Recurring concern

Failure to reassess safety risks during significant mental-health medication changes

Get email alerts

Request correction

First reported 6 Mar 2023•Latest report 19 Dec 2025

Definition

What this concern includes

Includes failures in mental-health care to reassess safety risks when medication is started, stopped, reduced, increased or substantially changed, and to use the reassessment to determine protective measures, monitoring, contact frequency, escalation or other risk-management actions.

Not included

Excludes generic mental-health risk-assessment failures where no significant medication change is materially involved.
Excludes routine medication prescribing, administration, monitoring or review failures where the safety impact of a significant mental-health medication change is not the shared condition.
Excludes failures limited to general appointment or contact-frequency arrangements when no significant medication change should have triggered enhanced risk consideration.
Excludes medication changes for physical-health treatment unless the assertion explicitly concerns the same mental-health medication-change risk-management process.

Reports: 3
Individual concerns: 5
Date range: 2023–2025
Stated actions: 4

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.

East London NHS Foundation Trust1

North East London NHS Foundation Trust1

Sheffield Health Partnership University 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.

19 Dec2025
South Yorkshire (Eastern)
Concerns raised2
1. Lack of full assessment after abrupt medication cessation
2. Risk of relapse and serious mental-health deterioration following abrupt medication cessation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Standardise formal logging, multidisciplinary review, risk-based monitoring decisions, named clinical ownership and contingency recording after antipsychotic medication changes across all relevant services.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progress
AI-generated summary

Jason Ricardo White · 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

Jason Ricardo White died on 10 December 2024; the cause of death is redacted in the supplied text, and the inquest conclusion was suicide. The principal concerns were the abrupt cessation of olanzapine, failure to follow the planned daily monitoring, and the resulting risk of relapse and serious deterioration in mental health.

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 full assessment after abrupt medication cessation
Wider context from the report
“1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed. 2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health. 3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health. ”
Source location
Jason Ricardo White · 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
Risk of relapse and serious mental-health deterioration following abrupt medication cessation
Wider context from the report
“1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed. 2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health. 3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health. ”
Source location
Jason Ricardo White · 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
Standardise formal logging, multidisciplinary review, risk-based monitoring decisions, named clinical ownership and contingency recording after antipsychotic medication changes across all relevant services.

Verbatim wording from the response
“As a direct response to the learning from this case, we have strengthened our approach to monitoring service users following changes to antipsychotic medication. These improvements are already being implemented in practice, with full standardisation across all relevant services to be completed by 1 March 2026.”

Source location
2025-0638 - Response from Sheffield Health Partnership University NHS Foundation Trust
Page 1 · response
Published 23 December 2025
Open published response
29 Oct2025
Inner North London
Concerns raised1
1. Failure to automatically consider significant medication changes when setting mental-health service contact levels
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
  Communicate the learning about significant medication changes to the Tower Hamlets consultant psychiatrist body by email.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Include significant medication changes as a factor for multidisciplinary consideration in the Tower Hamlets Early Intervention Service RAG guidance.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Reinforce the guidance through Operational Lead-led shared learning and scheduled service and team business-meeting discussions and review.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Evan Amon DANDOU-DAMBELLE · 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

Evan Dandou-Dambelle was at home on the evening of 2 May 2025 while experiencing symptoms of psychosis and command hallucinations. The concerns relate to a change in his mental-health service contact from weekly to fortnightly at the same time that his olanzapine was stopped and risperidone commenced, without the medication change being specifically considered when setting the level of contact. The inquest determined that he died by suicide.

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 automatically consider significant medication changes when setting mental-health service contact levels
Wider context from the report
“When Mr Dandou-Dambelle was discussed at an ELFT multi disciplinary meeting on 9 April 2025, his level of contact was changed from red (weekly) to amber (fortnightly). This was the last MDT before his death. This was also the point when the consultant psychiatrist decided to stop his olanzapine that day and commence risperidone, titrating it up gradually. However, the psychiatrist did not suggest that, in deciding the level of contact (red being weekly; amber fortnightly; and green monthly), the medication change was worthy of particular consideration. Even if the consultant had raised the medication change for particular consideration, the team might still have decided to move Mr Dandou-Dambelle to amber, and even if they had kept him on red, it might not have impacted on the outcome. However, in deciding level of contact from the mental health services, it does seem worthy of automatic consideration that the patient’s medication has been altered significantly. ”
Source location
Evan Amon DANDOU-DAMBELLE · 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
Communicate the learning about significant medication changes to the Tower Hamlets consultant psychiatrist body by email.

Verbatim wording from the response
“Since receiving your Regulation 28 report, this learning has already been communicated by email to the Tower Hamlets consultant psychiatrist body, and Clinical Directors in other Trust Directorates have been asked to relay it to their consultant bodies too.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 31 October 2025
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
Include significant medication changes as a factor for multidisciplinary consideration in the Tower Hamlets Early Intervention Service RAG guidance.

Verbatim wording from the response
“I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 31 October 2025
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
Reinforce the guidance through Operational Lead-led shared learning and scheduled service and team business-meeting discussions and review.

Verbatim wording from the response
“I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 31 October 2025
Open published response
6 Mar2023
East London
Concerns raised2
1. Lack of detailed risk assessment when weaning Clonazepam medication
2. Failure to establish a risk management plan when weaning Clonazepam medication
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Evelina Vilkiene · 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

Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.

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 detailed risk assessment when weaning Clonazepam medication
Wider context from the report
“2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe. ”
Source location
Evelina Vilkiene · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to establish a risk management plan when weaning Clonazepam medication
Wider context from the report
“2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe. ”
Source location
Evelina Vilkiene · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of full assessment after abrupt medication cessation

Risk of relapse and serious mental-health deterioration following abrupt medication cessation

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 automatically consider significant medication changes when setting mental-health service contact levels

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

Concerns raised2

Lack of detailed risk assessment when weaning Clonazepam medication

Failure to establish a risk management plan when weaning Clonazepam medication

Actions described in response 1

Actions described in response 3