Recurring concern

Failure to investigate concerning presentations beyond initial appearance and self-report

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First reported 28 Apr 2015•Latest report 30 Mar 2026

Definition

What this concern includes

Includes failures by staff responsible for safety assessment or care to investigate further when a person’s presentation, behaviour, withdrawal, history or reported account should prompt additional enquiry, collateral information gathering or assessment; include the anchor, over-reliance on a prisoner's presentation in ACCT work, and failure to recognise withdrawal as a significant risk.

Not included

Excludes failures belonging to a separately named assessment, observation or risk-management system when that system provides the more specific supported parent boundary.
Excludes generic professional-curiosity, communication or training concerns where no failure to investigate a concerning presentation or risk beyond initial appearance or self-report is identified.
Excludes failures limited to the quality of treatment, escalation or follow-up after a sufficiently thorough assessment has been completed.
Excludes ordinary reliance on a patient's account or presentation where no concerning feature, change or risk required further investigation.

Reports: 19
Individual concerns: 20
Date range: 2015–2026
Stated actions: 37

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.

Cornwall Council2

Cygnet Health Care Limited2

Department of Health and Social Care2

Ministry of Justice2

NHS Cornwall and the Isles of Scilly Integrated Care Board2

Bolton Cares1

British Sub-Aqua Club1

Cambridgeshire and Peterborough NHS Foundation Trust1

Cornwall Partnership NHS Foundation Trust1

Derby City Council1

Derbyshire Constabulary1

Derbyshire Healthcare NHS Foundation Trust1

General Medical Council1

Glen Parva Young Offender Institution1

Greater Manchester Mental Health NHS Foundation Trust1

Concerns and responses across reports

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

27 Sep2021
Manchester City
Concerns raised1
1. Failure to enquire with professional curiosity about suicidal thoughts and plans
This report raised 9 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
  Introduce a structured HBTT note format prompting documentation of visit purpose, presentation, and risk to self and others.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Train HBTT staff in contact requirements and documentation, supported by senior colleagues to embed the process.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
3. Action
  Update clinical risk policy and mandatory training to include professional curiosity, with refresher attendance at least every three years.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Records indicate that HBTT staff explored risk and made care plans, although documentation did not always reflect discussions with the patient.
  Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concern
AI-generated summary

Antony Declan Schofield · 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

Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.

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 enquire with professional curiosity about suicidal thoughts and plans
Wider context from the report
“1. a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care. b. The transfer and communication process from inpatient care to the HBTT appeared inadequate. b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated. c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it. d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this. e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile. f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”
Source location
Antony Declan Schofield · 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
Introduce a structured HBTT note format prompting documentation of visit purpose, presentation, and risk to self and others.

Verbatim wording from the response
“Following the Trust’s review into Mr Schofield’s death it was acknowledged that the documentation was not always in keeping with Trust Record Keeping Policy in respect of the notes being recorded in the clinical record and that they did not always reflect the discussions that were occurring with the patient and so had the potential to impact on communication and decision making within the team. The HBTT SOP has been updated and states that clinical risk and management are reviewed at each contact with the service user and changes responded to where necessary and escalated to the MDT if necessary. Since the review, in addition to the daily MDT meetings, HBTT have introduced a structured note format to prompt staff to review and record the purpose of the HBTT visit, how the patient was presenting and specific prompts in respect of assessing risk to self and others.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 4 · response
Published 5 October 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 HBTT staff in contact requirements and documentation, supported by senior colleagues to embed the process.

Verbatim wording from the response
“All staff have undergone training in respect of what they should be addressing in an HBTT contact and how this should be recorded and have received support from senior colleagues to embed the process. Since the introduction of the structured note the Team Manager has put into place a process whereby senior undertaking supervision select notes to review prior to the staff members supervision, as per Trust Supervision Policy. There is also a quarterly audit planned to be undertaken across the team in respect of record keeping providing assurance that this structured note is being adhered to and record keeping is in line with Trust policy. The Trust Clinical risk policy and training has been updated to reflect the use of professional curiosity, this training is mandatory and all staff should attend the training every three years as a minimum.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 4 · response
Published 5 October 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
Update clinical risk policy and mandatory training to include professional curiosity, with refresher attendance at least every three years.

