5 Jul 2022 Antony Christopher MCLELLAN · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 1
Failure to incorporate autism into assessment and management of self-harm risk View source
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.
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AI-generated summary
Antony Christopher MCLELLAN · 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
Antony Christopher McLellan was found unresponsive, hanging by a ligature in the garage at his home on 9 July 2021; his death was recognised that afternoon and the inquest concluded that he died by suicide. Concerns included that assessment and formulation of risks and safety did not fully explore the impact of his autism, including how he might communicate distress and risk, and that autism-informed support and services required significant improvement and expansion.
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 incorporate autism into assessment and management of self-harm risk
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Source location Antony Christopher MCLELLAN · Prevention of Future Deaths report
Open source report
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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 TEWV is responsible for delivering mental health services and making autism-related reasonable adjustments under its contract.
Verbatim wording from the response “The CCG (and now ICB) commission Tees, Esk, Wear Valley NHS Trust (TEWV) to provide the Mental Health provision to the residents of North Yorkshire. This would be the case whatever the Mental Health condition is and whether that is suspected, being assessed or diagnosed. The contract requires this provision of service. In addition to this where an individual with mental health conditions also has a diagnosis of autism, the contractual expectation would be that TEWV would make reasonable adjustments to their service to ensure that it is delivered to meet the needs of those individuals with autism and a mental health condition.” Source location Response from NHS England
Open published response
Concerns raised 7
Lack of multidisciplinary clinical assessment and formulation addressing autism View source Lack of local specialist autism assessment and adapted psychological therapy View source Failure to understand autism-related trauma in risk assessment View source
Failure to respond promptly to distress and remove discounted diagnostic references View source Failure to make timely reasonable sensory and environmental adjustments View source Lack of person-centred autism-informed holistic care planning View source Failure to avoid attributing an undiagnosed personality disorder to an autistic patient View source See 4 more concerns
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.
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. 25
Action
Review 134 patients’ autism and EUPD diagnoses, communications, withdrawals, reasonable adjustments and treatment options.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Require autism-informed care, treatment, safety summaries and safety plans within multidisciplinary team processes, including patient and advocate involvement where possible.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Invest £40 million to improve seven-day specialist multidisciplinary and crisis support capacity for autistic people and people with learning disabilities.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Support projects testing improvements to autism diagnostic pathways.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Use project learning and research to inform guidance and support for improved autism diagnostic assessments.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022. View source
Action
Audit individual funding referrals to identify demand for autism-related therapy and inform service planning.
Stated by NHS Humber and North Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Hold learning events with TEWV and service users to inform autism-related therapy commissioning and delivery.
Stated by NHS Humber and North Yorkshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Consider how autism-related services should be commissioned and delivered in future.
Stated by NHS Humber and North Yorkshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Examine immediate and interim arrangements for autism-related therapy in light of the Regulation 28 notice and service-user discussions.
Stated by NHS Humber and North Yorkshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Deliver autism-awareness and trauma-informed training addressing reasonable adjustments, autism-related trauma and staff understanding of autistic people’s needs.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Implement revised risk-assessment and safety-planning tools with associated multidisciplinary training, including autism-specific suicide-risk content.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Provide autism training, supervision and consultation for clinical and non-clinical staff on risk, diagnosis, needs and holistic care planning.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Require registered providers to ensure staff receive role-appropriate learning disability and autism training.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Implement the National Autism Strategy while considering effective mechanisms, including empowering local systems to improve outcomes.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Fund autism training for staff working in adult mental health inpatient settings.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022. View source
Action
Obtain specialist autism support for community teams to review care quality and reasonable adjustments, while monitoring uptake.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Fund projects improving sensory environments in mental health hospitals through environmental changes, staff training and patient-experience learning.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Develop a sensory-friendly resource pack for health trusts and Integrated Care Systems.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Develop and embed an autism-informed care-planning process with evaluation and sustainability work for person-centred holistic plans.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Adopt nationally recommended collaborative care planning using holistic, individualised recovery plans based on the DIALOG model.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Communicate learning from Zoe’s death and subsequent inquiries, including the need to validate or review EUPD diagnoses, to relevant clinical and senior medical staff.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Communicate learning from Zoe’s death and inquiries, including the need to validate or review EUPD diagnoses, to clinical and senior medical staff.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source See 22 more actions
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AI-generated summary
Zoe Emma ZAREMBA · 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
Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.
