Recurring concern

Unreliable care-coordinator provision and cover for mental health service users

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First reported 16 Jan 2015•Latest report 18 May 2026

Definition

What this concern includes

Includes appointment, replacement, caseload, absence-cover and required-task failures concerning a designated mental-health Care Co-ordinator or equivalent role.

Not included

Generic multi-agency coordination without a designated care-coordinator role
Referral-pathway failures
Clinical treatment failures unrelated to care-coordinator provision or performance

Reports: 21
Individual concerns: 26
Date range: 2015–2026
Stated actions: 54

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

NHS England3

Norfolk and Suffolk NHS Foundation Trust3

Kent and Medway Mental Health NHS Trust2

Sussex Partnership NHS Foundation Trust2

Brunswick Ward at Lindridge1

Derbyshire County Council1

Derbyshire Healthcare NHS Foundation Trust1

East London NHS Foundation Trust1

Essex Partnership University NHS Foundation Trust1

Gray's Inn Road Medical Practice1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Herefordshire and Worcestershire Health and Care NHS Trust1

Lincolnshire County Council1

Concerns and responses across reports

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

17 Jul2021
Stoke-on-Trent and North Staffordshire
Concerns raised2
1. Failure to ensure allocation of an appropriate Care Co-Ordinator
2. Failure of Care Co-Ordinators to carry out required care coordination tasks
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Implement procedures ensuring Care Coordinator allocation complies with the Trust Care Management Policy.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated completed
2. Action
  Train Care Coordinators on required allocation, assessment, care planning and review standards.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated completed
3. Action
  Monitor Care Coordinator performance and compliance through weekly reports and management performance reviews.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated completed
1. Action
  Allocate Care Coordinators according to assessed clinical need and record the allocation in the electronic patient record.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated completed
2. Action
  Undertake process mapping to identify consistent Care Coordinator allocation practice and document existing developments.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated planned
3. Action
  Develop and ratify standard operating procedures covering referral, triage and Care Coordinator allocation.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated planned
4. Action
  Review the Care Management Policy to clarify required standards and support Community Mental Health Framework implementation.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated in progress
5. Action
  Provide additional training clarifying Care Coordinator role expectations.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated completed
6. Action
  Develop and roll out a training package defining staff roles and responsibilities alongside the revised policy.
  Stated by North Staffordshire Combined Healthcare NHS TrustStated planned
Respondent positions 2
1. Position
  Care coordinators are allocated according to assessed clinical need, rather than routinely or merely to satisfy the electronic record system.
  Stated by North Staffordshire Combined Healthcare NHS TrustDisputes the concern
1. Position
  The reported five-day allocation, patient contact and care-plan requirements are not stated in the current Trust Care Management Policy.
  Stated by North Staffordshire Combined Healthcare NHS TrustDisputes the concern
AI-generated summary

Rebecca Claire Pykett · 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 Claire Pykett, who had a history of mental health difficulties including PTSD, was found deceased at home on 25 February 2019 after intentionally hanging herself using a tie fashioned into a ligature. The concerns identified included the absence of a system to ensure that a Care Co-Ordinator was allocated, and that the expected care co-ordinator role, including timely patient contact and care planning, was not carried out in her case. The report also describes routine allocation of consultant psychiatrists as a “box ticking” exercise to satisfy the patient record system.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure allocation of an appropriate Care Co-Ordinator
Wider context from the report
“(1) During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive. (2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role. What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator. (3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pyketts’ case. (4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator. The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the Care Co-Ordinator was being dealt with as a “box ticking” exercise, to satisfy the record keeping system. (5) Once allocated, in this way, it ws clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator. ”
Source location
Rebecca Claire Pykett · Prevention of Future Deaths report
Page 2 · concerns
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 of Care Co-Ordinators to carry out required care coordination tasks
Wider context from the report
“(1) During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive. (2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role. What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator. (3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pyketts’ case. (4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator. The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the Care Co-Ordinator was being dealt with as a “box ticking” exercise, to satisfy the record keeping system. (5) Once allocated, in this way, it ws clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator. ”
Source location
Rebecca Claire Pykett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement procedures ensuring Care Coordinator allocation complies with the Trust Care Management Policy.