Verbatim wording from the response
“All staff have undergone training in respect of what they should be addressing in an HBTT contact and how this should be recorded and have received support from senior colleagues to embed the process. Since the introduction of the structured note the Team Manager has put into place a process whereby senior undertaking supervision select notes to review prior to the staff members supervision, as per Trust Supervision Policy. There is also a quarterly audit planned to be undertaken across the team in respect of record keeping providing assurance that this structured note is being adhered to and record keeping is in line with Trust policy. The Trust Clinical risk policy and training has been updated to reflect the use of professional curiosity, this training is mandatory and all staff should attend the training every three years as a minimum.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 4 · response
Published 5 October 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
Records indicate that HBTT staff explored risk and made care plans, although documentation did not always reflect discussions with the patient.

Verbatim wording from the response
“The clinical records show that HBTT staff did review Mr Schofield prior to his discharge from Safire ward including risks to self and on 20 August 2019 when the records identify risk was explored and a plan of care that included Mr Schofield being given numbers for the Crisis Line, Sanctuary and Crisis Point. During the assessment by the Clinical Psychologist on 26 August 2019 issues in respect of ████████ thoughts were explored including risk during which Mr Schofield indicated he was able to keep himself safe and denied any thoughts to ████████ himself in any way and a plan arising from that assessment was made accordingly.”

Source location
2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Page 4 · response
Published 5 October 2021
Open published response
12 Dec2019
Norfolk
Concerns raised1
1. Failure to exercise professional curiosity and consider GP information
This report raised 6 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

Peter Frosdick · 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

Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.

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 exercise professional curiosity and consider GP information
Wider context from the report
“(3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol. ”
Source location
Peter Frosdick · Prevention of Future Deaths report
Page 1 · concerns
Open source report
29 Jul2019
Manchester City
Concerns raised1
1. Failure to account for partial disclosure of symptomology and history
This report raised 7 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.
Respondent positions 1
1. Position
  The actions taken regarding partial disclosure were considered reasonable and proportionate, so no further action was identified.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustNo action considered necessary
AI-generated summary

Alistair Patrick McDonald · 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

Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.

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 account for partial disclosure of symptomology and history
Wider context from the report
“1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted 2. The lack of a specific plan for referrals to other services which proved unsuccessful 3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist. 4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates 5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress 6. Recognising that some patients will only make partial disclosure of their true symptomology and history. 7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this 8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this. ”
Source location
Alistair Patrick McDonald · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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 actions taken regarding partial disclosure were considered reasonable and proportionate, so no further action was identified.

Verbatim wording from the response
“As previously stated the staff working within the CAMHS SPA are experienced mental health practitioners from a wide range of professional backgrounds, with extensive support and supervision arrangements in place. It is not unusual for patients to not fully disclose the extent of their symptomology. Clinicians are skilled in assessing patients holistically, through a range of mechanisms.”

Source location
2019-0257-Worcestershire-Health-and-Care-NHS-Trust
Page 3 · response
Published 6 September 2019
Open published response
12 Jun2019
Sunderland
Concerns raised1
1. Over-reliance on offender self-reporting and ineffective challenge of accounts
This report raised 8 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
  Roll out the national Supervision and Line Management Framework across National Probation Service divisions, including required supervision meetings, practice observations and recording of challenged decisions.
  Stated by HM Prison and Probation ServiceStated in progress
AI-generated summary

Miss Nguyen Ngoc Quyen · 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

Miss Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.

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
Over-reliance on offender self-reporting and ineffective challenge of accounts
Wider context from the report
“There was an over reliance on self-reporting by the offenders. The evidence exposed a system for the protection of the public, which was at times dysfunctional, contributed to by human factors. Evidence heard during the hearings demonstrated that there was a disconnect between the reality on the ground and, in particular, ████████’s accounts to his Probation Officer. Although inevitably he would minimise his actions, there was little or no evidence that he was challenged effectively. ”
Source location
Miss Nguyen Ngoc Quyen · 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
Roll out the national Supervision and Line Management Framework across National Probation Service divisions, including required supervision meetings, practice observations and recording of challenged decisions.

