Recurring concern

Failure to recognise and respond to deteriorating mental health in service users

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First reported 12 Sep 2013•Latest report 25 Jun 2026

Definition

What this concern includes

Includes failures by mental health or care services to identify deterioration or serious acute mental health risk and take an appropriate response, including assessment, escalation, communication, safeguarding action or urgent intervention when these controls are dedicated to the deteriorating mental-health response.

Not included

Excludes generic staffing, leadership, training, documentation or communication deficiencies that are not explicitly tied to recognising or responding to deteriorating mental health.
Excludes failures concerning physical deterioration or medical emergencies unless the report explicitly links them to deterioration of the service user’s mental health.
Excludes failures in a separate safeguarding, emergency alarm, welfare-check or treatment-refusal process where the report does not identify deteriorating mental health as the shared concern.

Reports: 28
Individual concerns: 31
Date range: 2013–2026
Stated actions: 57

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England5

Central and North West London NHS Foundation Trust3

Department of Health and Social Care3

HM Prison and Probation Service3

Ministry of Justice3

Essex Partnership University NHS Foundation Trust2

Norfolk and Suffolk NHS Foundation Trust2

All Care In One Limited1

All Care In One Ltd1

Bolton Borough Council1

Cambridge Nursing Home Ltd1

Care Quality Commission1

Coldingley Prison1

Cumbria Constabulary1

Department of Community Mental Health, Woolwich Station Medical Centre1

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.

28 Jul2017
London (City)
Concerns raised1
1. Inappropriate reduction of observation frequency despite deteriorating mental state
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Apply the prison-wide procedure defining healthcare staff responsibilities before, during and after ACCT reviews.
  Stated by Central and North West London NHS Foundation TrustStated completed
AI-generated summary

SARAH LYNNE REED · 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

Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

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
Inappropriate reduction of observation frequency despite deteriorating mental state
Wider context from the report
“(7) The jury concluded that the decision to reduce the frequency of observations on Sarah Reed at ACCT Review No.4 on 5 January 2016, six days before Sarah’s death, was inappropriate given the clear evidence of the deterioration of her mental state. ”
Source location
SARAH LYNNE REED · 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
Apply the prison-wide procedure defining healthcare staff responsibilities before, during and after ACCT reviews.

Verbatim wording from the response
“CNWL Offender Care have developed a “Roles and Responsibilities for Attendance at ACCT Reviews” Local Operating Procedure for all of our staff at our prison sites. This has been written in conjunction with NOMS Prison Service Instruction 64/2011 and has been operationalised at all of our prison sites.”

Source location
2017-0238-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 1 August 2017
Open published response
14 Mar2017
Inner North London
Concerns raised1
1. Failure to advise callers to contact emergency services during urgent mental health crises
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement and provide written discharge care plans to service users and relatives after psychiatric assessment in A&E.
  Stated by East London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Directing callers to Police and Ambulance services is considered an appropriate and robust response in emergencies.
  Stated by East London NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Mariana Hungria Bayam Veiga PINTO · 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

Mariana Pinto jumped from the third-floor balcony of her home as a deliberate act, without a proper understanding of what she was doing, after attending the emergency department the previous day. The concerns included whether the crisis team’s limitations and possible symptom worsening had been adequately communicated to her family, and whether the urgent crisis-line call was escalated appropriately.

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 advise callers to contact emergency services during urgent mental health crises
Wider context from the report
“3. The band 7 mental health nurse who took the call to the crisis line at 3.32pm on 16 October, did not suggest to Ms Pinto’s husband that ████████ call the emergency services while the nurse rang Ms Pinto and spoke to her to offer what support he could. When ████████ told him that the situation was now urgent, the nurse responded that the time for home visits was 5-7pm. After the call had ended, the nurse did not discuss with colleagues the potential to bring the home visit forward. The nurse did not ring the emergency services himself in case ████████ had been unable to make the call. ”
Source location
Mariana Hungria Bayam Veiga PINTO · 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 provide written discharge care plans to service users and relatives after psychiatric assessment in A&E.

Verbatim wording from the response
“It is obviously important to ensure that both the patient and relatives/carers are aware of the steps to take should there be a serious deterioration in an individual’s mental state. Having considered your concern I am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service users/relatives prior to discharge from A&E following a psychiatric assessment.”

Source location
response-Pinto
Page 2 · response
Published 5 April 2017
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
Directing callers to Police and Ambulance services is considered an appropriate and robust response in emergencies.

Verbatim wording from the response
“In relation to your final point regarding the handling of the call made by Mr Parra-Braun on the afternoon of 16th October it is important to confirm that in an emergency situation advice to contact Police and Ambulance is an appropriate and robust response. I believe that your specific concern related to what support the HTT could have provided in the interim, for example the member of staff attempting to speak to the service user to deescalate the situation and/or personally contacting the emergency services.”