Verbatim wording from the response
“(1) The revised Trust Care Management Policy provides details on the role of the Care Co-ordinator being responsible for co-ordinating patient care. On receipt of this notice, we reviewed our practice to provide assurance that there were no gaps in Care Co-ordinator provision. I can confirm that procedures have been implemented since the incident to ensure that the Trust policy is adhered to. This is monitored and reviewed on a monthly basis at internal performance meetings.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 2 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Train Care Coordinators on required allocation, assessment, care planning and review standards.

Verbatim wording from the response
“(3) The revised Trust Care Management Policy provides expectation in terms of the timeframes required for allocation, assessment, care planning and review (see appendix 1). Training for all Care Co-ordinators has taken place to ensure that staff are aware of the full requirements of their role. Assurance that this process is followed is monitored through the weekly review of compliance reports, overseen by Team Leaders. This data is further reviewed at Service Manager and Associate Director Level with accountability being provided through Monthly Performance Review sessions with the Executive team.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 2 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor Care Coordinator performance and compliance through weekly reports and management performance reviews.

Verbatim wording from the response
“(2) Since this incident, we have reviewed our processes and procedures and have clarified the expectations associated with the role of Care Co-ordinator through additional training. Weekly reports are reviewed by the Team Leaders to monitor the performance of all staff allocated as Care Co-ordinators. Individual staff members are provided with information pertaining to their individual case load with the expectation that they will address any outstanding issues, the following week’s report provide assurance that this has been done.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 2 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Allocate Care Coordinators according to assessed clinical need and record the allocation in the electronic patient record.

Verbatim wording from the response
“(4) Care Co-ordinators are allocated according to the patients assessed clinical needs. For many patients, it is appropriate that a consultant psychiatrist fulfils the role of a Care Co-ordinator should the patient remain on standard care. This is recorded in the Electronic Patient Record (EPR) using the Care Programme Approach (CPA) determination tool or the individual’s core assessment. The allocated Care Co-ordinator may change should the individual needs of the patient change. Therefore, the Trust can confirm that this is not treated as a “box ticking” exercise. This process is aligned to the Trust Policy.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 2 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Undertake process mapping to identify consistent Care Coordinator allocation practice and document existing developments.

Verbatim wording from the response
“During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive. | 1 | A process mapping exercise will be undertaken to ensure that there is consistency in practice and no gaps in the process. This will capture the developments in practice that have been implemented but for which we currently have no documented procedure. | ████████ | October 4th 2021 | NA”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 4 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and ratify standard operating procedures covering referral, triage and Care Coordinator allocation.

Verbatim wording from the response
“During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive. | 2 | Standing Operating procedures will be developed which will encompass the referral, triage and care coordinator allocation processes as identified through the process mapping exercise. | ████████ | October 31st 2021 | SOP will be ratified at directorate and trust level. The reports referred to in action 3 will provide assurance that standards are being met.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 4 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the Care Management Policy to clarify required standards and support Community Mental Health Framework implementation.

Verbatim wording from the response
“As the transformation process progresses there is a need to review our current policy in light of the above requirements whilst maintaining the standards that are embedded within the current CPA framework.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 3 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide additional training clarifying Care Coordinator role expectations.

Verbatim wording from the response
“(2) Since this incident, we have reviewed our processes and procedures and have clarified the expectations associated with the role of Care Co-ordinator through additional training. Weekly reports are reviewed by the Team Leaders to monitor the performance of all staff allocated as Care Co-ordinators. Individual staff members are provided with information pertaining to their individual case load with the expectation that they will address any outstanding issues, the following week’s report provide assurance that this has been done.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 2 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and roll out a training package defining staff roles and responsibilities alongside the revised policy.

Verbatim wording from the response
“Action: In conjunction with the policy review a training package will be developed which outlines the roles and responsibilities of staff. This to be rolled out to support the implementation of the revised policy.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 5 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Care coordinators are allocated according to assessed clinical need, rather than routinely or merely to satisfy the electronic record system.

Verbatim wording from the response
“(4) Care Co-ordinators are allocated according to the patients assessed clinical needs. For many patients, it is appropriate that a consultant psychiatrist fulfils the role of a Care Co-ordinator should the patient remain on standard care. This is recorded in the Electronic Patient Record (EPR) using the Care Programme Approach (CPA) determination tool or the individual’s core assessment. The allocated Care Co-ordinator may change should the individual needs of the patient change. Therefore, the Trust can confirm that this is not treated as a “box ticking” exercise. This process is aligned to the Trust Policy.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 2 · response
Published 9 August 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The reported five-day allocation, patient contact and care-plan requirements are not stated in the current Trust Care Management Policy.

