Recurring concern

Failure to recognise physical illness in mental health patients

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First reported 30 Apr 2014•Latest report 12 Aug 2024

Definition

What this concern includes

Includes failures within mental health or related acute-care processes to recognise, assess or respond to physical illness in patients whose behaviour, presentation or symptoms may be incorrectly attributed to their mental health condition; include deficiencies in staff recognition of physical-illness signs when directly connected to this concern.

Not included

  • Excludes generic mental-health assessment or treatment failures where physical illness recognition is not the identified unsafe condition.
  • Excludes failures to recognise physical deterioration in patients without a mental-health-care context unless the assertion explicitly supports the same physical-illness recognition concern.
  • Excludes generic staff training, staffing or communication deficiencies that are not directly tied to recognising physical illness in mental health patients.
  • Excludes downstream treatment, referral or escalation failures where physical illness was reliably recognised and assessed.
Reports
6

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Nottinghamshire Healthcare NHS Foundation Trust3
NHS England2
East London NHS Foundation Trust1
HM Prison and Probation Service1
Leeds Teaching Hospitals NHS Trust1
Nottingham Prison1

Concerns and responses across reports

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

  1. Inner North London

    AI-generated summary

    Nimo OSMAN · 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

    Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

    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 consider physical illness as an explanation for patients’ behaviour

    Wider context from the report

    “I heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). I was taken through the detailed ‘Action Plan’ that was devised as a result of the various ‘service delivery problems’ (SDP), ‘care delivery problems’ (CDP), and ‘additional lessons learned’ (ALL) that were identified as a result of the SI Report. Not all of the SDPs, CDPs or ALLs are of such seriousness that I consider that they create a risk of future deaths unless action is taken. However, some of them do, in my opinion, reach that threshold. While the evidence of Nurse A and the accompanying Action Plan did provide prima facie reassurance that action has been taken, the evidence of Nurse B (who, as previously stated is relatively senior and experienced) has significantly undermined what I heard from Nurse A. The undermining of that evidence and reassurance from Nurse A, leads me to conclude that there is, at the very least, a realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist. For this reason, I consider that further reassurance is required in relation to the following matters of concern: (a) CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients. (b) CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients. ”

    Source location

    Nimo OSMAN · Prevention of Future Deaths report
    Page 4 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Disseminate to nursing staff that emergency services may be called without senior permission and physical health may contribute to behaviour.

    Verbatim wording from the response

    “6. This matter was also brought up with all the Lead Nurses at the Trust shortly after the inquest to ensure that the message that ‘permission from senior staff is NOT required to call emergency services’ was disseminated to all nursing staff. As a reminder, this was followed up at the Lead Nurses meeting on 28 August 2024.”

    Source location

    Response from East London Foundation Trust
    Page 3 · response
    Published 13 August 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver mandatory physical-health training for Tower Hamlets inpatient nursing staff and social therapists, including recognition of physical causes of concerning behaviour.

    Verbatim wording from the response

    “8. It is important that all staff are aware of the impact that physical health as well as mental health can have on a service user’s behaviour. As outlined in the BLN’s oral evidence, to ensure this information is embedded, all Tower Hamlets in-patient nursing staff and social therapists undertake a mandatory two-day physical health training course. It includes content on service users presenting as unwell and whether this may be related to their mental or physical health. This course started on 03 May 2023 and is delivered regularly. Further training courses will take place on:”

    Source location

    Response from East London Foundation Trust
    Page 3 · response
    Published 13 August 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce simulations addressing whether clinical concerns are physical-health or mental-health related.

    Verbatim wording from the response

    “9. Additionally, Tower Hamlets clinical staff already engage in once weekly emergency scenarios that include when it is appropriate to call 999. By30 November 2025 simulations will take place which include considerations whether something is a physical health verse mental health concern.”

    Source location

    Response from East London Foundation Trust
    Page 4 · response
    Published 13 August 2024

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Tammy Mary Louise WATKINS · 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

    Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.

    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 deteriorating patients

    Wider context from the report

    “1. Poor Quality Acute Physical Healthcare in the mental health setting Tammy’s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention. Her death comes after repeated concerns have been raised about the quality of the Trust’s physical healthcare service in secure settings since 2018 (when Angus Bowie died from sepsis due to a perforation), in 2019 (when Christopher Howard Smith died from a pulmonary embolus), in 2020 (when Alexander Braund died from a chest infection) and in 2021 (when Michelle Louise Whitehead died from Hyponatraemic Encephalopathy). At each of those inquests, the Trust committed to improving the quality of physical healthcare across all secure settings and yet the same poor quality has prevailed in Tammy’s care. These are examples of preventable deaths and the similarity in themes across them is exceptionally worrying. Action needs to be taken at the most senior level to effect meaningful change to the quality of physical healthcare across all secure settings at which the Trust provides services, recognising this class of patients as exceptionally vulnerable to deterioration as they are unable, either through mental health challenges and/or incarceration, to access healthcare services of their own volition. ”

    Source location

    Tammy Mary Louise WATKINS · 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

    Scope physical healthcare models across inpatient services and roll the work out across all services.

