1 Mar 2023 Annabel Jean Findlay · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Failure to arrange follow-up appointments before discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Priory Group
Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
View source
Priory Group
Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.
View source
Priory Group
Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
View source
×
AI-generated summary
Annabel Jean Findlay · 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
Annabel Jean Findlay had a history of psychiatric illness and depression and discharged herself from Priory Hospital, Roehampton on 27 August 2021 after a change in antidepressant medication. The concerns identified were that next of kin or emergency contacts were not contacted, no follow-up appointment was booked before discharge, and no attempt was made to contact her until 6 September 2021; the inquest recorded a short-form conclusion of suicide and fatal pressure to the neck as the medical cause of death.
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 arrange follow-up appointments before discharge
Wider context from the report “Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021.
A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release.
B. No follow up appointment was booked prior to Ms. Findlay’s discharge .
C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge).
” Source location Annabel Jean Findlay · Prevention of Future Deaths report
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 Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
Verbatim wording from the response “This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.” Source location Response from Priory
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 Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.
Verbatim wording from the response “This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.” Source location Response from Priory
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 Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
Verbatim wording from the response “This matter had already been identified as an improvement action as part of the internal learning review which took place before the inquest. The improvement action has been taken forward by the hospital management team and consequently, two reminders have been circulated to all relevant medical colleagues at PHR to ensure that any required outpatient follow-up appointments are booked prior to a patient’s discharge. A third reminder will be shared during April 2023. We have continued our monthly audit of this arrangement and will continue to do so until we reach 100% compliance for three consecutive months. This requirement was also reiterated to staff during the Consultants meeting and Clinical Governance meeting referenced above.” Source location Response from Priory
Open published response
24 Oct 2022 Terri Ann Malone · Prevention of Future Deaths report Herefordshire
View report summary
Concerns raised 1
Discharge of service users after missed appointments without adequate follow-up View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Herefordshire and Worcestershire Health and Care NHS Trust
×
AI-generated summary
Terri Ann Malone · 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
Terri Ann Malone was drinking excessively and probably died from ketoacidosis as a consequence of excessive alcohol consumption. The concerns included treatment planning without direct contact by an experienced practitioner, discharge after a missed appointment and unanswered voicemail despite a lengthy wait, and discharge without establishing her current circumstances or other agencies’ involvement.
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 Discharge of service users after missed appointments without adequate follow-up
Wider context from the report “(2) Notwithstanding the above a service user is discharged from the service if they fail to attend an appointment and do not respond to a voicemail by the end of the day . This despite the patient being required to wait several months for an appointment .
” Source location Terri Ann Malone · Prevention of Future Deaths report
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 Discharging a patient after a missed appointment was considered sufficient under IAPT policy, with contact attempts and re-referral information provided.
Verbatim wording from the response “Finally, I recognise your concern that the patient was discharged when she did not attend her treatment appointment, however, I also note that our actions were in line with the service policy and national model for IAPT services. In order for IAPT therapy to be successful the patient must be motivated and ready to engage, unfortunately, at times whilst patients initially indicate that they wish to access IAPT support, this is not always sustained. The patient received details of the treatment appointment by letter and a SMS prior to the appointment time. Following her missing the appointment she received a call to her mobile phone asking her to contact the service if she wished to continue. She was also sent a detailed letter discharging her from the service, which provided information on how she could refer back into the service if she wished to do so.” Source location Response from Herefordshire and Worcestershire Health and Care
Open published response
18 May 2022 Matthew John Evans · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to offer face-to-face consultation or arrange follow-up View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Matthew John Evans · 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
Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.
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 offer face-to-face consultation or arrange follow-up
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Source location Matthew John Evans · Prevention of Future Deaths report
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 Offer face-to-face appointments to patients presenting with new mental-health issues.
Verbatim wording from the response “24. ████████ and the Practice have agreed that patients presenting with new mental health issues, are to be offered face-to-face appointments. This policy was introduced with immediate effect from the date of the SEA.” Source location Response from Farnham Practice
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 patient follow-up timescales and require GPs to book follow-up appointments rather than asking patients to call.
