH · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to resolve unmet discharge conditions and escalated self-harm concerns before discharge View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
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Abbigail Louise SMITH · 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
Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.
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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 resolve unmet discharge conditions and escalated self-harm concerns before discharge
Wider context from the report “11. On 9 February 2022 community mental health staff required 3 conditions to be met before they would support Abbi’s discharge, none of which were met on 14 February 2022. Abbi’s was a very complex patient and her care co-ordinator wanted to attend Abbi’s ward review on 14 February and emailed the consultant psychiatrist that she had not received a link. The ward review went ahead in absence of the care co-ordinator and concerns that the care co-ordinator had about Abbi’s risks of her harming herself and ending her life on the discharge were escalated. The plan did not change.
” Source location Abbigail Louise SMITH · 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 Recruit a Community and Inpatient Liaison Practitioner CPN to coordinate inpatient communication and safer discharge planning.
Verbatim wording from the response “The GabIes Specialist Mental Health Team (SMHT) have recruited a new post, a Community and Inpatient Liaison Practitioner Community Psychiatric Nurse (CPN). This role is intended to work directly with inpatient services.” Source location Response from Essex Partnership University 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 Hold weekly ward discharge-planning meetings with key care workers and community leads, documenting complex-discharge actions.
Verbatim wording from the response “Discharge Planning meetings occur throughout the patient’s admission, this ensures constant focus on how to support someone through to discharge and provides enhanced opportunities for MDT in-put.” Source location Response from Essex Partnership University 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 Ensure Home First Home Team staff attend inpatient MDT meetings and ward reviews to coordinate discharge interventions.
Verbatim wording from the response “A weekly discharge planning meeting is held on each ward with all key care workers and community leads present to highlight any complex discharges. This is documented within the action plan. Meetings may still proceed without a member of the community team being present. All members of the team have access to the records / MDT notes relating to planned discharges. All MDT’s and ward reviews have a member of staff from the Home First Home Team in attendance.” Source location Response from Essex Partnership University NHS Trust
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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 Discharge to community mental health services was considered appropriate and proportionate based on multidisciplinary risk assessment and the patient’s clinical presentation.
Verbatim wording from the response “Abbi was reviewed by the Care Coordinator on the day following discharge. The contemporaneous clinical records indicate that the Care Coordinator assessed Abbi’s presentation and concluded that ongoing follow-up by the Community Mental Health Team was appropriate and that the Home Treatment Team involvement was not warranted at that stage. The risks identified at the time were recognised by both inpatient and community teams as longstanding and chronic in nature.” Source location Response from Essex Partnership University NHS Trust
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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 Discharge planning meetings may proceed without a community team member because records and multidisciplinary notes remain accessible to all relevant staff.
Verbatim wording from the response “Discharge Planning meetings occur throughout the patient’s admission, this ensures constant focus on how to support someone through to discharge and provides enhanced opportunities for MDT in-put.” Source location Response from Essex Partnership University NHS Trust
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21 Nov 2025 Timothy Thomas Reading · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Timothy Thomas Reading · 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
Timothy Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of 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 Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers
Wider context from the report “(1) The absence of a formal documented s.117 plan agreed by all those responsible for a patient’s care and treatment upon discharge into the Community from a lengthy inpatient stay creates a risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious mental health conditions . This, in turn, may cause them to feel unsupported and helpless. BSMHFT did not provide a Plan despite requests to do so. S.117 is intended to ensure that patients receive planned and structured support tailored to their requirements. Such planning was absent in this case.
” Source location Timothy Thomas Reading · 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 Use a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.
Verbatim wording from the response “The Trust has now looked at the inpatient care and CMHT care around the s.117 plan on the back of your concerns. Section 117 of the Mental Health Act 1983 places a joint duty on the NHS Integrated Care Board and local authority to provide aftercare services for individuals detained under certain sections of the Act following discharge.” Source location Response from Birmingham and Solihull MH NHS Foundation Trust
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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 The Trust is better placed to respond to concerns about the absence of a requested Section 117 plan.
Verbatim wording from the response “We note that your report has also been addressed to the Trust who will be better placed to respond to the concerns raised around the absence of Section 117 plan provided by the Trust despite it being requested.” Source location Response from NHS England
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5 Jun 2025 Cain Alex River Donald · Prevention of Future Deaths report Oxfordshire
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Concerns raised 2
Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community View source Failure to rapidly coordinate complex discharge arrangements View source
This report raised 6 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. 3
The Trust
Produce and circulate additional discharge guidance for staff through the discharge checklist.