    Verbatim wording from the response

    “1. Poor Quality Acute Physical Healthcare in the Mental Health Setting The Trust recognises that Physical Healthcare is a key quality priority to improve the care to patients and reduce the risk of harm. The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated training needs and structure of who provides what care across the inpatient services to mitigate future harm associated with the deteriorating patient.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 1 · response
    Published 19 January 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver NEWS2 training to all frontline clinical staff required to undertake the assessment.

    Verbatim wording from the response

    “NEWS 2 training has been delivered to all frontline clinical staff who would be required to undertake this assessment and supports the policy requirements.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 19 January 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide clinical supervision through senior Quality Matrons to support NEWS2 practice and continuous learning.

    Verbatim wording from the response

    “In addition to this, at a glance posters are within each of the inpatient wards alongside lanyard attachments to support easy to access guidance when undertaking a NEWS2 assessment. A full audit process around NEWS2 is now in place and is monitored and responded to within normal governance frameworks with current compliance at 98%. Rampton hospital have ensured that senior nursing staff have increased visibility and presence in patient facing areas, to provide’ in action’ learning, role modelling and opportunity to provide direct feedback to colleagues. Clinical supervision is also recognised as a key aid to supporting and developing practice by sharing feedback and providing one to one clinical input to improve practice and aid a culture of learning.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 19 January 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce scenario-based NEWS2 examples during clinical supervision to assess staff competency around escalation.

    Verbatim wording from the response

    “Having senior Quality Matrons deliver and provide clinical supervision further strengthens this approach and encourages a culture of continuous learning and improvement. Quality Matrons will use clinical supervision to introduce scenario-based examples of patients who require escalation to assess staff members competency around NEWS2.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 19 January 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Undertake a further training needs analysis to identify enhancements to frontline knowledge and clinical skills.

    Verbatim wording from the response

    “A further training needs analysis is currently being undertaken to understand if this can be enhanced to support and improve front line knowledge and clinical skills. HM Coroner will be updated as this moves forward.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 19 January 2024

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Michelle Louise WHITEHEAD · 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

    Michelle Louise Whitehead died on 7 May 2021 while an inpatient, after acute hyponatraemia caused by psychogenic polydipsia. The report identified failures to follow the Rapid Tranquilisation policy, including inadequate monitoring of consciousness and delays in responding to her deterioration, and raised concerns about staff training, policy clarity, monitoring guidance, and the detection and management of psychogenic polydipsia.

    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 guidance on detection and management of psychogenic polydipsia

    Wider context from the report

    “4. Psychogenic Polydipsia – there appears to be no guidance, either locally or nationally, on the management of this condition, despite the research literature demonstrating that 50% of reported cases of over-hydration appear to be linked to psychosis. The Mental Health Commission for Scotland issued a report on the final day of Michelle’s inquest, related to the death of another mental health patient, Mr D, making recommendations for all NHS bodies to ensure staff have information to detect and manage acute psychical health scenarios including polydipsia and water intoxication. The Trust should take urgent action to ensure their staff are able to detect and manage this rare but potentially fatal condition. ”

    Source location

    Michelle Louise WHITEHEAD · 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

    Include psychogenic polydipsia and overhydration symptoms, risks and escalation in Trustwide physical healthcare training.

    Verbatim wording from the response

    “Immediate actions The Trust have included a teaching session within the ‘Trustwide 2-day Physical healthcare Training’ for mental health staff on the symptoms, risk, and necessary escalation of overhydration including Psychogenic Polydipsia as a core training section. The sharing of the learning from Michelle’s inquest has and will continue to be shared to raise awareness in relation to Psychogenic polydipsia within staff groups. This includes within the Trustwide Dietitians Professional Advisory Group, physical healthcare staff and medical teams though continued professional development sessions, journal clubs, and Trustwide Physical Healthcare meetings as well as inclusion within the Trustwide Learning the Lessons Safety Bulletin circulated to all staff.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 6 · response
    Published 18 October 2023

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Share psychogenic polydipsia learning with relevant staff groups through professional development, journal clubs, meetings and the Learning the Lessons bulletin.