Verbatim wording from the response
“Action 4 Finding: An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pykett’s case.”

Source location
2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Page 5 · response
Published 9 August 2021
Open published response
17 Mar2021
Inner North London
Concerns raised1
1. Lack of a care co-ordinator or community mental health team member in overall charge of care
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Benjamin Rajinder O’HARA · 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

Benjamin Rajinder O’Hara died after jumping from the fourth floor balcony of his home on 2 November 2020, following repeated contacts with mental health services and episodes of suicidal thoughts and psychosis. Concerns included that professionals did not ask permission to contact his family, an outdated hospital-admission alert was not reviewed, a review was not a formal mental health assessment, and he had no care co-ordinator or other community mental health team member overseeing his care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a care co-ordinator or community mental health team member in overall charge of care
Wider context from the report
“4. Mr O’Hara did not have a care co-ordinator or other member of the community mental health team in overall charge of his care. This person would have been in a position to note his deterioration and the increasing frequency of his contacts with the mental health services in 2020. ”
Source location
Benjamin Rajinder O’HARA · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Aug2020
Lincolnshire
Concerns raised1
1. Failure to appoint a care coordinator to monitor care under an appropriate care plan
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review the Care Programme Approach to ensure appropriate care-coordinator allocation, including for all patients with dual diagnosis.
  Stated by Lincolnshire Partnership NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Care coordination and assertive outreach concerns relate to services commissioned by the CCG and provided by Lincolnshire Partnership NHS Trust.
  Stated by Lincolnshire County CouncilRedirects responsibility
AI-generated summary

Toby Peter Edward Nieland · 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

Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to appoint a care coordinator to monitor care under an appropriate care plan
Wider context from the report
“4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan; ”
Source location
Toby Peter Edward Nieland · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the Care Programme Approach to ensure appropriate care-coordinator allocation, including for all patients with dual diagnosis.

Verbatim wording from the response
“v. To review the Care Programme Approach to ensure the right decisions are made about allocating care coordinators to patients and also to ensure that all patients with a dual diagnosis are allocated a care coordinator. Lead: The Trust Quality and Safety Lead – by 31 April 2021.”

Source location
2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 8 · response
Published 26 October 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Care coordination and assertive outreach concerns relate to services commissioned by the CCG and provided by Lincolnshire Partnership NHS Trust.

Verbatim wording from the response
“This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust. If Care coordination is in place it is imperative that the substance misuse services work in partnership with the mental health team to provide a comprehensive individually tailored care package.”

Source location
2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Page 3 · response
Published 26 October 2020
Open published response
9 Feb2018
Worcestershire
Concerns raised1
1. Failure of the care co-ordinator to see the patient
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Gail Ann Bannister · 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

Gail Ann Bannister had a long history of fluctuating mental health and experienced deterioration after her father’s illness and death. She died by suicide, with the medical cause of death recorded as hanging. Concerns included that her care coordinator did not see her after appointment, undermining the intended care arrangement, and that it took several hours for her husband to reach the care team during a crisis because of a known single-phone-line problem.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of the care co-ordinator to see the patient
Wider context from the report
“(1) The rationale behind discharging Mrs Bannister from the HTT to CARS was that she had been seeing too many different people. It was felt that by concentrating her care in the hands of the community consultant psychiatrist and a Care Co-ordinator, who would arrange the psycho-social services she would benefit from, this would improve her treatment. The fact that the care co-ordinator did not see her frustrated and undermined this approach. ”
Source location
Gail Ann Bannister · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 Sep2017
Inner North London
Concerns raised1
1. Failure to maintain care-coordinator meetings
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Janet WILLIAMS · 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

Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain care-coordinator meetings
Wider context from the report
“5. Between 11 October 2016 when Ms Williams was discharged by the home treatment team, to 21 February 2017 when she saw her general practitioner and her care co-ordinator together, Ms Williams’ care co-ordinator did not meet with her. ”
Source location
Janet WILLIAMS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Apr2017
Central and South East Kent
Concerns raised1
1. Failure to maintain manageable case-loads for Care Co-ordinators
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Jamie Fairclough · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Jamie Fairclough, who had complex difficulties and was receiving mental health services, was discharged from the Community Mental Health Team in November 2016 after unsuccessful attempts to engage with him. He was found dead at home on 9 December 2016 from chemical asphyxiation, and the inquest recorded a conclusion of suicide. Concerns included the discharge decision being contrary to the agreed care plan and made without meaningful consultation, and high caseloads for care co-ordinators.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain manageable case-loads for Care Co-ordinators
Wider context from the report
“In the course of the inquest, I heard evidence that the Care Co-ordinator identified in this case had an allocated case-load of around 75 – 80 service-users. Whilst I heard evidence that the Trust has plans in place to reduce the case-loads of Care co-ordinators by August 2017, case-loads currently remain at similar levels to those which pertained when Mr Fairclough was under the care of the CMHT, notwithstanding the findings of the Trust’s own investigation into this case. Indeed, an operational manager who also gave evidence at the inquest confirmed that her current case-load was 86, in addition to managerial responsibilities. ”
Source location
Mr Jamie Fairclough · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Feb2017
Brighton and Hove
Concerns raised1
1. Failure to appoint a care coordinator under the Care Programme Approach
This report raised 25 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Derek LEE · 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

Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to appoint a care coordinator under the Care Programme Approach
Wider context from the report
“(14) A Care Co-ordinator was not appointed, even though at the Inquest, it was confirmed that Mr Lee was being looked after on the Care Programme Approach (CPA). The appointment of a Care Co-ordinator is at the heart of this framework and it was clear that such an appointment could have been helpful if not crucial in Mr Lee’s case. ”
Source location
Derek LEE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Oct2015
Derby and Derbyshire
Concerns raised1
1. Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review and clarify the respective roles and responsibilities of mental health and social care workers at the Service Manager Interface Meeting.
  Stated by Derbyshire County Council and Derbyshire Healthcare NHS Foundation TrustStated planned
2. Action
  Update the Care Programme Approach Policy with clearer guidance on the relationship between CPA and Self-Directed Support.
  Stated by Derbyshire County Council and Derbyshire Healthcare NHS Foundation TrustStated planned
3. Action
  Cascade the Service Manager Interface Meeting's role-clarification outcomes to staff through line-management supervision.
  Stated by Derbyshire County Council and Derbyshire Healthcare NHS Foundation TrustStated planned
AI-generated summary

Louise Sharon Henry · 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 Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities
Wider context from the report
“1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co-ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co-ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity. ”
Source location
Louise Sharon Henry · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and clarify the respective roles and responsibilities of mental health and social care workers at the Service Manager Interface Meeting.

Verbatim wording from the response
“In order to address these concerns the Council and DCHFT intend to review:-”

Source location
2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Page 3 · response
Published 16 January 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update the Care Programme Approach Policy with clearer guidance on the relationship between CPA and Self-Directed Support.

Verbatim wording from the response
“2. Preliminary discussions have already taken place between Health and Social Care senior managers about the interface between CPA and SDS. Both organisations are clear that the two policies are intended to be complementary. It is acknowledged there may be cases where the individual is subject to CPA but where a social worker is the lead practitioner. The Council is clear that in following SDS, this will also fulfil the requirements of CPA. A plan involving senior managers from both organisations has been agreed to update the DCHFT Care Programme Approach Policy to provide clearer updated guidance upon this issue.”

Source location
2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Page 4 · response
Published 16 January 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Cascade the Service Manager Interface Meeting's role-clarification outcomes to staff through line-management supervision.

Verbatim wording from the response
“4. The Council has also established that there is still some work to be done in terms of education for health and social care workers on the expectations of each service pathway. The outcomes of the Service Manager Interface Meeting described above will be cascaded down to staff via line management supervision.”

