Recurring concern

Failure to complete timely direct mental health assessments after referral

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First reported 24 Nov 2014•Latest report 25 Mar 2024

Definition

What this concern includes

Includes failure or material delay in arranging, contacting for, undertaking or completing a referred full, specialist or psychiatric assessment, including rejection or closure without required direct assessment.

Not included

  • Deficient assessment content after the referred assessment was completed unless non-completion is also identified.
  • Post-discharge or post-acceptance follow-up where no referred assessment remains incomplete.
  • General referral or service-access delay where completion of the referred mental health assessment is not the unsafe condition.
Reports
12

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
21

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.

Department of Health and Social Care3
Norfolk and Suffolk NHS Foundation Trust2
North London NHS Foundation Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Black Country Healthcare NHS Foundation Trust1
Brighton and Hove City Council1
East London NHS Foundation Trust1
Hellesdon Hospital1
NHS Birmingham and Solihull Integrated Care Board1
NHS England1
Norfolk County Council1
North East London NHS Foundation Trust1
Practice Plus Group Health And Rehabilitation Services Limited1
Sussex Partnership NHS Foundation Trust1
West Midlands Police1

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. Norfolk

    AI-generated summary

    Christopher Edward SIDLE · 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

    Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.

    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

    Delays in arranging assessments for people requiring an immediate response

    Wider context from the report

    “6. A person can be identified at triage risk assessment as being in need of an “immediate response, within 4 hours” but an assessment is then arranged for within a 24-hour period. ”

    Source location

    Christopher Edward SIDLE · 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

    Provide capital investment for urgent and emergency mental health infrastructure, including crisis services, emergency departments and crisis lines.

    Verbatim wording from the response

    “For those in crisis, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co-occurring physical and mental health issues.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 April 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

    Fund the national rollout of specialised mental health ambulances supported by practitioners trained in co-occurring physical and mental health needs.

    Verbatim wording from the response

    “For those in crisis, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co-occurring physical and mental health issues.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 April 2024

    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

    Operate one generic CRHTT email address with a defined process for qualified practitioners to check and action messages.

    Verbatim wording from the response

    “These have now been merged into one generic team email address. The process for receipt and management of emails to the CRHTT generic team e mail address has been reviewed.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 3 · response
    Published 3 April 2024

    Open published response
  2. West Sussex

    AI-generated summary

    Robyn Lily Audrey SKILTON · 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

    On 7 May 2021, 14-year-old Robyn Lily Audrey Skilton was found in Southwater Park with a ligature around her neck, and her death was confirmed by emergency services. The inquest concluded that Robyn took her own life while struggling with her mental health, and that mental health services failed to recognise the deterioration in her mental health or provide the care and treatment she required. The report raised concerns about delayed assessment and treatment, including a lack of timely access to Child Psychiatrist and CAMHS services and insufficient resourcing.

    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

    Delays in specialist child mental health assessment

    Wider context from the report

    “Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner. I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn. It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS). By way of an example:- Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761) West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147) West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494) Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021). Additionally, across Sussex CAMHS, as a whole, the referrals data shows:- • May 2022 was the highest number of referrals the service has ever received (1350). • Of those 1350 referrals, 80% (1,081) were accepted into the service. • In comparison, in May 2019, 579 were accepted (65% accepted) • So, an additional 502 young people have been accepted in May 2022 compared to May 2019 Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk. ”

    Source location

    Robyn Lily Audrey SKILTON · Prevention of Future Deaths report
    Page 1 · 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

    Expand and strengthen the NHS mental health workforce, including adding 27,000 mental health professionals by 2023/24.

    Verbatim wording from the response

    “Growth of the mental health workforce, as well as retaining and re-skilling our current workforce, is the key strategic priority to ensure we can deliver our commitments to expand services and increase access. This is why, through the Plan we are committed to expanding the NHS workforce, with an aim of having and additional 27,000 mental health professionals by 2023/24, to deliver the expansion and transformation of mental health services, including those for children and young people.”