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The Trust
Review the Discharge Policy and recommend amendments, including a new section on unplanned discharge.
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The Trust
Obtain approval and publish the revised Discharge Policy, then brief ward teams on its requirements.
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Cain Alex River Donald · 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
Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.
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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 Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU . Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” Source location Cain Alex River Donald · 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 Failure to rapidly coordinate complex discharge arrangements
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge . Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” Source location Cain Alex River Donald · 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 Produce and circulate additional discharge guidance for staff through the discharge checklist.
Verbatim wording from the response “The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording.” Source location Response from Oxford Health NHS Foundation 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 Review the Discharge Policy and recommend amendments, including a new section on unplanned discharge.
Verbatim wording from the response “The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording.” Source location Response from Oxford Health NHS Foundation 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 Obtain approval and publish the revised Discharge Policy, then brief ward teams on its requirements.
Verbatim wording from the response “The Trust accepts of course that we must be prepared for a Tribunal to take a different view to the Trust’s view and the period of time to discharge being limited. You expressed concern that – faced with a very short period between the Tribunal’s decision and the date of Mr Donald no longer being lawfully detainable – there were deficiencies in the discharge process. Our Associate Director of Nursing has reviewed the Trust’s Discharge Policy and has recommended some amendments to the policy. The proposed amendments include a new section headed “Unplanned discharge”. We had previously produced some additional guidance to staff in the discharge checklist, which was completed and circulated before your letter. The proposed amendments were taken on 26 June 2025 to the relevant committee for discussion and approval of final wording.” Source location Response from Oxford Health NHS Foundation Trust
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29 Jan 2025 Naomi SULEYMAN · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to provide an out-of-hours social worker welfare check on the day of discharge View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Naomi SULEYMAN · 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
Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide an out-of-hours social worker welfare check on the day of discharge
Wider context from the report “(3) On the day of discharge, Ms Suleyman should have received a welfare check from the LBL out of hours social worker which did not happen .
” Source location Naomi SULEYMAN · 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 Provide same-day Enablement Care Officer visits after discharge to assess care suitability and escalate changes.
Verbatim wording from the response “• Any client in receipt of Enablement or brokered out care provision now receives a visit from an Enablement Care Officer, this visit happens the same day that the patient is discharged from hospital and reviews the suitability of care provision once the patient is in their own environment. Any changes are fed back to the Discharge to Assess Team (occupational therapist, physiotherapist or social worker) and patient, carer or other family members.” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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How this respondent action was interpreted
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PFD Monitor interpretation Provide next-day out-of-hours welfare calls by a therapist or social worker for patients discharged between 5pm and 8pm.
Verbatim wording from the response “• For those patients discharged out of hours between 5pm-8pm) the out of hours social worker ensures that a welfare call is carried out the next day by a therapist and/or social worker” Source location Response from Lewisham and Greenwich NHS Trust and Lewisham Council
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25 Jul 2024 Danny Jay Anderson · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of safety planning before discharge 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. 7
The Trust
Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
View source
The Trust
Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
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The Trust
Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.
View source
The Trust
Provide Trust-wide community mental-health-team training on enhanced transition care planning.
View source
The Trust
Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.
View source
The Trust
Re-share the clinical risk policy and provide ward posters on safe discharge steps.
View source
The Trust
Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
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Danny Jay Anderson · 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
Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community 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 Lack of safety planning before discharge
Wider context from the report “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023.
The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny.
From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy).
There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022).
Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk.
There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed.
” Source location Danny Jay Anderson · 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 Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
Verbatim wording from the response “The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.” Source location Response from Essex Partnership NHS
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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 named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
Verbatim wording from the response “The Trust recognises that there was confusion around responsibilities of the named nurse, which includes risk assessment and formulating risks including plan at point of discharge. The Trust Quality Matron for Fundamentals of Care is leading on an improvement project looking at processes for the named nurse which aims to ensure there is consistent understanding of the named nurse role” Source location Response from Essex Partnership NHS
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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 Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.
Verbatim wording from the response “The Trust is on an ongoing journey for improved documentation, which has included training sessions and a specific focus on this within supervision reviews. Work has been undertaken to update the discharge letter template to include discharge planning prompts and the incorporation of carer involvement in the Care Programme Approach review documentation. Discharge letters have been reviewed by the Service User Network Group to review content and tone of correspondence.” Source location Response from Essex Partnership NHS
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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 Provide Trust-wide community mental-health-team training on enhanced transition care planning.
Verbatim wording from the response “Additional training has been undertaken Trust wide in Community Mental Health Teams to support enhanced transition care planning.” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.
