18 May 2026 Rebecca Jessie Mclellan (known as Becca) · Prevention of Future Deaths report Suffolk
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Concerns raised 3
Failure to identify a dedicated, named care co-ordinator for mental health patients during prolonged planned leave View source Lack of a documented system for highlighting and managing planned, prolonged key care co-ordinator absence View source Failure to ensure coverage of named key care co-ordinators’ roles and responsibilities during planned leave View source
Linked responses
Norfolk and Suffolk NHS Foundation Trust The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Norfolk and Suffolk NHS Foundation Trust
Implement and apply ratified guidance for managing planned prolonged Youth Team care-coordinator absence, including handover, patient review, reallocation decisions, notification and joint transition appointments.
View source
The Trust
Operate the Trust-wide E-Roster to identify staffing gaps, manage absences, arrange temporary cover and monitor team capacity.
View source
The Trust
Maintain an accessible Youth Team off-duty chart, updated for absences and changes, with daily huddles confirming staffing and cover requirements.
View source
The Trust
Conduct monthly Early Warning Trigger Score audits to identify staffing-capacity risks and support escalation for additional staffing support.
View source
The Trust
Conduct a monthly Associate Director of Nursing Check and Challenge review of the E-Roster to identify factors affecting team capacity and support forward planning.
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AI-generated summary
Rebecca Jessie Mclellan (known as Becca) · 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
Becca was found hanging in her flat on 20 November 2023 after police forced entry following concerns raised by a colleague; the postmortem concluded that her death was due to hanging, and the inquest concluded suicide. The report identified an ongoing risk arising from the lack of a dedicated, named care co-ordinator during prolonged planned leave, including a period of approximately nine weeks before Becca’s death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify a dedicated, named care co-ordinator for mental health patients during prolonged planned leave
Wider context from the report “There is no documented system that I consider adequately highlights and manages planned, prolonged key care co-ordinator absence in the Youth team, nor a formal, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered during periods of planned leave. There is no process to ensure a dedicated, named care co-ordinator is identified to the mental health patient to provide continuity of care during prolonged periods of planned leave .
I consider that the risk of a lack of a dedicated and identified care co-ordinator for a significant period during planned leave creates an ongoing risk of future deaths for people with significant mental health disorders, so consider this a matter for a PFD report.
” Source location Rebecca Jessie Mclellan (known as Becca) · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a documented system for highlighting and managing planned, prolonged key care co-ordinator absence
Wider context from the report “There is no documented system that I consider adequately highlights and manages planned, prolonged key care co-ordinator absence in the Youth team , nor a formal, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered during periods of planned leave. There is no process to ensure a dedicated, named care co-ordinator is identified to the mental health patient to provide continuity of care during prolonged periods of planned leave.
I consider that the risk of a lack of a dedicated and identified care co-ordinator for a significant period during planned leave creates an ongoing risk of future deaths for people with significant mental health disorders, so consider this a matter for a PFD report.
” Source location Rebecca Jessie Mclellan (known as Becca) · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure coverage of named key care co-ordinators’ roles and responsibilities during planned leave
Wider context from the report “There is no documented system that I consider adequately highlights and manages planned, prolonged key care co-ordinator absence in the Youth team, nor a formal, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered during periods of planned leave . There is no process to ensure a dedicated, named care co-ordinator is identified to the mental health patient to provide continuity of care during prolonged periods of planned leave.
I consider that the risk of a lack of a dedicated and identified care co-ordinator for a significant period during planned leave creates an ongoing risk of future deaths for people with significant mental health disorders, so consider this a matter for a PFD report.
” Source location Rebecca Jessie Mclellan (known as Becca) · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and apply ratified guidance for managing planned prolonged Youth Team care-coordinator absence, including handover, patient review, reallocation decisions, notification and joint transition appointments.
Verbatim wording from the response “As explained in the attached letter to you dated 13 May 2026 (enclosed), there are specific processes in place both for planned and unplanned leave. I note your concern set out in the prevention of future deaths report, specifically relates to the management of planned and prolonged absence of care-co-ordinators in the Youth Team however.” Source location Response from Norfolk and Suffolk NHS Foundation Trust (2)
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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 Operate the Trust-wide E-Roster to identify staffing gaps, manage absences, arrange temporary cover and monitor team capacity.