Verbatim wording from the response “25. The Practice will review patient follow up timescale and GP should book them in rather than ask patient to call in as they may not be able to get through.” Source location Response from Farnham Practice
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 Remote consultations during the COVID-19 pandemic were consistent with NHS England guidance, although face-to-face appointments were required from May 2021.
Verbatim wording from the response “c) The GP did not offer a face-to-face consultation” Source location Response from NHS England
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 circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Verbatim wording from the response “We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where” Source location Response from Care Quality Commisson
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 No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Verbatim wording from the response “We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where” Source location Response from Care Quality Commisson
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 Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Verbatim wording from the response “As you may be aware, CQC can only take regulatory action against a registered manager or a registered provider, but not when failings of an individual have been identified.” Source location Response from Care Quality Commisson
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 concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
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 No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
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 Face-to-face consultation was not offered because pandemic advice was to avoid face-to-face appointments where possible.
Verbatim wording from the response “The GP did not offer a face-to-face consultation or arrange a follow up appointment.” Source location Response from Farnham Practice
Open published response
4 Apr 2022 Faizan Qadeer Nazar · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1
Failure to provide patients with written reminders of forthcoming appointments View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Spire Harpenden Hospital
Send appointment confirmation letters and 48-hour reminder text messages for appointments booked on the hospital management system.
View source
×
AI-generated summary
Faizan Qadeer Nazar · 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
Faizan Qadeer Nazar, who had a longstanding history of depression and anxiety, sustained fatal injuries after deliberately lying on a ████████ on 13 September 2021. The inquest found it more likely than not that he intended his own death. Evidence raised concern that Spire Harpenden Hospital did not customarily send written reminders of patients’ forthcoming appointments, prompting consideration of reviewing that practice.
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 provide patients with written reminders of forthcoming appointments
Wider context from the report “During the course of the inquest I heard evidence from Dr ████████, Faizan’s treating Consultant Psychiatrist who told me that it was not customary at Spire Harpenden Hospital to forward written reminders of a patients forthcoming appointments .
” Source location Faizan Qadeer Nazar · Prevention of Future Deaths report
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 Send appointment confirmation letters and 48-hour reminder text messages for appointments booked on the hospital management system.
Verbatim wording from the response “b) Process for sending reminders of an appointment that has been made” Source location Response from Spire Healthcare
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 Regulation 28 concern is factually incorrect because the evidence did not establish that Spire lacked customary written appointment reminders.
Verbatim wording from the response “Having now had an opportunity to consider the recording of the evidence that was provided to the Court, we believe that the concern expressed in the Regulation 28 Report is factually incorrect. At no point during his evidence did ████████ state that it was not customary to forward written reminders of a patient’s forthcoming appointments. Had he stated as such, this would in any event have been incorrect (for the reasons we have set out below).” Source location Response from Spire Healthcare
Open published response
2 Jul 2021 Samantha Singh · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to offer follow-up appointments for allergy-related issues View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Samantha Singh · 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
Samantha Singh developed a suspected nut allergy, was assessed as having a mixed nut allergy, and was prescribed an EpiPen. On 25 July 2020, she became unwell at home and suffered a cardiac arrest attributable to anaphylactic shock; she could not be resuscitated. The concerns included the miscategorisation of her test results, prescription of only one EpiPen, and lack of referral to an allergy clinic or follow-up appointment.
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 offer follow-up appointments for allergy-related issues
Wider context from the report “(3) Following the appointment on 27 November 2019 Miss Singh was not referred to allergy clinic or offered a follow-up appointment to address issues arising from her allergy diagnosis .
” Source location Samantha Singh · Prevention of Future Deaths report
Open source report
9 May 2021 Eva Hayden · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Failure to follow up missed appointments for investigation of neutropenia View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Mersey and West Lancashire Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Mersey and West Lancashire Teaching Hospitals NHS Trust
Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Require consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Audit the outpatient non-attendance pathway and review cases where children were not clinically reviewed.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
View source See 3 more actions
×
AI-generated summary
Eva Hayden · 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
Eva Hayden, aged four, developed neutropenia following an illness and later became seriously unwell with fever-like symptoms. She collapsed on 10 January 2020 and died in the emergency department on 11 January 2020; the inquest found sepsis and bone marrow hypoplasia. Concerns included missed follow-up of her neutropenia, inadequate communication between hospitals, and insufficient communication with her parents about infection risks.