Verbatim wording from the response “and development of our staff with the new Skills Training on Risk Management (STORM) training. This is an evidence-based training methodology given to frontline team members who have the opportunity to practice, reflect, and give and receive feedback on skills in a safe and supportive learning environment. It uses the highest standard level of skills development, which includes filmed skills practice for the more advanced courses. The focus is on the person, collaboration, assessment, and safety planning, and they are joined by new skill sets including Suicide and self-harm – exploring the similarities and differences for assessment. We aim to have 60% of all registered practitioners across all urgent care pathways trained by end of 2024. Achievement of this training roll out is overseen by the Trust’s suicide prevention quality priority group.” Source location Response from Essex Partnership NHS
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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 Re-share the clinical risk policy and provide ward posters on safe discharge steps.
Verbatim wording from the response “In addition we have re-shared the clinical risk policy with staff supported with poster for wards on safety discharge steps” Source location Response from Essex Partnership NHS
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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 Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
Verbatim wording from the response “Action is already underway as part of the Safety Action Plan to ensure there are clear documented actions agreed at discharge meetings and that the MDT outcome form is completed for each person clearly stating any actions and an overview of relapse signatures and recorded in the patient record.” Source location Response from Essex Partnership NHS
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21 Mar 2024 Sarah Elizabeth ADAMS · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Lack of training for practitioners in the discharge process, including issues arising from out of area admissions View source
Linked responses
Berkshire Healthcare NHS Foundation Trust Cygnet Health Care Limited Reading Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Cygnet Health Care Limited
Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.
View source
Cygnet Health Care Limited
Update risk e-learning guidance to address risk assessment around discharge.
View source
Cygnet Health Care Limited
Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.
View source
Berkshire Healthcare NHS Foundation Trust
Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
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Sarah Elizabeth ADAMS · 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
Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.
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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 training for practitioners in the discharge process, including issues arising from out of area admissions
Wider context from the report “That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions
” Source location Sarah Elizabeth ADAMS · 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 Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.
Verbatim wording from the response “Care planning and risk assessment training is provided to staff to support them in completing care plans, including discharge care plans. This is via a 4.5 hour face to face session. The session is provided by the Regional Nursing Director to all the Clinical Managers to then be cascaded at each site. At Cygnet Harrow this session has been provided to all members of the multi-disciplinary team (MDT) and is due to be refreshed on an annual basis, or more frequently if a need is identified.” Source location Response from Cygnet Healthcare
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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 risk e-learning guidance to address risk assessment around discharge.
Verbatim wording from the response “This training is aligned with Cygnet's broader training offering, particularly our e-learning risk training. This training is provided to all members of the MDT and refreshed on a two-yearly basis. The session provides guidance to staff in assessing risk, utilising the relevant tools and ensuring that risk assessments are of high quality and triangulated with the care plans, continuous notes and information from families and carers. We are acutely aware that risks can increase at discharge and that risk assessments need to be undertaken carefully to ensure that we implement steps to minimise this. The risk training has been reviewed and from 1 July 2024 will include updated and more specific guidance in relation to risk assessing around discharge.” Source location Response from Cygnet Healthcare
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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 deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.
Verbatim wording from the response “Further, a supplemental set of training slides for staff induction are in development to provide support to staff in understanding the content of the discharge policy, including the discharge checklist, the key risks to consider, accurate documentation and communication with community teams. These slides will be deployed by 1st June 2024 for all Cygnet Hospital sites to assist new staff with prompt familiarisation with our processes.” Source location Response from Cygnet Healthcare
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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 Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
Verbatim wording from the response “All clinical staff in the Mental Health Divisions undertake Clinical Risk training which includes a focus on admission and discharge from inpatient services. We have now reviewed and revised this training offer across the organisation to ensure that moving forward there will be an increased focus on high-risk situations such as:” Source location Response from Berkshire Healthcare NHS Foundation Trust
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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 The existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.
Verbatim wording from the response “9. We confirm that all Adult Social Care practitioners involved in discharge planning are required to know and act in accordance with the SOP. Precise processes regarding discharge planning may differ from Trust to Trust.” Source location Response from Reading Borough Council
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Concerns raised 1
Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities 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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Philip David Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.
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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 joint discharge planning between the Health Board and out-of-area psychiatric facilities
Wider context from the report “b. There was no joined up planning or joint meeting between the Health Board and Ty Grosvenor prior to the deceased’s discharge .
” Source location Philip David Taylor · 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 Hold formal weekly multidisciplinary out-of-area monitoring meetings with documented actions, escalation and oversight of repatriation, clinical activity and discharge planning.