Verbatim wording from the response “1. E-roster: this is an electronic platform which holds all shifts across the Trust so that it is easy to see who is working and who is not at any given time to enable planning. Oversight of the E-Roster is undertaken by the Operational Manager and Community Team Manager identify gaps, manage staff absence, book additional temporary staff and provide an overview of how many hours a day each team has to manage capacity.” Source location Response from Norfolk and Suffolk 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 Maintain an accessible Youth Team off-duty chart, updated for absences and changes, with daily huddles confirming staffing and cover requirements.
Verbatim wording from the response “2. Team off duty chart: this is a chart of all staff within the team, noting who is on and off duty, on leave (of any type, planned or unplanned) at any given time. It also records who is responsible for covering the duty role (availability for urgent calls and referrals) on each day, and who is covering for staff that are off. This chart is held in the Youth Team Microsoft Teams channel to enable all staff who are working on and off site to access it quickly. The chart is created 2 months ahead of time and updated by the team administrator whenever there are reported absences or changes.” Source location Response from Norfolk and Suffolk 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 Conduct monthly Early Warning Trigger Score audits to identify staffing-capacity risks and support escalation for additional staffing support.
Verbatim wording from the response “4. Early Warning Trigger Score (EWTS) Audit: this is a monthly audit providing a structured approach to the early identification of quality risks within a clinical team. Upon completion of the audit, a Trigger Score is calculated. The Community Early Warning Trigger Tool has 25 indicators to categorise the team capacity including vacancies, sickness, complaints, leadership post filled, medic posts filled, and more. This supports managers to recognise the risk within their team and escalate as necessary for support with staffing. The EWTS is used in conjunction with Clinical Audit outcomes, financial oversight and key performance indicators, and is a tool used across the Trust.” Source location Response from Norfolk and Suffolk 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 Conduct a monthly Associate Director of Nursing Check and Challenge review of the E-Roster to identify factors affecting team capacity and support forward planning.
Verbatim wording from the response “5. Check and Challenge for the staff roster: this includes monthly review by Associate Director of Nursing for community of the E-roster in relation to anything that may impact on team capacity (for example staff vacancies, sickness, planned leave). This regular review began in April 2026, to ensure we are looking ahead as well as at the current capacity to enable planning of team capacity.” Source location Response from Norfolk and Suffolk 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 Existing rostering, absence-management and risk-monitoring systems are considered sufficient to address staffing vacancies and maintain continuity of care.
Verbatim wording from the response “As indicated in the Trust's legal team letter on 6 May 2026, the Trust were not aware that you had an ongoing concern in relation to the management of key staff vacancies and absent staff in the Youth team. As such we would be grateful if you would consider the information below, as the Trust considers there is a system in place that addresses the ongoing concerns you have.” Source location Response from Norfolk and Suffolk 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 Existing planned-absence processes and ratified guidance are considered sufficient to document and manage prolonged Youth Team care-coordinator leave.
Verbatim wording from the response “As explained in the attached letter to you dated 13 May 2026 (enclosed), there are specific processes in place both for planned and unplanned leave. I note your concern set out in the prevention of future deaths report, specifically relates to the management of planned and prolonged absence of care-co-ordinators in the Youth Team however.” Source location Response from Norfolk and Suffolk NHS Foundation Trust (2)
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11 Jan 2026 Mark Stuart VIDLER · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Lack of care co-ordinators View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mark Stuart VIDLER · 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
Mark Vidler had severe depression and was receiving mental health care from Kent and Medway Mental Health NHS Trust. After serious suicide attempts on 30 April and 7 May 2025, he was discharged from the Home Treatment Team and was not reviewed by an out-of-hours clinician on the night of 7 May after a Rapid Response Team referral was declined. He was found dead at home on 8 May 2025, and the inquest concluded that his suicide was contributed to by a failure in care. Concerns included shortcomings in patient-centred care, clinical oversight and referral processes, risk recognition, discharge decision-making, continuity of care, care coordination, and the implementation and recording of suicidality management.