Source location
response-Pinto
Page 2 · response
Published 5 April 2017
Open published response
13 Jun2016
Cheshire
Concerns raised2
1. Failure to recognise relapse into depression
2. Failure to plan ongoing mental health care and relapse management
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Maintain nationally specified integrated stepped mental-health care, including consultant psychiatry, long-term care planning and continuity of care.
  Stated by NHS EnglandStated completed
2. Action
  Roll out the revised Person Escort Record and provide training so operational staff transfer relevant health information throughout custody transitions.
  Stated by NHS EnglandStated in progress
AI-generated summary

Kevin Dermott · 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

Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his 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 recognise relapse into depression
Wider context from the report
“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”
Source location
Kevin Dermott · 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 plan ongoing mental health care and relapse management
Wider context from the report
“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”
Source location
Kevin Dermott · 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
Maintain nationally specified integrated stepped mental-health care, including consultant psychiatry, long-term care planning and continuity of care.

Verbatim wording from the response
“Better integration of health care services within prisons has also been supported by the development of a national set of service specifications for primary care services (including GP and nursing services), mental health services and substance misuse services. The mental health service specification outlines the requirement for mental health services to provide an integrated stepped care model for mental health which enables patients to flow seamlessly between mild to moderate and severe and enduring stages based on clinical need and include the provision of a consultant psychiatrist. These service specifications were developed in December 2013 and set the outcomes and standards required from the services including long-term care planning and continuity of care.”

Source location
2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016
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
Roll out the revised Person Escort Record and provide training so operational staff transfer relevant health information throughout custody transitions.

Verbatim wording from the response
“NHS England is supporting the National Offender Management Services (NOMS) with their review of the Person Escort Record (PER). This revised form ensures that all current and relevant information, including health information, is held in one document and transfers with the prisoner from police custody through to reception into prison and during any subsequent prison transfer or release. The roll out of the paper form pilot is still ongoing and work is being undertaken to ensure PER training will be available to all operational staff. This is expected to be launched by March 2017. The digital PER form is being piloted in a couple of prisons and NOMS are leading on this work.”

Source location
2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016
Open published response
4 Jun2015
Cumbria
Concerns raised1
1. Failure of psychiatric assessments to recognise mental disorder and suicide risk
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Alice Anne McMeekin · 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

Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

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 psychiatric assessments to recognise mental disorder and suicide risk
Wider context from the report
“2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day. 3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference. It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder. ”
Source location
Alice Anne McMeekin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
25 Mar2015
Essex
Concerns raised1
1. Failure to refer firearms licence holders with deteriorating mental health to the police
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Mr Harold Ambrose and Mrs Wendy Ambrose · 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 Harold Ambrose shot his wife, Mrs Wendy Ambrose, and then himself; police found both bodies. Mr Ambrose had a shotgun licence and developed worsening mixed dementia, but neither his GP nor the mental health trust referred the matter to the police firearms department. The report identified that there was no requirement for them to notify police about mental health concerns when aware that a patient held a firearms licence.

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 firearms licence holders with deteriorating mental health to the police
Wider context from the report
“Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system. In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012. In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued. Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence. ”
Source location
Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report
Page 1 · concerns
Open source report
4 Dec2014
Norfolk
Concerns raised1
1. Failure to investigate and act on correlations between deteriorating physical and mental health
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

JO ANNE CAROL NOBBS · 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

Jo Anne Carol Nobbs had longstanding physical and mental health problems and was found dead at home on 2 June 2014 after disengaging from professionals and stopping collection of her medications. Concerns included failure to investigate or act on the relationship between her deteriorating physical and mental health, and the lack of a revised care plan when she stopped engaging with mental health services.

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 investigate and act on correlations between deteriorating physical and mental health
Wider context from the report
“(1) A correlation between Miss Nobbs’ deteriorating physical health and her deteriorating mental health was noted by some mental health professionals and documented in her mental health records but this was not investigated or acted upon by other mental health professionals, despite Miss Nobbs attending at A & E Department, Norfolk & Norwich University Hospital on at least 10 occasions between January and March 2014 presenting with a variety of symptoms and at varying times of day and night ”
Source location
JO ANNE CAROL NOBBS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Apr2014
Exeter & Greater Devon
Concerns raised1
1. Failure to respond sufficiently seriously and promptly to mental health crisis calls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Investigate the ambulance response to the relevant calls and complete the investigation report.
  Stated by SWASFTStated completed
2. Action
  Disseminate information on the correct process for arranging ambulance transport.
  Stated by SWASFTStated completed
3. Action
  Upgrade the NHS Pathways system to version 6.5.1 with a dedicated Mental Health Pathway.
  Stated by SWASFTStated completed
1. Action
  Train Clinical Hub staff, including new starters, to use the Mental Health Pathway through NHS Pathways training and scenarios.
  Stated by SWASFTStated completed
2. Action
  Establish a Mental Health Group to monitor responses to mental health concerns and develop policies, procedures and guidelines.
  Stated by SWASFTStated completed
AI-generated summary

Roger Clive DUGGAN · 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 Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.

