Recurring concern

Unsafe operation of multidisciplinary clinical meetings

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First reported 10 Jan 2014•Latest report 27 May 2026

Definition

What this concern includes

Includes failures of explicitly multidisciplinary clinical meetings, ward rounds, CPA meetings or comparable clinical case meetings involving inadequate preparation, relevant-record review, appropriate attendance, patient participation, risk discussion, decision-making, meeting effectiveness or recording where these impair safe care decisions.

Not included

  • Excludes non-clinical, governance, learning or administrative meetings unless the assertion directly concerns a multidisciplinary clinical meeting about a patient's care.
  • Excludes generic communication, staffing, training or documentation deficiencies that are not directly tied to the operation of a multidisciplinary clinical meeting.
  • Excludes failures of a separately named clinical pathway or safety system where meeting operation is only an incidental component and the wider named concern provides the appropriate boundary.
  • Excludes inappropriate treatment, discharge or referral decisions where no deficiency in the multidisciplinary clinical meeting is identified.
Reports
33

Distinct published reports

Individual concerns
38

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
32

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 Care8
NHS England7
Essex Partnership University NHS Foundation Trust3
HM Prison and Probation Service3
Greater Manchester Mental Health NHS Foundation Trust2
Leicestershire Partnership NHS Trust2
Ministry of Justice2
Recipient name withheld2
Alternative Futures Group Limited1
Birmingham and Solihull Mental Health NHS Foundation Trust1
British Transport Police1
Browning Street Surgery1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Colchester Hospital1

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. Berkshire

    AI-generated summary

    Francis Osborne Barnes · 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

    Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the 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 record multidisciplinary team meeting minutes

    Wider context from the report

    “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death. I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust. The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital. There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed. There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed. There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death. Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored. It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned. Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar). No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed. We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason. The matters of concern can be summarised as follows: 1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector). 2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients. 3. Consideration of how the Oxford Trust responds to and learns from deaths. ”

    Source location

    Francis Osborne Barnes · 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

    Discuss and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.

    Verbatim wording from the response

    “3.1 Future Governance of cross-organisational incidents within TVVN”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 3 · response
    Published 6 November 2023

    Open published response

  2. Leicester City and South Leicestershire

    AI-generated summary

    Marie ZARINS · 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

    Marie Zarins, aged 42, was reported missing by her family and found suspended in Leicestershire; her death was confirmed at the scene on 24 November 2021. The report raised concerns about flawed multidisciplinary team discussions, inaccurate understanding and documentation of her medication status, failures to prescribe antidepressants and sleeping tablets, and inadequacies in the subsequent serious incident investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of CRISIS team MDT meetings to use accurate patient medication information when agreeing treatment plans

    Wider context from the report

    “1) I am concerned about the CRISIS team MDT meetings and their functionality. It is difficult to understand how a meeting attended by around 7 people agreed a treatment plan which was based upon incorrect information relating to the patient’s medication status. This is particularly difficult to understand when the correct medication status is clearly documented in the patient’s core assessment paperwork (which was completed by the Liaison Team on 22 November 2021 and sent to the CRISIS Team). An LPT staff member was candid about the fact that he did not have enough time to review patients’ records before the MDT meetings, this is a grave concern. ”

    Source location

    Marie ZARINS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Sandra Adina Lomax · 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

    Sandra Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.

    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 ensure regular participation of all Trusts in the GM Upper GI MDT

    Wider context from the report

    “3. The inquest also heard evidence that to support management of cases such as Mrs Lomax there was a regular GM Upper GI MDT led by Salford Royal Hospital. However staffing issues meant that there was not a regular presence for all Trusts at the meeting. This impacted effective communication and impacted patient care; ”

    Source location

    Sandra Adina Lomax · 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

    Share the Report and concerns through System Quality Groups with relevant NHS England trusts and clinicians to support learning, including effective frequent MDT meetings.

    Verbatim wording from the response

    “In addition, the national Regulation 28 Working Group will ensure that your Report and the concerns raised are shared with System Quality Groups for onward sharing to relevant Trusts and clinicians across NHS England, so that they may take learnings from this case.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 24 February 2023

    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

    Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.

    Verbatim wording from the response

    “GM are the appropriate organisation to respond to your concerns around GM staffing issues and ineffective communication between the MDT. I have been sighted on their response and welcome the Greater Manchester Cancer Alliance improvement programme for MDT reform. I also note that they will be sharing learning from Sandra’s death across the Greater Manchester System.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 24 February 2023

    Open published response

  4. Norfolk

    AI-generated summary

    Eliot HARRIS · 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

    Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.

