Recurring concern

Failure to prevent harmful isolation among vulnerable mental-health service users

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First reported 12 May 2014•Latest report 13 Nov 2023

Definition

What this concern includes

Includes failures by mental-health or closely related care services to identify and address harmful isolation among vulnerable service users, including practical anti-isolation support, appropriate family or support-network contact, and arrangements to maintain connection while people await assessment, coordination or treatment.

Not included

  • Excludes ordinary loneliness, social isolation or limited social activity where no mental-health-care responsibility or safety consequence is identified.
  • Excludes generic family communication or involvement failures where isolation or a related mental-health safety risk is not part of the asserted concern.
  • Excludes general delays, care-coordinator shortages or service-access problems where they do not leave the person isolated or materially increase isolation-related risk.
  • Excludes failures in treatment, crisis response or suicide prevention where isolation is not the shared unsafe condition.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
0

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 England2
Department of Health and Social Care1
Hafod Community Mental Health Team1
Windsor and Maidenhead Community Mental Health Team1
Wokingham Community Mental Health Team1

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. Mid Kent and Medway

    AI-generated summary

    Roger Adrian Stevenson · 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

    Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of steps to address isolation among service users suffering ill health

    Wider context from the report

    “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed. 2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions. 3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm. 4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department, ”

    Source location

    Roger Adrian Stevenson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS England is responsible for addressing the report’s concerns about local mental health service issues.

    Verbatim wording from the response

    “I note that you have also addressed matters of concern to the Chief Executive of NHS England, and I would expect her response to address the concerns raised around local issues.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    Open published response

  2. Inner West London

    AI-generated summary

    Keiran Michael John Toman · 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

    Keiran Michael John Toman had fixed delusions, withdrew from social and psychiatric support, and subsequently starved himself to death due to paranoia before being found deceased in a hotel. The report raised concerns that psychiatric services did not maintain contact with his family despite his lack of insight and capacity, potentially leaving him isolated and increasing the risk of deterioration and 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

    Isolation of vulnerable patients and increased risk of deterioration and death from lack of family contact

    Wider context from the report

    “(2) That the lack of contact with families in such circumstances may leave vulnerable patients isolated and increase their risk of deterioration and death, as occurred in this case and in others that I have investigated. ”

    Source location

    Keiran Michael John Toman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026