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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 care co-ordinators
Wider context from the report “(6) I heard evidence that the Trust does not have care co-ordinators and the clinician felt that this could lead to similar situations arising in the future .
” Source location Mark Stuart VIDLER · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a named worker within the refined community model of care.
Verbatim wording from the response “6. I heard evidence that the Trust does not have care co-ordinators and the clinician felt that this could lead to similar situations arising in the future.
The Trust has and is undergoing transformation in line with the Community Mental Health Framework (CMHF) which includes a national directive to move away from care co-ordination. As part of our continuous improvement agenda and refinement of the community model of care the Trust has identified a number of service improvement which we will be making and which will include the introduction of a named worker.” Source location Response from Kent and Medway NHS Mental Health 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 Care coordinators will not be introduced because the national Community Mental Health Framework directs services to move away from care coordination.
Verbatim wording from the response “6. I heard evidence that the Trust does not have care co-ordinators and the clinician felt that this could lead to similar situations arising in the future.
The Trust has and is undergoing transformation in line with the Community Mental Health Framework (CMHF) which includes a national directive to move away from care co-ordination. As part of our continuous improvement agenda and refinement of the community model of care the Trust has identified a number of service improvement which we will be making and which will include the introduction of a named worker.” Source location Response from Kent and Medway NHS Mental Health Trust
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10 Apr 2025 Jonathan Mark George Hamer · Prevention of Future Deaths report West London
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Concerns raised 1
Lack of cover arrangements for care co-ordinator absence View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jonathan Mark George Hamer · 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
Jonathan Mark George Hamer, who had bipolar affective disorder and was receiving community mental health care, died by suicide on 24 April 2024 after going onto railway tracks in front of a train. Concerns included communication failures during care-coordinator absences, the lack of systems to redirect or action unanswered communications, and the failure to prioritise and regularly review his case.
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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 cover arrangements for care co-ordinator absence
Wider context from the report “2. The community mental health team actively encouraged communication by text messages and emails but had no system in place to intervene when the care co-ordinator was not at work and had left no “out of office” message . There was no system to return or redirect incoming calls or messages so these remained unread and unanswered. Those initiating the communication were unaware that the information was not being received or actioned by the Trust.
” Source location Jonathan Mark George Hamer · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Envoy messaging across all community teams, with monitored patient communication and absence-cover support.
Verbatim wording from the response “The Trust has procured a digital communication system, called Envoy which enhances communication and engagement with patients. Envoy enables centralised, monitored messaging across SMS from the Trust to patients regarding appointments and provides some ability for patients to provide a SMS through to Envoy around appointments.” Source location Response from South West London and St George’s Hospitals 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 Implement an Envoy operating procedure covering planned and unplanned staff leave, out-of-office messages and alternative contact arrangements.
Verbatim wording from the response “▪ A new Standard Operating Procedure (SOP) for using Envoy, including cover arrangements during periods of planned and unplanned leave.” Source location Response from South West London and St George’s Hospitals NHS Trust
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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 Revise case-list management when unplanned leave occurs to support continuity of care.
Verbatim wording from the response “▪ A revised process for case list management when unplanned leave occurs, to ensure continuity of care.” Source location Response from South West London and St George’s Hospitals NHS Trust
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11 Oct 2024 Oliver Davies · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Delays in initial mental-health care coordinator appointments due to workload pressures 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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AI-generated summary
Oliver Davies · 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
Oliver Davies died by suicide by hanging in his cell at HMP Hewell on 31 December 2022. The concerns included delayed and incomplete mental health assessment, failures to share relevant information about his self-harm and suicide risk, inadequate prioritisation and follow-up by the mental health care coordinator, and failures to keep him informed about healthcare and appointments.