Verbatim wording from the response
“To better support front line probation staff in the effectiveness of their supervision of offenders a new national Supervision and Line Management Framework has been developed and is being rolled out across the NPS Divisions during 2019. This work forms part of the National Probation Service 2020 Change Programme and has been developed using ideas and evidence from the Skills for Effective Engagement Development and Supervision Programme (SEEDS). This Framework is designed to ensure a consistent and appropriate level of management oversight through practice supervision sessions and observation of practice. Through observation of practice senior probation officers will be able to see whether staff are being sufficiently challenging and adopting a properly investigative approach in their face to face supervision of the offender.”

Source location
2019-0194-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 15 August 2019
Open published response
1 Apr2019
Avon
Concerns raised1
1. Failure to recognise and mitigate bias when assessing possible intoxication
This report raised 2 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 4
1. Action
  Develop a tool guiding staff to exclude brain injury safely in intoxicated patients, including examination findings and a step-by-step head examination.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progress
2. Action
  Establish a pathway for senior review and further investigation when intoxicated patients do not recover within the expected timeframe after significant head injury is excluded.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated completed
3. Action
  Create a training tool addressing confirmation bias and challenging diagnoses when patients fail to follow the expected clinical course.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated completed
1. Action
  Use the confirmation-bias training tool in every ED junior doctor teaching programme and reiterate it in department handovers.
  Stated by Royal United Hospitals Bath NHS Foundation TrustStated planned
AI-generated summary

Alexander Frederick Richard GREEN · 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

Alexander Green died at Southmead Hospital on 3 October 2017 after falling while out socialising and subsequently being found in the road. He was initially treated as intoxicated, and his head injury was not diagnosed until he suffered a respiratory collapse; the report identifies concerns about ineffective handover and communication, failure to apply head-injury guidance, and assumptions that intoxication explained his condition.

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 recognise and mitigate bias when assessing possible intoxication
Wider context from the report
“3. There was an assumption by everyone managing Alex that he was intoxicated when in fact he had a significant head injury; SWAST I am told have developed training in relation to bias (and intoxication is included in that). ”
Source location
Alexander Frederick Richard GREEN · 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
Develop a tool guiding staff to exclude brain injury safely in intoxicated patients, including examination findings and a step-by-step head examination.

Verbatim wording from the response
“We are developing a tool that will assist and guide staff in safely excluding a brain injury in those patients who are believed to be intoxicated, that will strike the right balance between CT scanning those patients who need a scan and avoiding scanning those patients where a CT scan is only likely to cause potentially avoidable harm through exposure to radiation. It is envisaged that this tool will set out specific findings on an examination that might indicate a brain injury as opposed to intoxication, including a detailed step by step guide on how to carry out a thorough physical examination of a patient’s head.”

Source location
2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019
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
Establish a pathway for senior review and further investigation when intoxicated patients do not recover within the expected timeframe after significant head injury is excluded.

Verbatim wording from the response
“For those patients in whom a significant head injury has been excluded and are diagnosed as being intoxicated, the Trust has developed a pathway to ensure that patients who fail to recover within the anticipated timeframe are reviewed by a senior doctor. This is to consider the possibility of an alternative diagnosis such as injury or illness not detected on initial assessment and to allow appropriate further investigations to be completed.”

Source location
2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019
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
Create a training tool addressing confirmation bias and challenging diagnoses when patients fail to follow the expected clinical course.

Verbatim wording from the response
“Working with the South West Ambulance Service, a training tool has been created which includes “Confirmation Bias” and the need to challenge the working diagnosis in any patient who fails to follow the anticipated clinical course. This will be utilised in every ED junior doctor teaching programme and reiterated in department handovers.”

Source location
2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019
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
Use the confirmation-bias training tool in every ED junior doctor teaching programme and reiterate it in department handovers.

