Recurring concern

Failure to provide families with information needed to support people receiving mental health care

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First reported 17 Jul 2014•Latest report 5 Jun 2025

Definition

What this concern includes

Includes failures by mental-health services to provide families or household supporters with clear, actionable information about how to support a person receiving care, access support for themselves, or contact, reopen or reinstate relevant mental-health support.

Not included

  • Excludes failures to involve families in clinical decisions, discharge planning or risk management where the specific deficiency is participation rather than provision of support-access information.
  • Excludes clinical assessment, treatment, referral or crisis-response failures where family-facing information was not the deficient control.
  • Excludes generic communication failures and information about unrelated services or administrative matters.
  • Excludes information provided directly to patients or professionals unless the assertion also concerns information needed by families to support mental-health care.
Reports
12

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
18

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3
Kent and Medway Mental Health NHS Trust2
NHS England2
North London NHS Foundation Trust2
Care Quality Commission1
Cornwall Council1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Home Office1
Leicester City Council1
Leicestershire Partnership NHS Trust1
Livewell Southwest1
London Borough of Camden1
Metropolitan Police Service1
National Institute for Health and Care Excellence1
NHS Cornwall and the Isles of Scilly Integrated Care Board1

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. Inner North London

    AI-generated summary

    Sandra Bodrožič’ · Prevention of Future Deaths report

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

    Report summary

    Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.

    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 inform families of the route to obtain an immediate Mental Health Act assessment

    Wider context from the report

    “3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral. However, once the referral was made, it took until the following week for this to be arranged, and Ms Bodrožič’ had killed herself in the meantime, on Sunday, 29 June. Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday. The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family. Ms Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit. ”

    Source location

    Sandra Bodrožič’ · 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

    A private bed was not considered necessary because Trust bed availability was changing and a bed was expected within the required timeframe.

    Verbatim wording from the response

    “1. When ████████ took the decision to admit Ms Bodrozic to hospital on an informal basis on 23rd May 2014 she spoke to the duty nurse at the Highgate Mental Health Centre (the Centre) to make the referral. They discussed the urgency of the referral and although there was no bed available at the Centre it was anticipated that a bed would become available within the next few days. This was appropriate given the clinical urgency of the case at the time. Therefore, a private bed was not considered to be necessary. The family had been advised that they could take Ms Bodrozic to the Accident & Emergency department over the bank holiday weekend if there were any changes in her state of mind or behaviour.”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    Open published response

  2. North East Kent

    AI-generated summary

    Joshua Lewis BROWN · 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

    Joshua Lewis BROWN died on 13 June 2011 after climbing over railings at the edge of cliffs at Louisa Bay and dropping forward from the cliff. The report identified concerns about limited information-sharing and engagement between the Community Health Team and Mr Brown’s family, including the absence of a process for family members to check the accuracy of information recorded about them. It also noted that the family was not made aware of available support and information about how best to support Mr Brown and themselves.

    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 inform family members about available support information and support for themselves

    Wider context from the report

    “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown. (2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members. (3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support. (4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team. ”

    Source location

    Joshua Lewis BROWN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026