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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 Delays in initial mental-health care coordinator appointments due to workload pressures
Wider context from the report “2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s assessment. An appointment was fixed for Oliver to meet the care coordinator for the first time on 14.12.22. Due to workload pressures, the care coordinator was unable to fulfil that appointment before he went on leave from 16-28.12.22. Shortly before he went on leave, the care coordinator conducted a “RAG rating” exercise to determine whether he should prioritise seeing Oliver, and determined that Oliver’s case merited the lowest priority RAG rating ( green ). When conducting that RAG rating exercise, the care coordinator did not take into account:
(a) The prison officer’s urgent TAG mental health referral of 30.11.22 ( above ); and
(b) A further TAG mental health referral made by a prison paramedic which cited “mild concerns” about deliberate and unintentional self-harm on Oliver’s part, the details of which had been entered onto Oliver’s SystmOne medical record.
In addition, the care coordinator did not raise in the mental health team’s daily forum.the fact that he was unlikely to have time to see Oliver before he went on leave.
Had the care coordinator taken into account the referrals at (a)-(b) above, and raised at the daily forum his difficulty in being able to see Oliver, it may well have been that Oliver’s case would have merited a more urgent response from the care coordinator or someone else in his stead.
Having heard evidence at the inquest from your Trust’s Clinical Director, ████████, I was not satisfied that the Trust has fully recognised the above shortcomings, and taken action to ensure that they are not repeated for other mental health patients in custody at HMP Hewell.
” Source location Oliver Davies · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed continuity-of-care arrangements for planned and unplanned staff absence, including guidance, multidisciplinary discussion and joint daily huddles.
Verbatim wording from the response “There is now also a process embedded within the service to ensure continuity of care during planned and unplanned staff absence. This is set out in the MPFT guidance called “Reallocation when staff are leaving and when absent for 2 weeks or more”. Patients of concern are also discussed within our multidisciplinary forums, both internally within our service, and at joint daily huddles that are now in place led by Practice Plus Group.” Source location Response from Midlands Partnership 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 Require daily meetings to identify absent care-coordinator patients, assign temporary responsibility, and document handovers and rationale in minutes and SystmOne, with induction and attendance requirements.
Verbatim wording from the response “A standing agenda item of “Provision of Care to Patients in the Absence of Care Coordinator” was added to the Daily Meeting standing agenda. This ensures continuous care for all patients, regardless of staff availability. When a patient concern is raised during these meetings and the assigned care coordinator is absent, the issue is thoroughly discussed among the present team members. A specific worker is then designated to address the concern and assume temporary responsibility for the patient's care. This handover of responsibility is formally documented in the meeting minutes and the patient’s SystmOne record along with rationale. New staff members are introduced to this process during their induction, with details available in the induction folder, and all team members are required to attend these daily meetings.” Source location Response from Midlands Partnership NHS Foundation Trust
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27 Sep 2024 Maria Patricia Kelly · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Delay in allocation of a replacement mental health care coordinator View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
North London NHS Foundation Trust
Strengthen staff re-allocation and handover using a standardised handover template and clear successor contact information.
View source
North London NHS Foundation Trust
Recruit to address team vacancies, including targeted recruitment activity and continuing recruitment to remaining posts.
View source
North London NHS Foundation Trust
Increase staffing capacity through experienced agency staff, permanent social workers, a Band 7 supervisory role and a nursing Team Manager.
View source
North London NHS Foundation Trust
Mobilise locality teams to collaborate with Integrated Community Teams and provide flexible staffing from February 2025.
View source
North London NHS Foundation Trust
Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.
View source
North London NHS Foundation Trust
Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.
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AI-generated summary
Maria Patricia Kelly · 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
Maria Patricia Kelly, who lived alone and was in poor health, was found deceased at home by police on 15 May 2024 after concerns were raised by neighbours and a housing officer. The report identifies prolonged lack of contact with primary care and mental health services, numerous failed encounters, and no welfare check until the neighbours’ concerns were raised; the inquest determined natural causes.
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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 Delay in allocation of a replacement mental health care coordinator
Wider context from the report “Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past.
She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024.
From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening.
Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023 . It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts.
Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024.
” Source location Maria Patricia Kelly · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen staff re-allocation and handover using a standardised handover template and clear successor contact information.