    Verbatim wording from the response

    “Immediate actions The Trust have included a teaching session within the ‘Trustwide 2-day Physical healthcare Training’ for mental health staff on the symptoms, risk, and necessary escalation of overhydration including Psychogenic Polydipsia as a core training section. The sharing of the learning from Michelle’s inquest has and will continue to be shared to raise awareness in relation to Psychogenic polydipsia within staff groups. This includes within the Trustwide Dietitians Professional Advisory Group, physical healthcare staff and medical teams though continued professional development sessions, journal clubs, and Trustwide Physical Healthcare meetings as well as inclusion within the Trustwide Learning the Lessons Safety Bulletin circulated to all staff.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 6 · response
    Published 18 October 2023

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise the Trustwide Nutrition and Hydration Policy to cover psychogenic polydipsia risks, signs, symptoms and escalation.

    Verbatim wording from the response

    “Short term actions The Trustwide Nutrition and Hydration Policy is currently under review – psychogenic polydipsia will be specifically referenced within the overhydration section, including risks, signs and symptoms and escalation – this review has commenced and planned to be finalised by the end of February 2024.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 7 · response
    Published 18 October 2023

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review identified secure-setting polydipsia cases to assess management and inform learning and guideline development.

    Verbatim wording from the response

    “Following the learning from the inquest, the Trust have identified a number of cases of polydipsia within our secure settings. A clinical case review of these patients will be undertaken to ensure the management of these patients is appropriate and support any learning and guideline development. The case reviews will be undertaken in December 2023, the learning from which will inform further actions necessary.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 7 · response
    Published 18 October 2023

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  4. London (West)

    AI-generated summary

    Alice Amaryllis Gibson-Watt (“Alice”) · 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 Gibson-Watt developed postpartum psychosis and, after receiving Haloperidol during seclusion in an acute mental health ward, suffered cardiac arrest and later died from hypoxic brain damage on 20 November 2012. The report raised concerns about inadequate monitoring and documentation of vital signs, missed opportunities for medical assessment and ECG, delayed recognition of the arrest, and delays in commencing CPR and using a defibrillator.

    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 follow NEWS/MEWS scoring processes for identifying acutely unwell patients

    Wider context from the report

    “This is: The identification of acutely physically unwell patients being nursed in an acute mental health setting, and thereon appropriate escalation of care In Alice’s case, even before there were signs that she was physically unwell, there was no regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health. No serial measurements of her observations meant that abnormalities could not be easily, or at all, identified once they occurred. In mental health units the threshold that prompts the use of regular vital sign observations appears to be high, and there maybe good reasons for that and clearly this is a patient-specific issue. However, identification of patients who are becoming acutely physically unwell does need more attention in general, with or without reconsidering how readily vital sign observations are ordered. Even when the NEWS (previously MEWS) system is in place - a process which is there to assist in the identification of patients who are becoming acutely unwell - it is not always followed. This is a recurring theme I see as a coroner. Having policies and procedures in place does not appear to be sufficient. I am aware that Nurse Consultants in Physical Healthcare are now working in acute mental health settings. That seems like a big step in the right direction. I am told there are very few Nurse Consultants in Physical Healthcare working in mental health settings currently (maybe as few as six). I was impressed with the Nurse Consultant who currently works for the West London Mental Health NHS Trust. I am aware that remote physiological monitoring of patients in acute mental health settings has been trialled and this may assist in the future. As with the NEWS scoring system, predisposes that staff will accurately use, interpret and act upon abnormal observations appropriately. From what I have seen with the use of MEWS/NEWS scoring, this will be the challenge. Nurse Consultants in Physical Healthcare would be able to assist. ”

    Source location

    Alice Amaryllis Gibson-Watt (“Alice”) · 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

    Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.

    Verbatim wording from the response

    “• In parallel, NHS England continues to support the ongoing inspection and regulation of mental health in-patient wards by the CQC. CQC require that all providers implement safe and effective systems for identifying and responding to the deteriorating patient including application and audit of compliance with the National Early Warning Score- NEWS.”

    Source location

    2017-0163-Response-by-NHS-England
    Page 2 · response
    Published 17 August 2017

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Shalan Blackwood · 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

    Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.

    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 healthcare staff to recognise urgent physical symptoms obscured by mental health issues

    Wider context from the report

    “5. That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues. ”

    Source location

    Shalan Blackwood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. West Yorkshire (East)

    AI-generated summary

    Mary WANYA · 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

    Mary Wanya died after falling through a hospital window on 1 November 2011 while in an acutely confused and agitated state. The window restrictor was defective, allowing the window to be fully opened. Concerns included delays in psychiatric assessment, the assessment and treatment of mental illness on the Medical Admissions Unit, her earlier diagnosis and discharge, and the inadequacy of the Trust’s investigation report.

    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 promptly rule out physical illness contributing to mental disturbance

    Wider context from the report

    “1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James’s University Hospital to assess Mary Wanya. In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment. (ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service. (iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay. (iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided. (v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill. The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness. ”

    Source location

    Mary WANYA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026