    Source location

    Response from department of Health and Social Care
    Page 2 · response
    Published 30 September 2022

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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

    Work with NHS England on next steps following consultation on proposed mental health waiting-time standards.

    Verbatim wording from the response

    “More broadly, NHS England consulted on the potential to introduce a range of new waiting time standards as part of its Clinically-led Review of NHS Access Standards⁴. These include:”

    Source location

    Response from department of Health and Social Care
    Page 3 · response
    Published 30 September 2022

    Open published response
  3. West Yorkshire Eastern

    AI-generated summary

    Dominic Robert Noble · 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

    Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged referrals.

    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

    Delays in providing psychiatrist appointments after assessment referrals

    Wider context from the report

    “(1) Evidence was taken at the inquest that: (i) HMP Leeds has only 3 days per week of a psychiatrist's time available (ii) HMP Leeds has some 5000 prisoners arriving each year. (iii) A large proportion of the prisoners arriving have mental health issues (iv) The mental health team is mainly a nurse-led service (v) The division of labour between mental health nurses and psychiatrists is that a doctor is responsible for the diagnosis of mental illness, prescribing medication such as anti-psychic drugs and seeing prisoners/patients with severe or complex conditions. Mental health nurses make initial assessments and provide ongoing care. (vi) Concern was expressed about the adequacy of the psychiatric doctor provision to provide psychiatric treatment for a large population which includes men with significant mental health issues. (vii) Mr Noble was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given. (viii) A mental health nurse working on behalf of PPG on 10 July 2020 identified the “possibility of emerging psychotic features” and noted the sentiment that engaging in treatment as soon as possible mitigated in favour of a better outcome. Where such a suspicion was raised it would have been advantageous to obtain a second opinion from a psychiatrist swiftly (particularly after his mother contacted the prison to report his paranoid and bizarre conversation regarding a gun, a secret room in the prison and some unknown person trying to kill him.) ”

    Source location

    Dominic Robert Noble · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Approach NHS England and discuss seeking additional psychology and psychiatry resource for HMP Leeds.

    Verbatim wording from the response

    “Intended Changes Following the Learned Coroner’s comments during the inquest into the death of Mr Afzal, ████████, Practice Plus Group’s Regional Director North – Health in Justice, began discussions with Commissioners at NHS England. Whilst Practice Plus Group maintains that the level of psychiatry provision is at least equivalent to that offered in the community, we also recognise that there are significant levels of mental health morbidity in prisons, particularly in a local remand setting such as HMP Leeds. The Learned Coroner’s comments and subsequent report have highlighted a potential need and we have therefore approached our Commissioners for additional resource.”

    Source location

    2022-0204 - Response from Practice Plus Group
    Page 4 · response
    Published 23 September 2022

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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

    Submit a business case to Commissioners for increased psychology and psychiatry provision at HMP Leeds.

    Verbatim wording from the response

    “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.”

    Source location

    2022-0204 - Response from Practice Plus Group
    Page 4 · response
    Published 23 September 2022

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    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

    Existing stepped-care provision and multidisciplinary referral arrangements are considered sufficient to meet patients’ psychiatric needs at current levels.

    Verbatim wording from the response

    “As in the community, Practice Plus Group delivers a stepped care model, which focuses on providing the most appropriate care for the concerns a patient may have. By adopting this model most people with mental health problems do not need to see a consultant psychiatrist. The stepped care model of mental health focuses on providing people with the right level of support from the right clinician at the right time. For example, people experiencing mild to moderate depression and anxiety would see a primary care mental health clinician in the community, alongside the GP, which is step 2/3.”

    Source location

    2022-0204 - Response from Practice Plus Group
    Page 2 · response
    Published 23 September 2022

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    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

    Even if additional funding is approved, recruitment difficulties may prevent immediate increases in psychiatric provision.