    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 fully record Multi Team Meetings and decision rationales in clinical records

    Wider context from the report

    “3) Multi Team Meetings were not fully and properly recorded in the clinical records. At the inquest, evidence was heard there “is still some way to go” with regard to improving record keeping and for ensuring important matters such as rationale for decisions is fully recorded ”

    Source location

    Eliot HARRIS · 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

    Improve MDT record completeness using a meeting aide memoire and recorded daily brief reviews of patients.

    Verbatim wording from the response

    “Comprehensive recording of the Multi-Disciplinary Team (MDT) meeting is essential as this supports high quality effective care. Record keeping is an essential action to support the evidence of care provided. The ward has developed an aide memoire to guide staff as to the areas to be considered as part of the MDT review. This serves as a Terms of Reference for the meeting in order to improve the comprehensiveness of record keeping. In addition, the MDT hold a daily brief review of each patient which is recorded in the patient’s records. An audit of the quality of MDT meetings was completed in August by the Nurse Consultant which demonstrated on sustained improvement. An anonymised copy of the audit is attached. The changes are being monitored on a monthly basis with results fed back to the team by the Nurse Consultant.”

    Source location

    Response form Norfolk and Suffolk Foundation Trust
    Page 2 · response
    Published 3 October 2022

    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

    Monitor MDT meeting quality monthly and provide results and feedback to the ward team.

    Verbatim wording from the response

    “Comprehensive recording of the Multi-Disciplinary Team (MDT) meeting is essential as this supports high quality effective care. Record keeping is an essential action to support the evidence of care provided. The ward has developed an aide memoire to guide staff as to the areas to be considered as part of the MDT review. This serves as a Terms of Reference for the meeting in order to improve the comprehensiveness of record keeping. In addition, the MDT hold a daily brief review of each patient which is recorded in the patient’s records. An audit of the quality of MDT meetings was completed in August by the Nurse Consultant which demonstrated on sustained improvement. An anonymised copy of the audit is attached. The changes are being monitored on a monthly basis with results fed back to the team by the Nurse Consultant.”

    Source location

    Response form Norfolk and Suffolk Foundation Trust
    Page 2 · response
    Published 3 October 2022

    Open published response

  5. Dorset

    AI-generated summary

    Ryan Albert Frederick Merna · 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

    Ryan Albert Frederick Merna died from injuries sustained in a knife attack at his home on 14 August 2016. The concerns included that information about the perpetrator possessing a knife and sleeping rough was not probed, recorded, or raised at a care programme meeting, resulting in a missed opportunity to reassess risk.

    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 raise offensive-weapon disclosures at Care Programme Meetings

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Dorset

    AI-generated summary

    Alexander Charles George Tostevin · 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

    Corporal Alexander Charles George Tostevin died on 18 March 2018 after a significant deterioration in his mental health and while under the care of the Royal Navy Department of Community Mental Health and Welfare Team. A risk management email containing significant disclosures was not seen until the following week, resulting in a missed opportunity to reassess his risk before the weekend. The concerns included the lack of independence of the DCMH, the primacy of its view in multidisciplinary risk assessments, and the absence of a composite risk assessment and care plan.

    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

    Primacy of DCMH views in multidisciplinary risk assessment

    Wider context from the report

    “ii. The primacy of the view of DCMH when considering the risk of ████████ in MDT/Case Conferences again means that the true risk of ████████ may not be accounted for, particularly where a service user is providing different information to DCMH and Welfare and/or where there is a disagreement between DCMH and Welfare as to the presenting level of risk. Adopting a process similar to a Multi-Agency Risk Management Meeting ("MARM") or Multi Agency Risk Assessment Conference ("MARAC") in a civilian context may assist: in a MARM or MARAC, the level of risk adopted is the highest level raised in the meeting/conference, without any agency having primacy. Therefore, the risk management plan subsequently formulated addresses the highest level of risk brought to the meeting. ”

    Source location

    Alexander Charles George Tostevin · 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

    Apply AGAI 110 Vulnerability Risk Management within the Unit.

    Verbatim wording from the response

    “Societal stigma regarding mental health issues has reduced in recent years but does endure. This is a recognised risk within service communities with regards to the management of vulnerability. Cpl Tostevin’s Unit has now adopted the Army General Administrative Instruction (AGAI) 110 – Vulnerability Risk Management (VRM)⁵, which acknowledges the ongoing challenges, stating:”

    Source location

    2021-0407-Response-from-Ministry-of-Defence_Published
    Page 4 · response
    Published 7 December 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a joint DCMH–RNFPS working protocol for resolving disagreements and improving communication.

    Verbatim wording from the response

    “Since the tragic passing of Cpl Tostevin, to ensure this process runs effectively in the Unit, a joint working protocol between DCMH and the Royal Navy Families and People Support (RNFPS) team was agreed and signed in March 2020. A copy of this protocol is provided at Enclosure 2. This outlines the actions to be taken in cases where disagreements occur between the two organisations, which promotes improved lines of communication accounts for all views to ensure the wellbeing of the individual is protected.”