Verbatim wording from the response “1. Re-allocation and Handover Process
We have reviewed and strengthened our re-allocation and handover processes to ensure continuity of care during staff transitions. A new handover template is now in use, standardising the transfer of key information when a staff member leaves. This ensures that service users and carers are promptly informed of any changes and are provided with clear contact details for their new care coordinator.” Source location Response from North London 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 Recruit to address team vacancies, including targeted recruitment activity and continuing recruitment to remaining posts.
Verbatim wording from the response “2. Staffing Challenges and Recruitment
Between May and September 2023, there were a number of vacancies within the team (South Camden Rehabilitation and Recovery Team). This resulted in cases being added to the waiting list, impacting service continuity. The Trust has been actively recruiting to address this shortfall, including organising targeted recruitment events.” Source location Response from North London 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 Increase staffing capacity through experienced agency staff, permanent social workers, a Band 7 supervisory role and a nursing Team Manager.
Verbatim wording from the response “All substantive social work posts have now been recruited to. We have successfully recruited into three nursing vacancies and put long term experienced agency staff in place to address current shortfall. Additionally, we have introduced new roles, such as a Band 7 position to supervise Band 4 Assistant Practitioners, reducing the reliance on harder-to-recruit Band 6 nurse posts. Recruitment to these posts will continue.” Source location Response from North London 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 Mobilise locality teams to collaborate with Integrated Community Teams and provide flexible staffing from February 2025.
Verbatim wording from the response “Our new locality teams, set to be mobilised from February 2025, will work in collaboration with Integrated Community Teams to offer more flexible staffing options. This will enable us to manage resources more effectively during periods of reduced staffing, ensuring continued care for service users. We have also replaced two locum social workers with permanent social workers, ensuring greater stability in the team. A nursing Team Manager has been put in place to ensure effective nursing management and support.” Source location Response from North London 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 Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.
Verbatim wording from the response “The MaST tool will play a key role in improving caseload management and prioritisation. Staff training is currently underway, with sessions delivered throughout October to enable the implementation of MaST. A MaST Champion has been appointed to guide the team through the implementation process. Training will be completed by November 2024, after which MaST will enable real-time tracking and prioritisation of high-risk service users. This will ensure close monitoring of service users on the waiting list, and timely follow-up.” Source location Response from North London NHS Trust
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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 Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.
Verbatim wording from the response “We have reinforced our case tracking procedures using the RAG-rating system which identifies levels of risk (Red, Amber, Green). Weekly allocation meetings are held to ensure that high-risk cases are prioritised for follow-up. While we await MaST full implementation,” Source location Response from North London NHS Trust
Open published response
Concerns raised 1
Failure to appoint a care coordinator because of staff shortages 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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AI-generated summary
Nicolas Gerasimidis · 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
Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.
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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 appoint a care coordinator because of staff shortages
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff ;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Source location Nicolas Gerasimidis · 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 Grow the mental health workforce by an additional 27,000 staff to increase service capacity.
Verbatim wording from the response “You noted that Mr Gerasimidis was on a lengthy waiting-list to access psychological therapy at the time of his death with ensuing concerns that other patients may have to wait significant lengths of time for care. We recognise that the demand on NHS mental health services has risen significantly, and this means that some people may face waiting times that are much longer than we would like. That is why, through the NHS Long Term plan, the Government is providing record levels of investment and increasing the mental health workforce to expand and transform NHS mental health services in England.” Source location Response from DHSC
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25 Sep 2023 Robert Leigh · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to appoint interim Care Coordinator or Community Psychiatric Nurse cover View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Greater Manchester Mental Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Greater Manchester Mental Health NHS Foundation Trust
Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
View source
Greater Manchester Mental Health NHS Foundation Trust
Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
View source
Greater Manchester Mental Health NHS Foundation Trust
Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
View source
Greater Manchester Mental Health NHS Foundation Trust
Audit the absence-cover process after three months to verify that it is embedded and being followed.
View source See 1 more action
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AI-generated summary
Robert Leigh · 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
Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.
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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 appoint interim Care Coordinator or Community Psychiatric Nurse cover
Wider context from the report “1. During the Inquest evidence was heard that: -
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed.
ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences.