Verbatim wording from the response “All areas have stood up a formal weekly out of area monitoring meeting. The purpose of this meeting is to promote timely repatriation where possible, assurance that key clinical activity and standards are being met and that discharge plans are being implemented and actioned. These meetings are underpinned by terms of reference, agenda, minutes and a log of actions to be completed. Membership includes the multidisciplinary team, including Health and Social Care, Consultant and Medical staffing, Occupational Therapy, Home Treatment Team and Care Coordinators. Outcomes from the meetings are provided to Divisional Putting Things Right meetings and the weekly Divisional Senior Leadership meeting to ensure appropriate escalation arrangements can be put in place where required.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
Verbatim wording from the response “The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
Verbatim wording from the response “A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.” Source location Response from Betsi Cadwaladr University Health Board
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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 The described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.
Verbatim wording from the response “5. This is, therefore, as far as Elysium is concerned, not a case where the facts suggest a risk of future deaths in relation to the role of Elysium. Mr Taylor was an informal patient and was assessed as low risk. His details were already well known to Betsi who had summarised his position when referring him to Elysium in the first place. They had been informed by” Source location Response from Elysium Healthcare
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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 Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.
Verbatim wording from the response “2. The third ward round took place on 14 August. Mr Taylor wished to leave. He was an informal patient. He did not meet the criteria for detention under the MHA. Nor did he lack capacity so a deprivation of liberty under the Mental Capacity Act was not available. He had to be discharged as there was accordingly no lawful basis to refuse this. It was agreed that to enable this to take place in an orderly fashion he would leave the next day. Elysium had no alternative but to proceed with this.” Source location Response from Elysium Healthcare
Open published response
29 Jan 2024 Shahzadi Khan · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of out-of-area and private providers to coordinate effectively with local discharge arrangements 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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AI-generated summary
Shahzadi Khan · 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
Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.
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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 of out-of-area and private providers to coordinate effectively with local discharge arrangements
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Source location Shahzadi Khan · 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 Publish statutory guidance for discharge from all mental health inpatient settings.
Verbatim wording from the response “To improve the issue of out of area placements, and to support adult social care and discharge, up to £2.8 billion has been made available in 2023/24 and £4.7 billion in 2024/25. This can be used to support discharge from mental health inpatient settings, reducing bed occupancy and OAPs. The Department has been working with NHS England and other” Source location Response from Department of Health and Social Care
Open published response
19 Feb 2023 Molly Ann Sergeant · Prevention of Future Deaths report Essex
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Concerns raised 1
Discharge planning that compels a choice between family members and changes homelessness status View source
This report raised 12 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. 2
Essex County Council
Operate weekly multi-agency oversight meetings for autistic and learning-disabled young people in Tier 4 inpatient beds and coordinate safe discharge responsibilities.
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Essex County Council
Maintain the pan-Essex Section 117 protocol setting out multi-agency care planning processes, including accommodation responsibilities.
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AI-generated summary
Molly Ann Sergeant · 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
Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.
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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 Discharge planning that compels a choice between family members and changes homelessness status
Wider context from the report “(6) A lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet Molly’s needs related to her mental health disorder, by Essex County Council:
a. compelling Molly to choose between family members as part of her discharge planning and then as a consequence changing Molly’s status during her detention from homeless .
b. Lack of assessment for any s117 needs to facilitate discharge
c. Lack of appreciation of the impact of Molly’s autism diagnosis in a background of chronic suicide risk on decision-making and Molly’s potential to understand the decisions being made.
” Source location Molly Ann Sergeant · 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 Operate weekly multi-agency oversight meetings for autistic and learning-disabled young people in Tier 4 inpatient beds and coordinate safe discharge responsibilities.
Verbatim wording from the response “There are now weekly partnership meetings (from April 2022) at Senior Management level which specifically look at autistic young people and those with learning disabilities in Tier 4 (inpatient) beds. This meeting is chaired by the Director for Commissioning and Policy, Essex County Council and has representation from the Learning Disability / Autism Health Equalities Team ( including Commissioners and Case Managers), the Assistant Director of the Provider Collaborative ( Mental Health), Regional NHS England representation , ECC’s Head of Permanency and Placements, ECC’s Director from Children and Families, the Head of Individual Placements ( Health) and the Matron for the local Tier 4 beds.” Source location Response from Essex County Council
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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 Maintain the pan-Essex Section 117 protocol setting out multi-agency care planning processes, including accommodation responsibilities.