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 up missed appointments for investigation of neutropenia
Wider context from the report “b) When Eva missed the appointment at Ormskirk Hospital on the 25th November 2019 for her blood tests – there was no follow up by the hospital as there was an “assumption” that a follow-up orthopaedic appointment for cellulitis would investigate her neutropenia . The assumption was wrong and there was no clinical communication between the Trusts, which would have clarified that investigation of neutropenia had ceased without resolution. The onus for investigations cannot be on a four year old or her parents who were unaware of the potentially fatal implications.
” Source location Eva Hayden · Prevention of Future Deaths report
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 Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.
Verbatim wording from the response “1. At the time of this event there were paper-based systems in use, this has now changed and ward attender appointments are now scheduled on Medway (PAS) and clinically annotated at the time of the attendance. This ensures that patients are tracked and diarised electronically with outcomes recorded on the patient system.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
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 Require consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.
Verbatim wording from the response “3. The Trust immediately implemented safeguards to prevent a similar incident occurring when a child is not brought to a scheduled outpatient or ward attender appointment. All non-attendances are sent to the Consultant in charge of the care to clinically review and agree on what course of action needs to be taken. Examples of further actions could include, another appointment being offered or a discussion with another Trust if there are shared care arrangements. In all cases there will be documented evidence of the follow-up action that has taken place, e.g. letter to GP and/or parents.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
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 Audit the outpatient non-attendance pathway and review cases where children were not clinically reviewed.
Verbatim wording from the response “4. We have completed a full audit exercise to look at the pathway and scenario that Eva was under as she was those patients that attend through a standard outpatient appointment. Whilst this identified that in the majority of cases, the existing DNA Policy and processes were followed; there were 5 occasions where a patient didn’t attend an outpatient appointment and wasn’t clinically reviewed. Each incidence has been reviewed and there were no incidents of harm identified as a result.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
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 Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.
Verbatim wording from the response “5. We have reviewed our ‘Did Not Attend (DNA)’ Policy to reflect the requirements of the Regulation 28 report and ensure that any necessary safeguards from the work described above are contained within the policy. The Policy has also been re-vamped to ensure it reflects best practice and principles that a child ‘Was Not Brought’ as opposed to DNA. The updated policy is due to be presented at the clinical business unit (CBU) governance meeting on 08/07/2021 and will be subject to the governance arrangements of the Trust. The Was Not Brought Policy is a corporate Policy and will apply to all children anywhere within the trust.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
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 Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.
Verbatim wording from the response “6. We are confident that the implementation of the actions described in points 3 and 5 above will ensure that there is a clear response each time a child is not brought to an appointment and we have introduced a routine audit to be undertaken every month to measure that our updated policy and processes are being adhered to. This will be monitored through speciality and CBU governance arrangements with any breaches against the policy being escalated through the Trust incident management processes.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
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 Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
Verbatim wording from the response “10. The circumstances and details of this case have been widely shared. In addition, we are amending the local induction for staff in paediatrics to ensure that staff are provided with important information about the requirements of:” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
Open published response
5 May 2021 Hannah Bampfylde · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Unclear responsibility for re-booking appointments after non-attendance View source Failure to ensure re-booking of appointments after non-attendance for newly referred patients View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Hannah Bampfylde · 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
Hannah Bampfylde was found hanging in the garage of her mother’s home, where she had been staying, and the inquest determined that she took her own life. She had been referred to HATS for mental health input after an overdose, but missed or could not attend assessment appointments and was discharged without being assessed. The report identified unclear responsibility for rebooking missed appointments and a lack of routine notification to GPs when newly referred patients did not engage with the service.