    Verbatim wording from the response

    “HMP Leeds is a high demand remand site and we are seeking additional resource with the aim to improve the number of clinical sessions from 6 to 8 per week. In effect this means that HMP Leeds will need the equivalent of a half-time psychiatrist in addition to what is currently in place in order to achieve the additional clinical sessions. This is due to the non-patient facing time that all directly employed consultant psychiatrists working for Mental Health Trusts have in their contract. These activities include clinical administration tasks (e.g. letters and referrals), service development and training/development.”

    Source location

    2022-0204 - Response from Practice Plus Group
    Page 4 · response
    Published 23 September 2022

    Open published response
  4. Norfolk

    AI-generated summary

    Mary Jane BUSH · 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 Jane BUSH, who had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, was found at her home on 6 August 2020; the inquest conclusion was suicide. The principal concerns were delays in her mental health assessment and psychological therapy, ongoing delays in providing therapy, and difficulties with recruitment and retention of suitably skilled staff.

    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

    Delays in mental health assessment following referral

    Wider context from the report

    “1. Mary was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been. ”

    Source location

    Mary Jane BUSH · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. East London

    AI-generated summary

    Mr Stuart Tokam · Prevention of Future Deaths report

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

    Report summary

    Mr Stuart Tokam, who had a documented history of depressive illness and two previous attempts to take his own life, died after hanging himself from railings at Dalaman Airport, Turkey, on 18 September 2020. Concerns included an unacceptable delay in arranging a clinical assessment and the apparent absence of a process to triage referral acuity and expedite assessment where necessary.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a process to triage referral acuity and expedite clinical assessments where necessary

    Wider context from the report

    “2. There appears to have been no process in place to triage the acuity of a referral and expedite a clinical assessment where necessary. ”

    Source location

    Mr Stuart Tokam · 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

    Delays in arranging clinical assessments

    Wider context from the report

    “1. There was an unacceptable delay in arranging a clinical assessment of Mr Tokam. ”

    Source location

    Mr Stuart Tokam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Birmingham and Solihull

    AI-generated summary

    David Jonathon Jukes · 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

    David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.

    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 attempt timely assessment after a high-risk patient re-establishes contact

    Wider context from the report

    “6. On the 9th October 2018 an HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018. By this time he was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact. The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk. No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues. ”

    Source location

    David Jonathon Jukes · Prevention of Future Deaths report
    Page 3 · 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

    Increase Home Treatment Team workforce capacity through additional managers, practitioners, medical staff, psychologists and administrative staff.

    Verbatim wording from the response

    “We are conscious that our Home Treatment Teams have been operating within an environment of high demand and acuity and that may at times compromise their ability to consistently meet the important standards that we expect of staff. We are investing a significant amount of new financial resource into our Home Treatment Team to increase workforce capacity. This includes:”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 5 · response
    Published 26 July 2019

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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 the Home Treatment Team operating protocol to strengthen nurse-led triage, assessment screening and escalation to consultant psychiatrists.

    Verbatim wording from the response

    “In direct response to this matter of concern we are now reviewing our Home Treatment Team Operating Protocol to strengthen the requirement for nurse led triage and assessment screening and appropriate clinical escalation to a Consultant Psychiatrist. Consultant Psychiatrist overview and scrutiny of each case would either be through direct clinical assessment or review or through input and direction within the multi-disciplinary team or through formal or informal supervision of doctors and other home treatment staff. We note the view of the team that they felt they acted appropriately and are therefore also using this very sad incident as a Case Study in our new Clinical Risk Assessment and Management Training so that staff are fully alert to accumulative risk factors. This training is mandatory for all clinical staff in the Trust irrelevant of clinical profession or team.”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 4 · response
    Published 26 July 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Care and treatment concerns are largely for provider organisations to resolve.

    Verbatim wording from the response

    “2.8 These issues are largely within the remit of the provider organisations to resolve, and the CCG confirms that an appropriate action plan has been drawn up and completed by BSMHFT.”

    Source location

    2019-0329-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · response
    Published 26 July 2019

    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

    Local NHS agencies are expected to address the report’s local concerns.