” Source location Robert Leigh · 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 a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
Verbatim wording from the response “Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is completed by the Care Coordinator prior to any planned absence, such as annual leave or a planned medical intervention. This ensures the Care Coordinator has considered any follow up for service users that is required during their period of absence and identifies who will carry out any planned interventions such as administration of depot medications, undertaking face to face visits, and making telephone contacts. If specific follow up is not required during the period of planned absence, the service user, and their families or carers will be provided with the contact details for the team, should they require additional support. The Team Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions required are undertaken by the team.” Source location Response from Greater Manchester Mental 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 Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
Verbatim wording from the response “For unplanned absences such as sickness, it is expected that the Care Coordinator, at the point of contacting the Team Manager or Senior Practitioner to advise of their absence, will provide a detailed handover of any work that is required to be covered.” Source location Response from Greater Manchester Mental 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 Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
Verbatim wording from the response “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.” Source location Response from Greater Manchester Mental 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 Audit the absence-cover process after three months to verify that it is embedded and being followed.
Verbatim wording from the response “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
17 Jul 2022 Rebecca Jayne Flint · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Reliance on individual Care Coordinator capacity for comprehensive mental-health information View source Unavailability of alternative Care Coordinator cover during staff absence 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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AI-generated summary
Rebecca Jayne Flint · 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
Rebecca Flint was under the care of the Trafford Community Mental Health Team and was found at home on 7 September 2020. The report raised concerns about inconsistent Care Coordinator roles between Trusts and limited Community Mental Health Team resources, including the absence of cover when a Care Coordinator was unavailable.
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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 Reliance on individual Care Coordinator capacity for comprehensive mental-health information
Wider context from the report “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust.
The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required.
I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator .
(1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role.
(2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role.
” Source location Rebecca Jayne Flint · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of alternative Care Coordinator cover during staff absence
Wider context from the report “From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust.
The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required.
I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator.
(1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role.
(2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role .
” Source location Rebecca Jayne Flint · 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 the Living Well model across all ten Greater Manchester localities, including multidisciplinary community mental-health teams.
Verbatim wording from the response “Across GM, we are continuing to implement a place-based approach to mental health care with all ten GM localities implementing the Living Well model. Living Well will increase access to care and support for people with serious mental illness and high levels of complexity who are seeking help and advice with their mental health. Access will be at a neighbourhood level within primary care networks with close connections to a local network of community groups and voluntary organisations. People will be able to access redesigned community mental health services and multidisciplinary teams including: mental health practitioners, social care staff, voluntary sector staff and peer workers.” Source location Response from Greater Manchester Integrated Care
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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 embed multidisciplinary key-worker roles to strengthen community mental-health care and reduce reliance on individual care coordinators.
Verbatim wording from the response “In line with the Long Term Plan and the Community Mental Health Framework for Adults and Older Adults, the CPA framework is being replaced nationally. As a result, the role of care coordinators will be replaced by the development of key workers with a clearer multidisciplinary team (MDT) approach to both assess and meet the needs of service users, to reduce the reliance on care co-ordinators and to increase resilience in systems of care, allowing all staff to make the best use of their skills and qualifications, and drawing on new roles including lived experience roles.” Source location Response from Greater Manchester Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for local mental health staffing, operations and specific Care Coordinator role requirements lies with the relevant NHS trust.
Verbatim wording from the response “Your report raises concerns about the Care Coordinator role within community mental health services, how this role may differ across trusts, the level of responsibility placed on Care Coordinators to ensure effective multi-disciplinary working, and the resourcing of the Care Coordinator role. The government is not able to comment on specific role requirements, or staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GMMH’s existing systems maintain oversight, contact and risk responses when care coordinators are absent, so additional cover arrangements are not identified as necessary.
Verbatim wording from the response “All CMHTs in the GMMH footprint have systems and processes in place to ensure that the service is able to maintain oversight of all individuals under the care of the team in the absence of a care coordinator during periods of leave or sickness.” Source location Response from Greater Manchester Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation PCFT’s existing duty systems, care plans, caseload oversight and risk-based reallocation provide support during planned or unplanned clinician absence.