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 Unclear responsibility for re-booking appointments after non-attendance
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA , or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Hannah Bampfylde · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure re-booking of appointments after non-attendance for newly referred patients
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Hannah Bampfylde · Prevention of Future Deaths report
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 Assign the Referral Co-ordinator responsibility for booking further initial assessment appointments after non-attendance.
Verbatim wording from the response “Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. This measure reduces the risk of a patient not being followed up as highlighted the North West Sussex Referral, Triage, Assessment and Allocation Process Map attached.” Source location 2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 Audit compliance with the strengthened referral follow-up arrangements over the forthcoming months.
Verbatim wording from the response “The safety of patients referred to us is of paramount importance to the Trust. Our service cannot coerce engagement as the desire to engage must come from the patient themselves, particularly when they are capacious, like Hannah was. However, it is important for our systems to be effective and to ensure that no patient “falls” between services. I trust this letter demonstrates to you and Hannah’s family the action we took to strengthen our systems. I will ensure we audit compliance with this over forthcoming months.” Source location 2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Open published response
20 Apr 2020 Wendy Margaret Wilkes · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of follow-up review appointments for prescribed medication View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Wendy Margaret Wilkes · 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
Wendy Margaret Wilkes was found at her home on 6 August 2019, with toxicology showing a fatal level of ethanol and concomitant use of gabapentin, zopiclone, diazepam and amitriptyline. Concerns were raised about the absence of a clear system for alert notes and follow-up reviews, and about whether prescribers were aware of her high alcohol use and assessed the risks of mixing alcohol with her medication.
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 follow-up review appointments for prescribed medication
Wider context from the report “The inquest heard that there was no clear system of alert notes/follow up review appointments at her GP practice despite the extent of the prescribed medication;
” Source location Wendy Margaret Wilkes · Prevention of Future Deaths report
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 Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.
Verbatim wording from the response “Alert Note/Review System effective from 25 February 2020
The practice has identified relevant existing patients by running reports for patients coded on the practice’s clinical system as using neuropathic medication, cross referenced with patients coded with alcohol dependency who have had an intentional or accidental overdose. A “flag” is now placed on these patients’ medical records and a medication review is undertaken. The patients are then contacted to discuss their medication and their alcohol consumption.” Source location 2020-0095-Response-from-Tameside-Glossop_Redacted
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 Issue an alert to all GP practices about alert notes, follow-up reviews and considering systems to identify high alcohol use during prescribing.
Verbatim wording from the response “3. An alert will be issued to all GP practices to ensure that they have clear systems of alert notes/follow up review appointments for individuals with extensive prescribed medications. The alert also requests GP practices consider how their systems can alert prescribers to patients with high alcohol usage when prescribing medications to ensure effective risk assessments can be carried out.” Source location 2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Open published response
13 Dec 2019 Steven Keith Marsland · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to make a follow-up appointment at discharge View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Steven Keith Marsland · 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
Steven Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.
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 make a follow-up appointment at discharge
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made ;
” Source location Steven Keith Marsland · Prevention of Future Deaths report
Open source report
12 Mar 2018 MARTIN LEE TILLEY · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1
Failure to follow up patients after missed mental health appointments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
MARTIN LEE TILLEY · 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
Martin Lee Tilley had a long history of substance misuse and significant mental health problems, including self-harm discussions, suicidal thoughts, and apparent visual and auditory hallucinations before his last appointment with the Homeless Healthcare Team in July 2017. He was found deceased on 17 October 2017 from the combined toxic effects of prescribed and non-prescribed medication; concerns were raised that there was no evidence of follow-up by the team after July and no answer explaining whether his presentation should have led to an emergency psychiatric assessment or referral to tertiary mental health services.
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 up patients after missed mental health appointments
Wider context from the report “Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and auditory hallucinations. It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team.
Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such a presentation would result in a referral for an emergency assessment by a psychiatrist or the tertiary mental health services. No answer to this question was forthcoming. Furthermore there was no evidence that Mr Tilley was followed up by the Homeless Healthcare Team after July 2017.
” Source location MARTIN LEE TILLEY · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.