    Verbatim wording from the response

    “Please note this response will address the matters of concern from a national level and we would expect the local NHS agencies, which I note are copied in to the letter, to address the local concerns raised.”

    Source location

    2019-0220-Response-by-NHS-England
    Page 1 · response
    Published 26 July 2019

    Open published response
  7. Milton Keynes

    AI-generated summary

    Daniel Gary Dunkley · 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

    Daniel Gary Dunkley was found hanging in his cell at H.M.P. Woodhill on 29 July 2016 and subsequently died in hospital on 2 August 2016. Three referrals for a full mental health assessment had been made before his death, but none took place; the report identified concerns about the assessment process and the failure to notify the relevant unit or Mr Dunkley about an assessment scheduled for the morning he was found.

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    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 notify relevant staff and patients of scheduled mental health assessments

    Wider context from the report

    “During the course of the evidence it became clear that prior to Mr Dunkley's death three referrals were made for him to undergo a full mental health assessment. None of the assessments took place prior to his death. The assessment due on the morning that he was found hanging in his cell was never notified to House Unit 2 or indeed to Mr Dunkley. Such assessments are vital to keep those suffering from psychiatric problems to be kept safe and an urgent review of the whole process is necessary. ”

    Source location

    Daniel Gary Dunkley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  8. Inner North London

    AI-generated summary

    Jamie Neil Elliott · 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

    Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

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    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 timely face-to-face psychiatric assessment after worsened-condition referral

    Wider context from the report

    “2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment. ”

    Source location

    Jamie Neil Elliott · 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

    Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.

    Verbatim wording from the response

    “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

    Source location

    2017-0135-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide routine doctor review within 72 hours for Home Treatment referrals without prior professional assessment, with out-of-hours emergency review by on-call psychiatry.

    Verbatim wording from the response

    “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

    Source location

    2017-0135-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    Open published response
  9. East London

    AI-generated summary

    EMMA LOUISE BRAY · 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

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    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

    Delays in psychiatric referral and assessment after initial assessment

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · 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

    Review and implement AABIT standard operating procedures.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response
  10. Norfolk

    AI-generated summary

    DARREN HAYES · 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

    Darren Hayes had significant physical health problems, opiate dependence and alcohol abuse, and was losing weight, struggling with nutrition and personal care, living alone without a cooker. He died on 11 March 2014 before a planned community care assessment could take place; the inquest recorded poisoning by morphine and benzodiazepines, with empyema of the gallbladder. Concerns included delayed and inadequately documented attempts to contact him, insufficient consideration of the risks he presented, and failure to contact other relevant services when he did not respond.

    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

    Delays in contacting people referred for assessment despite identified risks

    Wider context from the report

    “(2) The time taken to contact Mr Hayes in the light of the information provided and the risks with which Mr Hayes was presenting. The initial referral to the ECCT was on 10.3.2014, he was allocated for initial assessment which was due to take place on 28.3.14; 3 weeks later. The first attempt to telephone Mr Hayes was on 1.4.2014. A letter was sent to Mr Hayes and on receiving no response, there was no further attempt to contact Mr Hayes until 16.4.2014, almost 5 weeks after both the initial referral and his death. ”

    Source location

    DARREN HAYES · 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

    Review Duty Operational Instructions to incorporate risk information into decisions about when referred people receive initial contact.

    Verbatim wording from the response

    “I confirm a review of the Duty Operational Instructions is already in progress, and the Coroner’s concerns will be built into this work. It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised.”

    Source location

    2014-0538-Response-by-Norfolk-County-Council
    Page 2 · response
    Published 17 December 2014

    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 guidance for prioritising referrals, including how individual risks are identified and assessed.

    Verbatim wording from the response

    “I confirm a review of the Duty Operational Instructions is already in progress, and the Coroner’s concerns will be built into this work. It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised.”

    Source location

    2014-0538-Response-by-Norfolk-County-Council
    Page 2 · response
    Published 17 December 2014

    Open published response
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Data last updated 7 September 2026