Verbatim wording from the response
“Working with the South West Ambulance Service, a training tool has been created which includes “Confirmation Bias” and the need to challenge the working diagnosis in any patient who fails to follow the anticipated clinical course. This will be utilised in every ED junior doctor teaching programme and reiterated in department handovers.”

Source location
2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019
Open published response
22 Mar2019
Norfolk
Concerns raised1
1. Failure to exercise professional curiosity in high-risk discharge decisions
This report raised 5 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

Brian Robert HAVARD · Prevention of Future Deaths report

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

Report summary

Brian Robert Havard attended the Emergency Department with chest pain and vomiting, was discharged with a diagnosis of musculoskeletal pain, then collapsed in the car and died while being taken back to hospital. The concerns included failure to review ambulance records, inadequate senior review arrangements, and poor record keeping.

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 exercise professional curiosity in high-risk discharge decisions
Wider context from the report
“1. The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew. He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG. He evinced no professional curiosity about a patient needing three doses of morphine and being considered for discharge. The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records. He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes. He did not give a convincing explanation for not reviewing the patient. ”
Source location
Brian Robert HAVARD · Prevention of Future Deaths report
Page 1 · concerns
Open source report
5 Nov2018
London Inner South
Concerns raised1
1. Failure to inquire into psychiatric history when presentation warrants further inquiry
This report raised 5 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

Name not published · 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

The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.

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 inquire into psychiatric history when presentation warrants further inquiry
Wider context from the report
“3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP. 4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose. 5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full. 6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance. 7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017. 8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing. 9. I accepted ████████ opinion on the various issues set out above. 10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when. ”
Source location
Name not published · Prevention of Future Deaths report
Page 1 · concerns
Open source report
8 Sep2015
East Riding and Kingston Upon-Hull
Concerns raised1
1. Inappropriate reliance by non-health-care staff on actual presentation and the subject’s own views without further investigation
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.

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

CRAIG CHAPPELL · 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

Craig Chappell was found hanging in his cell at HMP Humber Everthorpe Site on 8 August 2014 after experiencing depression, bereavement, pain, alcohol use and prescription drug use. The principal concerns were inadequate communication of family concerns, insufficient guidance for supporting potential abuse victims, and inappropriate reliance by non-healthcare staff on his presentation and views without further investigation.

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
Inappropriate reliance by non-health-care staff on actual presentation and the subject’s own views without further investigation
Wider context from the report
“(3) There was on occasions some inappropriate reliance by non health care staff on the subject’s actual presentation and the subject’s own views without investigating this further. ”
Source location
CRAIG CHAPPELL · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Apr2015
Leicester City and South Leicestershire
Concerns raised2
1. Over-reliance on prisoners’ accounts instead of previous recorded risk factors
2. Over-reliance on others to make further enquiries about statements of depression and self-harm
This report raised 2 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 4
1. Action
  Implement a robust clinical-information process with documented responsibilities, follow-up, escalation and senior risk-system scrutiny for obtaining prisoners’ clinical notes.
  Stated by Leicestershire Partnership NHS TrustStated completed
2. Action
  Implement the Safer Prisons recording procedure and train reception and healthcare staff to document risk information and decisions in O-Nomis and SystmOne.
  Stated by Glen Parva Young Offender InstitutionStated completed
3. Action
  Remind staff to open an ACCT whenever information indicates suicide or self-harm risk, even when the prisoner does not appear at risk.
  Stated by Glen Parva Young Offender InstitutionStated completed
1. Action
  Remind case managers to consider comprehensive dynamic and static risk information during individual case reviews.
  Stated by Glen Parva Young Offender InstitutionStated completed
AI-generated summary

Greg Revell · 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

Greg Revell was found hanging in his cell at HM YOI Glen Parva, and resuscitation was unsuccessful. The concerns included that a previous ligature self-harm attempt did not lead to an ACCT, uncertainty among prison officers about when to open an ACCT, insufficient consideration of recorded risk factors, and weaknesses in capturing healthcare information and obtaining a GP summary.