    Source location

    2021-0407-Response-from-Ministry-of-Defence_Published
    Page 6 · response
    Published 7 December 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use holistic composite Care Assessment Plans and VRMIS to consolidate risk information, update carers and notify them of changes.

    Verbatim wording from the response

    “In line with AGAI 110, composite CAP documents based on a holistic assessment of risk are now in place within Cpl Tostevin’s Unit. The Case Conferences continue to employ a multi-disciplinary approach to managing personnel deemed to be at risk, with carers’ meetings being conducted fortnightly. Meeting attendees now feed into a collaborative tool to manage vulnerable personnel, which is hosted on the Vulnerability Risk Management Information System (VRMIS).”

    Source location

    2021-0407-Response-from-Ministry-of-Defence_Published
    Page 6 · response
    Published 7 December 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing Chain of Command-led multidisciplinary processes and disagreement protocols provide holistic risk management without adopting a MARM or MARAC model.

    Verbatim wording from the response

    “While each Service has its own policies and frameworks to manage its vulnerable personnel, every case across Defence is Chain of Command led and supported, as appropriate, by welfare agencies, pastoral support and healthcare professionals (including DCMH). Cpl Tostevin’s Unit applies the Army’s Vulnerability Risk Management (VRM) Framework, which states:”

    Source location

    2021-0407-Response-from-Ministry-of-Defence_Published
    Page 5 · response
    Published 7 December 2021

    Open published response

  7. Mid Kent and Medway

    AI-generated summary

    TERENCE TALBOT · 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

    Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.

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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 of multidisciplinary meetings to focus on treatment needs

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”

    Source location

    TERENCE TALBOT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    Ben Buster KING · 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

    Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to hold multidisciplinary team meetings at required intervals

    Wider context from the report

    “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal ”

    Source location

    Ben Buster KING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Birmingham and Solihull

    AI-generated summary

    Azra Parveen HUSSAIN · 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

    Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

    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 families with direct remote participation in MDT meetings

    Wider context from the report

    “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs. ”

    Source location

    Azra Parveen HUSSAIN · 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

    Offer families participation in formal MDT meetings where clinically appropriate, subject to consent, confidentiality, relationship, risk and safeguarding considerations.

    Verbatim wording from the response

    “With regard to involvement of families in formal MDT meetings we will involve families within the MDT meeting itself where there is clinically appropriate. It will not always be appropriate as such decisions will be influenced by a number of things such as:-”

    Source location

    2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 30 March 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Family attendance at formal MDT meetings cannot always be offered because of consent, confidentiality, safeguarding, and risks to patients or others.

    Verbatim wording from the response

    “With regard to involvement of families in formal MDT meetings we will involve families within the MDT meeting itself where there is clinically appropriate. It will not always be appropriate as such decisions will be influenced by a number of things such as:-”

    Source location

    2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 30 March 2021

    Open published response

  10. Manchester North

    AI-generated summary

    Mr Nicky Raymond Reilly · 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 Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.

    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 ensure multidisciplinary attendance and formal reports for care-plan meetings

    Wider context from the report

    “The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made. ”

    Source location

    Mr Nicky Raymond Reilly · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement and embed the national Challenge Support Intervention Plan with multidisciplinary engagement, information-sharing, and effective record-keeping requirements.

    Verbatim wording from the response

    “Whilst recognising the significance of the introduction of the new national case management model, Challenge Support Intervention Plan (CSIP), which replaced the MCBS policy on 1 February this year and is currently being implemented and embedded across the prison estate, you have expressed concern that some of the issues covered during the inquest may still be relevant. You have specifically referred to poor record keeping, the lack of multi-disciplinary attendees and the lack of requirement for formal reports.”

    Source location

    2019-0014-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 24 May 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate weekly multidisciplinary meetings at HMP Manchester to manage complex and challenging prisoners and maintain decision-making records.

    Verbatim wording from the response

    “HMP Manchester has been holding a weekly multi-disciplinary meeting to manage complex and challenging prisoners since April 2018, and CSIP was introduced in June 2018. The purpose of the weekly meeting is assist the Residential function by providing multi-disciplinary case management for prisoners who require additional resources over and above their CSIP or ACCT Intervention, Support or Care plans. Departments who do not attend are expected to provide written submissions to the meeting. The meetings are chaired by a Senior Manager from the Residential and Safety function, and minutes are kept to ensure an ongoing record of decision-making is maintained.”

    Source location

    2019-0014-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 24 May 2019

    Open published response
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Data last updated 7 September 2026