Verbatim wording from the response “There is a pan-Essex SET Section 117 Protocol which was published in April 2022. This highlights the primary purposes of Section 117 and is intended to articulate a clear process by which multi-agency care planning in the context of Section 117 should be undertaken. It makes clear reference to the provision of accommodation issues within the Section 117 arrangements. It is currently a 26-page document.” Source location Response from Essex County Council
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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 The acknowledged shortcomings were not causation or contributory factors in Molly’s death.
Verbatim wording from the response “It is not our view that these shortcomings, which we have fully acknowledged and have taken significant steps to ensure do not happen again, were causation factors or contributory factors which led to Molly’s very sad death.” Source location Response from Essex County Council
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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 Molly was not made to choose between family members during discharge planning; independent supported living was the only feasible alternative.
Verbatim wording from the response “It is not our view that Molly was made to choose between family members as part of her discharge planning; the only other feasible alternative for Molly would have been independent supported living accommodation, and no professional working with Molly thought this would be an appropriate option.” Source location Response from Essex County Council
Open published response
25 Nov 2021 Marshall Metcalfe and Jane Ireland · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure of social care to remain involved throughout mental health admissions View source
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
Marshall Metcalfe and Jane Ireland · 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
Marshall Metcalfe was transferred to hospital after sustaining catastrophic injuries on 7 May 2020, where his death was verified. Jane Ireland was found deceased at home on 7 June 2020, after the death of her seventeen-year-old son; the report records toxic effects, fatty liver disease and bronchopneumonia in relation to her death, while her intent could not be established. The principal concern was the lack of Children’s Social Care involvement in Marshall’s discharge planning and the potential future risk arising when social care cases are closed during mental health admissions and require re-referral before discharge.
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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 of social care to remain involved throughout mental health admissions
Wider context from the report “The court heard that when Marshall was in the mental health facility during what was his 2nd admission, a decision was made to discharge him from children’s social care. He had been supported as a Child in Need (under section 17, Children Act 1989) for 28 months, and this continued for a large part of that admission until 14/10/19. In September 2019, a decision had been taken by Children’s Social Care to cease their involvement as no role could be identified for a statutory social worker at that time. Any home leave had been suspended indefinitely, and there were no definite plans for Marshall to be discharged. However, a request was made that in the event the decision about home leave were to change, or if discharge was to be considered likely for Marshall, then Children’s Social Care would again have a role and a re-referral should be made.
In fact, Marshall was discharged on 06/01/20, there being no evidence before the court that such a re-referral had in fact been received by Children’s Social Care by then and it follows there had been no social worker input into Marshall’s discharge planning .
At the inquest, the court received evidence [from Marshall’s Responsible Clinician, Consultant Child & Adolescent Psychiatrist, Dr ████████] that in his experience when patients are admitted to the facility Children’s Social Care will close their case for the patient, and that when the patient is later ready for discharge a re-referral becomes necessary . He also reminded the court that throughout a patient’s admission, consideration is being given to discharge in line with the recommendation of NHS England that all admissions should be kept as short as possible and the expectation that there should be discussion about discharge at every Care Programme Approach (CPA) meeting.
Another witness, ████████, a former Inpatient Social Worker at the facility with 25 years of experience as an Approved Mental Health Professional, told the court that in his view when such a re-referral does become necessary it is like “starting from scratch” and causes immense problems during Trusting therapeutic relationships with young people. He felt that there should be continual input from social care during the patient’s admission , and that in the event that there has been no social worker input into a patient’s discharge this raises the risk for that person once they leave the facility.
I also instructed Dr ████████, a Consultant Child and Adolescent Psychiatrist, to provide an independent expert opinion on the care provided to Marshall. In her evidence she shared the concerns of Dr ████████ and ████████ and described this as “a wider issue” that was not confined to this case.
The issue that I raise is as follows: I share ████████ concern, echoed by Dr ████████, and ideally social care not closing their case, but remaining involved throughout a patient’s admission would be helpful . It may be that they would play a minor role, if any, whilst the patient remains in hospital until discharge is felt to be a genuine prospect, but once their input does become necessary they would be more able to respond quickly and to actively participate in discharge planning without the need to wait for the re-referral process to be carried out , thereby ensuring that the effectiveness of role played by social care in discharge planning is not compromised.
In Marshall’s case, I found that there was no evidence that shortcomings in relation to discharge had materially contributed to his death, but I feel that this issue does pose a risk of deaths in the future, and that it is my duty to write this report.
” Source location Marshall Metcalfe and Jane Ireland · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.