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
Over-reliance on prisoners’ accounts instead of previous recorded risk factors
Wider context from the report
“4. There was over reliance upon what the Prison Officers were told by Greg, and insufficient emphasis on previous recorded risk factors in documentation available to them. ”
Source location
Greg Revell · 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
Over-reliance on others to make further enquiries about statements of depression and self-harm
Wider context from the report
“5. There was a culture of over-reliance on “others” being responsible for enquiring further into statements regarding depression and self harm made by Greg, rather than any focus on individual responsibility. ”
Source location
Greg Revell · 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 a robust clinical-information process with documented responsibilities, follow-up, escalation and senior risk-system scrutiny for obtaining prisoners’ clinical notes.

Verbatim wording from the response
“We now have a robust system in regard how clinical information is sought and there is a flow chart (Attachment 1) identifying team member's responsibilities to ensure consistency and follow up if required. This flowchart details the responsibility of each discipline within the team to ensure that there is a robust mechanism in place to ensure that Prisoners Clinical Notes are requested and followed up.”

Source location
2015-0165-Response-by-Leicestershire-Partnership-NHS-Trust
Page 1 · response
Published 28 April 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
Implement the Safer Prisons recording procedure and train reception and healthcare staff to document risk information and decisions in O-Nomis and SystmOne.

Verbatim wording from the response
“A new Safer Prisons strategy was launched in October 2014. This includes a new procedure for recording decisions made in response to the risk information on the self-harm warning form. The new procedure has been disseminated through training and briefings with reception and health care staff, who have been informed that they must refer to all relevant information about newly arrived prisoners, including the Person Escort Record, and make an entry on O-Nomis to record what they have observed and decided. Healthcare staff have also been reminded to record this information on SystmOne (the electronic medical records system).”

Source location
2015-0165-Response-by-NOMS
Page 1 · response
Published 28 April 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
Remind staff to open an ACCT whenever information indicates suicide or self-harm risk, even when the prisoner does not appear at risk.

Verbatim wording from the response
“All staff have been reminded of the local policy which states that an ACCT must be opened whenever information is received to indicate that a prisoner is at risk, even if the prisoner himself does not present as being at risk. Case managers have also been reminded to take account of all the relevant information and to have regard to the dynamic and static risk factors for the individual when carrying out case reviews, and not simply to rely on their assessment of the prisoner’s presentation. This ensures that the level of risk is assessed on the basis of comprehensive information.”

Source location
2015-0165-Response-by-NOMS
Page 2 · response
Published 28 April 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
Remind case managers to consider comprehensive dynamic and static risk information during individual case reviews.

Verbatim wording from the response
“All staff have been reminded of the local policy which states that an ACCT must be opened whenever information is received to indicate that a prisoner is at risk, even if the prisoner himself does not present as being at risk. Case managers have also been reminded to take account of all the relevant information and to have regard to the dynamic and static risk factors for the individual when carrying out case reviews, and not simply to rely on their assessment of the prisoner’s presentation. This ensures that the level of risk is assessed on the basis of comprehensive information.”

Source location
2015-0165-Response-by-NOMS
Page 2 · response
Published 28 April 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to enquire with professional curiosity about suicidal thoughts and plans

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

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

Concerns raised1

Failure to exercise professional curiosity and consider GP information

Concerns raised1

Failure to account for partial disclosure of symptomology and history

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

Concerns raised1

Over-reliance on offender self-reporting and ineffective challenge of accounts

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

Concerns raised1

Failure to recognise and mitigate bias when assessing possible intoxication

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.4

Concerns raised1

Failure to exercise professional curiosity in high-risk discharge decisions

Concerns raised1

Failure to inquire into psychiatric history when presentation warrants further inquiry

Concerns raised1

Inappropriate reliance by non-health-care staff on actual presentation and the subject’s own views without further investigation

Concerns raised2

Over-reliance on prisoners’ accounts instead of previous recorded risk factors

Over-reliance on others to make further enquiries about statements of depression and self-harm

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.4

Actions described in response 3

Respondent positions 1

Respondent positions 1

Actions described in response 1

Actions described in response 4

Actions described in response 4