Verbatim wording from the response “PCFT confirmed that when any of the trust’s clinicians are on a period of planned leave, patients are usually kept updated and advised of how to contact the service if needed, usually via a duty worker.” Source location Response from Greater Manchester Integrated Care
Open published response
12 Jul 2022 Louise Asha Allen · Prevention of Future Deaths report East London
View report summary
Concerns raised 2
Excessive caseloads for care co-ordinators View source Insufficient number of care co-ordinators for clinical need View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
North East London NHS Foundation Trust
Use non-recurrent funding to recruit additional staff for increased referral volume and patient acuity.
View source
North East London NHS Foundation Trust
Audit care-coordinator caseloads and conduct a further scheduled audit to monitor caseload numbers.
View source
North East London NHS Foundation Trust
Introduce the Management and Supervision Tool to support manageable caseloads, supervision and staff support.
View source
North East London NHS Foundation Trust
Recruit eight additional band 6 community psychiatric nurses to meet increased workload.
View source
North East London NHS Foundation Trust
Continue reviewing service needs and risks and placing additional staff to manage them.
View source
North East London NHS Foundation Trust
Recruit temporary staff to maintain continuity while permanent care-coordinator vacancies are filled.
View source
North East London NHS Foundation Trust
Prioritise mental-health vacancies and use off-framework agencies to retain locum support and consistency during short-term vacancies.
View source
North East London NHS Foundation Trust
Deliver a training and career-development programme enabling band 5 staff to progress into band 6 care-coordinator roles.
View source
North East London NHS Foundation Trust
Continue the mental-health transformation programme to enhance service delivery and develop the care model.
View source
North East London NHS Foundation Trust
Use rolling advertisements and international recruitment to recruit and retain staff, while pursuing a zero-nursing-vacancy objective.
View source
North East London NHS Foundation Trust
Review resource and staffing levels through Trust executive and North East London system-wide work.
View source See 8 more actions
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AI-generated summary
Louise Asha Allen · 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
Louise Asha Allen, who had bipolar disorder and emotionally unstable personality disorder, was discharged from hospital in December 2020 and was regarded as a very high risk to herself. Between February and June 2021, she did not receive necessary mental state assessments or sufficient support, and inaccurate clinical details contributed to unreliable risk assessments. On 12 June 2021, she placed herself in front of a train. The principal concerns related to inadequate care coordination, including insufficient continuity of care, excessive caseloads, staff turnover and insufficient numbers of care coordinators.
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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 Excessive caseloads for care co-ordinators
Wider context from the report “Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
” Source location Louise Asha Allen · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient number of care co-ordinators for clinical need
Wider context from the report “Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
” Source location Louise Asha Allen · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use non-recurrent funding to recruit additional staff for increased referral volume and patient acuity.
Verbatim wording from the response “NELFT has programmes in place to encourage staff to work in the organisation; the Trust has used non-recurrent funding to recruit additional staff to manage the real time increase of referrals and acuity of patients, following the pandemic. All new starters’ salaries are matched to their previous employment, so they do not lose out on their pay when they join NELFT. There is also a staff wellbeing service in place which is available to substantively and locum staff. In addition, the Trust is working to understand how staff can be supported through cost-of-living issues.” Source location Response from 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 Audit care-coordinator caseloads and conduct a further scheduled audit to monitor caseload numbers.
Verbatim wording from the response “A recent quality audit of staff caseloads carried out on 19 July 2022 showed a reduction in care coordinator caseload from 27-30 patients per care coordinator to 19-27 patients. There is a further audit planned on 19 August 2022 to review the caseload numbers per care coordinator” Source location Response from 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 Introduce the Management and Supervision Tool to support manageable caseloads, supervision and staff support.
Verbatim wording from the response “In the meantime, the Trust is introducing a Management and Supervision Tool (MaST) to support staff and their managers to ensure care coordinator caseloads are manageable and that appropriate supervision and support are in place; this is anticipated to be fully operational by December 2022.” Source location Response from NHS Foundation Trust
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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 Recruit eight additional band 6 community psychiatric nurses to meet increased workload.