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 respond sufficiently seriously and promptly to mental health crisis calls
Wider context from the report
“(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend. It appears that staff lacked the necessary training to deal with Mental Health Crisis. After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013. ”
Source location
Roger Clive DUGGAN · 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
Investigate the ambulance response to the relevant calls and complete the investigation report.

Verbatim wording from the response
“Following notification of the incident by Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG) the Trust conducted an investigation into the ambulance response to ████████ calls. This investigation was completed in May 2013 and forwarded to NEW Devon CCG for inclusion within the Serious Incident investigation which they led on. A meeting chaired by NEW Devon CCG, and attended by all agencies involved, subsequently took place to discuss the findings of the investigation and develop an action plan. A copy of the investigation report is appended to this letter, unfortunately this Trust was not aware that the inquest into Mr Duggan’s death was taking”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 1 · response
Published 7 April 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Disseminate information on the correct process for arranging ambulance transport.

Verbatim wording from the response
“The investigation concluded that there appeared to be a misunderstanding by the Crisis team on the correct procedure for requesting ambulance transport for patients who required assessment or have a pre-arranged admission which subsequently led to communication difficulties. Following the meeting chaired by NEW Devon CCG, information was disseminated regarding the correct process for arranging transport and would have resulted in an appropriate ambulance response.”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Upgrade the NHS Pathways system to version 6.5.1 with a dedicated Mental Health Pathway.

Verbatim wording from the response
“Following this incident, in July 2013, the Trust upgraded its version of ‘NHS Pathways’ to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate. Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway, this training is also provided for all new Clinical Hub staff as part of their ‘NHS Pathways’ training and includes scenarios.”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Train Clinical Hub staff, including new starters, to use the Mental Health Pathway through NHS Pathways training and scenarios.

Verbatim wording from the response
“Following this incident, in July 2013, the Trust upgraded its version of ‘NHS Pathways’ to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate. Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway, this training is also provided for all new Clinical Hub staff as part of their ‘NHS Pathways’ training and includes scenarios.”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a Mental Health Group to monitor responses to mental health concerns and develop policies, procedures and guidelines.

Verbatim wording from the response
“In order to monitor the Trust’s response to patients with Mental Health concerns and develop robust policies, procedures and guidelines to improve the quality of care provided, a Mental Health Group has recently been established. This Group is chaired by a Trust Clinical Development Manager and is attended by managers from key areas of the Trust,”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
Open published response
12 Sep2013
Norfolk
Concerns raised1
1. Failure to recognise and act on suicide or serious self-harm risk
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Monitor urgent referrals against the four-hour standard through daily reporting, senior oversight, and clinical review of contact and minimum telephone-contact requirements.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
2. Action
  Audit the assessment structure and clinicians’ judgements to support further development of suicide-risk assessment.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
AI-generated summary

Matthew Christopher Dunham · 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

Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

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 recognise and act on suicide or serious self-harm risk
Wider context from the report
“c) On the 8th of April 2013, despite the fact that Mr Dunham was presenting as feeling suicidal and specifically that he had set up a noose in his flat the previous night, it was not thought appropriate to refer him to the crisis team for appropriately robust intervention. This raises the issue of the basis upon which the risk of suicide or serious self harm is recognised and acted upon particularly where the person concerned has gone beyond vague suicidal ideation and moved towards contemplating some specific way of ending his life. ”
Source location
Matthew Christopher Dunham · 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
Monitor urgent referrals against the four-hour standard through daily reporting, senior oversight, and clinical review of contact and minimum telephone-contact requirements.

Verbatim wording from the response
“The Trust has implemented monitoring mechanisms for the four hour 'urgent referral' standard which is reported daily to commissioners and is monitored by senior managers and clinicians.”

Source location
Response
Page 1 · response
Published 26 January 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit the assessment structure and clinicians’ judgements to support further development of suicide-risk assessment.

Verbatim wording from the response
“The Trust's internal investigation recognised that the AAT is a new service (commenced in February 2013). The investigation recommended that an audit be completed to seek assurance on the robustness of the assessment structure, both from the perspective of the framework and clinician's individual judgements within it. This will provide the evidence to support further developments in the assessment of suicide risk alongside the Trust's current mandatory training programme. This audit is currently in progress and I would be happy to share a copy of its report upon conclusion.”

Source location
Response
Page 2 · response
Published 26 January 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inappropriate reduction of observation frequency despite deteriorating mental state

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to advise callers to contact emergency services during urgent mental health crises

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to recognise relapse into depression

Failure to plan ongoing mental health care and relapse management

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure of psychiatric assessments to recognise mental disorder and suicide risk

Concerns raised1

Failure to refer firearms licence holders with deteriorating mental health to the police

Concerns raised1

Failure to investigate and act on correlations between deteriorating physical and mental health

Concerns raised1

Failure to respond sufficiently seriously and promptly to mental health crisis calls

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to recognise and act on suicide or serious self-harm risk

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 1

Actions described in response 1

Respondent positions 1

Actions described in response 2

Actions described in response 5

Actions described in response 2