Recurring concern

Failure to reliably refer patients to required specialist services

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First reported 19 Jan 2014•Latest report 4 Feb 2026

Definition

What this concern includes

Includes failures in making, recording, tracking or completing clinically required referrals to specialist services, including physiotherapy, occupational therapy, dietetics and specialist nursing, where the referral is needed for assessment, rehabilitation, treatment or safe care.

Not included

  • Excludes referral delays or omissions involving a named pathway or service with a more specific established recurring concern, such as mental-health, social-care or district-nursing referrals.
  • Excludes failures in specialist assessment or treatment after a referral has been reliably completed and accepted.
  • Excludes generic communication, staffing, documentation or care-planning deficiencies unless they directly cause failure to complete a required specialist referral.
  • Excludes requests for general advice or informal consultation where no required referral to a specialist service is identified.
Reports
35

Distinct published reports

Individual concerns
38

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
65

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.

NHS England4
Department of Health and Social Care3
Care Quality Commission2
Hc-One Limited2
Manchester University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
Adferiad Recovery1
Barts Health NHS Trust1
Bedfordshire Hospitals NHS Foundation Trust1
Belong Limited1
Betsi Cadwaladr University LHB1
Bristol NHS Foundation Trust1
Brunswick Ward at Lindridge1
Castlehill Specialist Care Centre1
Cornerstone Family Practice1

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. Manchester South

    AI-generated summary

    Mary Jones · 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 Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.

    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 or trace SALT referrals

    Wider context from the report

    “5. Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist. There was to have been a referral to SALT in February but no trace could be found of the referral; ”

    Source location

    Mary Jones · 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 refer frail patients to a dietician or nutritionist

    Wider context from the report

    “5. Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist. There was to have been a referral to SALT in February but no trace could be found of the referral; ”

    Source location

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

    Open source report

  2. Gateshead and South Tyneside

    AI-generated summary

    ARCHIE RAY GRIEVES · 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

    Archie Ray Grieves was born on 24 May 2017 following a complicated delivery involving shoulder dystocia. He initially showed no signs of life, later showed signs of life, and died a short time after being taken to the special care baby unit. The report identified an avoidable neonatal death, with an eight-minute delay in delivering his body after his head and missed opportunities during antenatal care and delivery to identify risks and plan a safe birth.

    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 refer women with elevated maternal or fetal growth indicators for Consultant Obstetric care

    Wider context from the report

    “4. The mother was not referred to a Consultant lead Obstetric examination and assessment when issues and concerns would have been identified both as to her presentational weight and the potential consequential size of the baby. 5. A subsequent test apparently indicated no diabetes and a determination that the ante natal care should follow a normal pathway 6. At the 34th week fundal size continued to identify the baby’s development as outwith the 95th centile and consequently on the basis of the Trust’s own guidelines this mother should have been referred also to Consultant Obstetric care. ”

    Source location

    ARCHIE RAY GRIEVES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. East London

    AI-generated summary

    Mr Frederick Raymond BROOKER · 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 Frederick Raymond Brooker, who used a wheelchair in a residential care home, sustained multiple falls, including a fall on 10 July 2018 that caused a catastrophic traumatic bleed and from which he died on 14 July 2018. The principal concerns were that, despite his recognised high risk of falling, the care home did not put adequate care plans or other measures in place, review the wheelchair or involve relevant services, investigate subsequent falls, or provide evidence of encouragement to use the wheelchair seatbelt.

    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 refer wheelchair suitability to wheelchair services

    Wider context from the report

    “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt. ”

    Source location

    Mr Frederick Raymond BROOKER · 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 refer mobility for occupational therapy review

    Wider context from the report

    “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt. ”

    Source location

    Mr Frederick Raymond BROOKER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Nottinghamshire

    AI-generated summary

    George Goldby · 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

    George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and 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

    Failure to re-refer residents to SALT when indicated

    Wider context from the report

    “(3) There were three missed opportunities to re-refer Mr Goldby to SALT and to review his care plan and dietary requirements. ”

    Source location

    George Goldby · 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

    Refer residents meeting the threshold to Speech and Language Therapy and schedule required follow-up reviews.

    Verbatim wording from the response

    “3. All Residents whose assessment indicated having reached the appropriate threshold of need have been referred to the Speech and Language team (SALT) service via the GP for review- New referrals have also been actioned and follow-ups reviews have been planned by SALT- 2 existing Residents are due a review, which have been scheduled.”

    Source location

    2018-0104-Response-by-HC-One
    Page 1 · response
    Published 17 June 2018

    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

    Assign the Care Manager oversight of communication and escalation between Speech and Language Therapy and home staff.

    Verbatim wording from the response

    “4. The Care Manager has taken responsibility for oversight of communication between SALT and colleagues at the home to ensure optimum communication and appropriate escalation for support. This has been reported by all parties as very much improved, with greater clarity and swifter partnership working.”

    Source location

    2018-0104-Response-by-HC-One
    Page 1 · response
    Published 17 June 2018

    Open published response

  5. Manchester South

    AI-generated summary

    Kenneth Longley · 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

    Kenneth Longley died at Tameside Hospital on 9 September 2017 after treatment for acute coronary syndrome and severe aortic stenosis led to an upper gastrointestinal bleed. The report identified delays in sending a cardiology referral letter and a lack of action by the GP practice after the letter and echocardiogram results were received.