Source location
2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Page 4 · response
Published 16 January 2015
Open published response
6 Aug2015
Norfolk
Concerns raised1
1. Failure to maintain clinical review and care coordination during prolonged staff absence
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Maintain guidance requiring clinical teams to contact service users and assess alternative arrangements during planned or unplanned staff absence.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
2. Action
  Direct clinical services to consider consistent compliance with staff-absence cover guidance, with feedback and further direction through the Quality Governance Committee.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
AI-generated summary

THOMAS THEO CHARLES THURLING · 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

Thomas Theo Charles Thurling, who had increasing depression, anxiety and suicidal ideation, was found dead at home on 28 October 2014 after he did not respond to visits. The inquest concluded that he took his own life, with medical cause of death recorded as asphyxiation. Concerns included medication changes not being adequately monitored, a prolonged absence of his Care Co-ordinator without alternative cover or review, and staff shortages.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain clinical review and care coordination during prolonged staff absence
Wider context from the report
“(2) Care Co-ordinator was on planned and unplanned leave from end September 2014 until the time of Mr Thurling's death. Her Line Managers were aware of this continuous absence. Prior to this there had been a general deterioration in Mr Thurling's mental health noted, he was clearly expressing suicidal ideation, He had attended A & E with thoughts of suicide and he had bought a penknife and cut his neck. His mother had contacted MH Team expressing her concerns on at least 2 occasions. The Care Co-Ordinator had recommended a Nurse be appointed. Mr Thurling had a known fear of being abandoned by his family and MH Services. Mr Thurling was not reviewed during this period. No alternative Care Co-Ordinator was appointed. ”
Source location
THOMAS THEO CHARLES THURLING · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain guidance requiring clinical teams to contact service users and assess alternative arrangements during planned or unplanned staff absence.

Verbatim wording from the response
“In respect of cover for planned and unplanned absence of staff, the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts. Clinical services have been directed to consider how they are consistently meeting this guidance with feedback and further direction via the Trust’s Quality Governance Committee.”

Source location
2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 6 August 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Direct clinical services to consider consistent compliance with staff-absence cover guidance, with feedback and further direction through the Quality Governance Committee.

Verbatim wording from the response
“In respect of cover for planned and unplanned absence of staff, the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts. Clinical services have been directed to consider how they are consistently meeting this guidance with feedback and further direction via the Trust’s Quality Governance Committee.”

Source location
2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 6 August 2015
Open published response
24 Jun2015
Brighton and Hove
Concerns raised1
1. Failure to replace and appoint a Care Co-ordinator
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement multidisciplinary caseload reviews, prioritising reviews when care coordinators leave and documenting decisions in electronic records.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
2. Action
  Allocate service users a lead practitioner or care coordinator according to clinical need.
  Stated by Sussex Partnership NHS Foundation TrustStated planned
AI-generated summary

Alice MEAD · 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

Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to replace and appoint a Care Co-ordinator
Wider context from the report
“(1) When her Care Co-ordinator left the Trust she was not replaced so Alice was left without one of the corner stones of the Care Programme Approach. Although later a Multi-Disciplinary Team meeting decided she should have a Care Co-ordinator, no action was taken to appoint one. ”
Source location
Alice MEAD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement multidisciplinary caseload reviews, prioritising reviews when care coordinators leave and documenting decisions in electronic records.

Verbatim wording from the response
“As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time Ms Mead’s case was reviewed, and the decision was made not to allocate a new care coordinator. ████████ General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where all care coordinators’ caseloads are reviewed with a Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is leaving and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system. Service users will be allocated a lead practitioner or care coordinator, based on their clinical need and are not reliant on calling the duty team.”

Source location
2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
Page 1 · response
Published 24 June 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Allocate service users a lead practitioner or care coordinator according to clinical need.

Verbatim wording from the response
“As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time Ms Mead’s case was reviewed, and the decision was made not to allocate a new care coordinator. ████████ General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where all care coordinators’ caseloads are reviewed with a Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is leaving and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system. Service users will be allocated a lead practitioner or care coordinator, based on their clinical need and are not reliant on calling the duty team.”

Source location
2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
Page 1 · response
Published 24 June 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to ensure allocation of an appropriate Care Co-Ordinator

Failure of Care Co-Ordinators to carry out required care coordination tasks

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of a care co-ordinator or community mental health team member in overall charge of care

Concerns raised1

Failure to appoint a care coordinator to monitor care under an appropriate care plan

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of the care co-ordinator to see the patient

Concerns raised1

Failure to maintain care-coordinator meetings

Concerns raised1

Failure to maintain manageable case-loads for Care Co-ordinators

Concerns raised1

Failure to appoint a care coordinator under the Care Programme Approach

Concerns raised1

Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Actions described in response 9

Respondent positions 2

Actions described in response 1

Respondent positions 1

Actions described in response 3