Verbatim wording from the response “The community mental health transformation programme will provide a better skill mix that will reduce the pressure on the care coordinator role. 8 additional Band 6 Community Psychiatric Nurses are being recruited to meet increased workload.” Source location Response from 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 Continue reviewing service needs and risks and placing additional staff to manage them.
Verbatim wording from the response “The NELFT Waltham Forest leadership team continuously reviews the needs and risk of the service. Additional staff will continue to be placed in the service to manage the need and risk, efforts are made at Trust executive and North East London system wide level to review the resource and staffing levels deployed into the service.” Source location Response from NHS Foundation Trust
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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 Recruit temporary staff to maintain continuity while permanent care-coordinator vacancies are filled.
Verbatim wording from the response “The service continuously recruits temporary staff, through the Trust’s temporary staffing service until all positions are permanently recruited to.” Source location Response from NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise mental-health vacancies and use off-framework agencies to retain locum support and consistency during short-term vacancies.
Verbatim wording from the response “Temporary staffing has been advised to prioritise Mental Health posts and to use off-framework agencies to support retaining locum support, and consistency to manage short term vacancies.” Source location Response from NHS Foundation Trust
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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 Deliver a training and career-development programme enabling band 5 staff to progress into band 6 care-coordinator roles.
Verbatim wording from the response “A NELFT training programme has been developed for band 5 staff to help them develop the skills and competencies to take up the role of care coordinator at band 6 level. This will constitute an intensive and supportive career development programme designed to attract recently qualified staff who have the potential to progress rapidly and will also help with staff retention in the community recovery service.” Source location Response from NHS Foundation Trust
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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 Continue the mental-health transformation programme to enhance service delivery and develop the care model.
Verbatim wording from the response “The Trust is undertaking a programme of mental health transformation, which once fully implemented will enhance the service offered to patients. Peer support workers have been given additional roles, with a focus on enhanced training in order that they can share their lived experiences with patients they manage. The Trust is re-designing care coordinator posts to increase the support available for professional development. Furthermore, the Trust continues to use Trust-wide work streams to have a zero-nursing vacancy; to use rolling advertisements to recruit and retain staff; utilise international recruitment to attract more professionals to work at NELFT; and to consider the use of financial incentives to attract and retain staff.” Source location Response from NHS Foundation Trust
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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 Use rolling advertisements and international recruitment to recruit and retain staff, while pursuing a zero-nursing-vacancy objective.
Verbatim wording from the response “The Trust is undertaking a programme of mental health transformation, which once fully implemented will enhance the service offered to patients. Peer support workers have been given additional roles, with a focus on enhanced training in order that they can share their lived experiences with patients they manage. The Trust is re-designing care coordinator posts to increase the support available for professional development. Furthermore, the Trust continues to use Trust-wide work streams to have a zero-nursing vacancy; to use rolling advertisements to recruit and retain staff; utilise international recruitment to attract more professionals to work at NELFT; and to consider the use of financial incentives to attract and retain staff.” Source location Response from NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review resource and staffing levels through Trust executive and North East London system-wide work.
Verbatim wording from the response “The NELFT Waltham Forest leadership team continuously reviews the needs and risk of the service. Additional staff will continue to be placed in the service to manage the need and risk, efforts are made at Trust executive and North East London system wide level to review the resource and staffing levels deployed into the service.” Source location Response from NHS Foundation Trust
Open published response
8 Feb 2022 John David Moore · Prevention of Future Deaths report Essex
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Concerns raised 1
Insufficient attention to the clinical significance of patient disengagement from services 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
John David Moore · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of concerns.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient attention to the clinical significance of patient disengagement from services
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients ;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” Source location John David Moore · 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 the MaST caseload-management tool through agreed pilot sites to support risk, disengagement, caseload, and record-keeping oversight.
Verbatim wording from the response “The Trust is in the process of gathering data in order to implement the Management and Supervision Tool (MaST) caseload management tool, which will help the care coordinator to” Source location Response from Essex Partnership 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 Review and update the Disengagement Guideline to add Purple RAG identification and regular multidisciplinary discussion of disengaging patients.
Verbatim wording from the response “(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;” Source location Response from Essex Partnership NHS Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.