    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 refer patients to Cardiology following relevant clinical findings or correspondence

    Wider context from the report

    “The letter from ████████, which was received by the GP surgery on the 7th August 2017, referred to an echocardiogram on the 16th May 2017 which confirmed severe aortic stenosis. It asked the GP surgery to arrange for Mr Longley for a specialist cardiology opinion and for him to be reassessed by the GP regarding any further syncopal episodes. The concern is that no action was taken by any GP at the practice to either refer Mr Longley to Cardiology in light of Dr Chambers’ letter or in light of the reported echocardiogram results. Further, no action was taken by any GP to review Mr Longley as requested. The concern is that there is a risk of future deaths if similar lack of action occurs in the future. ”

    Source location

    Kenneth Longley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Central and South East Kent

    AI-generated summary

    Peter Blakeney 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

    Peter Blakeney King was admitted to hospital with confusion, headache, fever and limb weakness, and later fell from his bed on 18 March 2017, sustaining fatal head injuries. The concerns included inadequate documentation and implementation of falls precautions, use of bed rails despite an assessment that they were not recommended, failure to provide an observable bed and crash mat, and failure to address falls risk at handover.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to make referrals to the falls team or physiotherapy

    Wider context from the report

    “(2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy. A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the fall. ”

    Source location

    Peter Blakeney KING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Leicester City and South Leicestershire

    AI-generated summary

    Margery Annie Astill · 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

    Margery Annie Astill was admitted to the Evington Centre under Section 2 of the Mental Health Act. On 2 September 2016, she collided with another agitated patient, fell, and was diagnosed with unsurvivable head injuries; she died three days later. Concerns included ineffective referral and incident-reporting systems, inadequate communication with family members, and delays in providing first aid after falls. The inquest also found that there was no care plan, the ward was understaffed, and not all patient observations 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

    Ineffective diary systems for referrals to different specialisms

    Wider context from the report

    “(1) Diary systems for ensuring referrals to different specialisms were not effective, such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion. ”

    Source location

    Margery Annie Astill · 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 a ward-diary procedure defining task allocation and documentation, with ongoing monthly audits.

    Verbatim wording from the response

    “Mental Health Services Older Persons (MHSOP) Ward Staff Teams have developed, and are in the process of implementing, a Standard Operating Procedure for the safe and effective management of the ward diary. Implementation is being led and embedded in daily practice by the Senior Inpatient Matrons and undertaken by each individual Ward Matron. The process also clearly defines how the ward tasks will be allocated and documented. This process will be subject to an ongoing monthly audit to provide assurance that this is being embedded in practice.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 1 · response
    Published 11 July 2017

    Open published response

  8. Leicester City and South Leicestershire

    AI-generated summary

    Michael John Halfpenny · 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

    Michael John Halfpenny requested screening for an aortic aneurysm in March 2016 because of a strong family history, but the referral was sent to the wrong department, rejected, and not followed up. He later presented with severe abdominal pain on 9 December 2016, but diagnosis was delayed until he was peri-arrest; he died following emergency surgery for a ruptured abdominal aortic aneurysm. Concerns included inadequate referral and follow-up processes, uncertainty about the screening programme, and failures to ensure screening requests reached the correct team.

    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

    Absence of a system to direct screening requests to the correct department

    Wider context from the report

    “Regarding the General Practice involvement - The referral should have been made directly to the vascular screening team but was made to the radiology department - No further action was taken when the screening request was refused - The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery. - The GP practice were uncertain of the existing screening programme and on what criteria to refer patients Regarding the University Hospitals of Leicester NHS Trust - The referral request was marked by the radiology department that screening was “not offered” and the request was refused - The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department - The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned. ”

    Source location

    Michael John Halfpenny · 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

    Operate a system for redirecting incorrectly assigned imaging referrals and notifying referrers of the action and any required follow-up.

    Verbatim wording from the response

    “2. We have implemented a new system for redirecting any imaging referrals that inadvertently get sent to the incorrect team. The Imaging Team, led by the Clinical Director for Imaging, has provided clear instructions to their administration and clerical staff to forward screening requests to the relevant service. A rejection letter will be sent to the referrer detailing the action that has been taken and any further actions required by them.”

    Source location

    2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
    Page 1 · response
    Published 4 August 2017

    Open published response

  9. Liverpool and the Wirral

    AI-generated summary

    Linsay Bushell · 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

    Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.

    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

    Poor coordination and delay in referral review for specialist placement

    Wider context from the report

    “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area. The Jury found: Para 3 1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital. 2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014. 3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation. 4. Linsay put herself in the position in which she was found however her intention was unclear. 5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder. 6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death. 7. The risk was managed adequately and effectively during Linsay's period as an in-patient. 8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made. a. In the Trust Position Statement Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them. 2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015. 3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material. 4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest. 5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity. 6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism. It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment. a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour. b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism. c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism. 7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust. 8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows: a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub. b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour. c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient. d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases. e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package. 9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation. 10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided. 11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels. 12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better. b. In the implementation of Lessons learnt the Trust further accepts 1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay". a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:- b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan. c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay. d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all. e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear. f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan. g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time. h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together. i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs. j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for. k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission. l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation. m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective. 2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation. Discontinuity of Care/Management of Care 3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B. 4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units. 5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach. 6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager. 7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse. 8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway. 9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible. Risk Assessment/Care Planning 10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk. 11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required. ”

    Source location

    Linsay Bushell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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 referring patients to required specialist services

    Wider context from the report

    “(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days. It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late. ”

    Source location

    Derek LEE · 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 record dates of specialist referrals

    Wider context from the report

    “(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days. It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026