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 multidisciplinary clinical assessment and formulation addressing autism
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism ;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
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 Lack of local specialist autism assessment and adapted psychological therapy
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy . Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
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 understand autism-related trauma in risk assessment
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe .
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
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 respond promptly to distress and remove discounted diagnostic references
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution . There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
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 make timely reasonable sensory and environmental adjustments
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all ;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
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 Lack of person-centred autism-informed holistic care planning
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender . As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
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 avoid attributing an undiagnosed personality disorder to an autistic patient
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”) .
3 That attribution was not formally diagnosed , and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
Open source report
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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 Review 134 patients’ autism and EUPD diagnoses, communications, withdrawals, reasonable adjustments and treatment options.
Verbatim wording from the response “Within the Trust we have now identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Require autism-informed care, treatment, safety summaries and safety plans within multidisciplinary team processes, including patient and advocate involvement where possible.
Verbatim wording from the response “To assist staff in practically achieving this goal, additional measures have been introduced into the MDT process to ensure that, where a patient has a diagnosis of autism, their care, treatment, safety summary and safety plan take that diagnosis into account and provide a comprehensive assessment of need. MDT formulation now includes patients and their advocates, wherever possible, in order to ensure honest and transparent communication when reaching a diagnosis.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Invest £40 million to improve seven-day specialist multidisciplinary and crisis support capacity for autistic people and people with learning disabilities.
Verbatim wording from the response “You raised the importance of community provision. In 2022/2023, we are investing £70 million to prevent avoidable admissions and improve community support for autistic people and people with a learning disability. This includes £40 million to improve the capacity and capability of 7-day specialist multidisciplinary and crisis support for autistic people and people with a learning disability in every area of the country. Additionally, £30 million has been committed for keyworker services for autistic children and young people and children and young people with a learning disability with the most complex needs at risk of being admitted to mental health settings or who are inpatients.” Source location Response from Department of Health and Social Care
Open published response
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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 Support projects testing improvements to autism diagnostic pathways.
Verbatim wording from the response “In the context of the NHS Long Term Plan, initiatives have been undertaken by NHS England that are of relevance to the issues raised following Zoe’s death. This includes one off funding made in 2021/2022 for future improvements, to include:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use project learning and research to inform guidance and support for improved autism diagnostic assessments.
Verbatim wording from the response “• £7 million for local areas to test ways to improve the quality of autism diagnostic pathways. This funding supported a wide range of projects that tested new ways to support people and their families through the autism diagnostic pathway (39 projects for children and young people and 25 projects for adults: a total of 64 one-off projects). The projects are still underway, and outcomes are expected to be reported to the programme later this year and into early 2023. We will use the learning from these projects along with any available research to inform guidance/support for local systems on how to improve the quality and access to autism diagnostic assessments including pre and post diagnostic support” Source location Response from NHS England
Open published response
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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 individual funding referrals to identify demand for autism-related therapy and inform service planning.
Verbatim wording from the response “The CCG/ICB has audited the referrals for individual funding which it has received within the last 24 months and there is a trend for requests for therapy for those with autism spectrum disorder which appears to highlight a need for further consideration of the commissioned service. The CCG/ICB is clear that TEWV are the commissioned mental health provider of services and as such; even where a patient” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
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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 Hold learning events with TEWV and service users to inform autism-related therapy commissioning and delivery.
Verbatim wording from the response “has a dual diagnosis of autism spectrum disorder and some other mental health condition; TEWV should be in a position to deliver adjusted services to support their needs. The level of requests for additional therapy for those with autism diagnosis suggests that this is not proving to be fully effective at this time. The CCG/ICB is therefore working on a series of learning events with both TEWV and service users at present whilst considering how services ought to be commissioned and delivered moving forwards, whilst also looking at more immediate and interim arrangements based on the findings in the regulation 28 notice and from direct discussions and queries with service users.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
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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 Consider how autism-related services should be commissioned and delivered in future.
Verbatim wording from the response “has a dual diagnosis of autism spectrum disorder and some other mental health condition; TEWV should be in a position to deliver adjusted services to support their needs. The level of requests for additional therapy for those with autism diagnosis suggests that this is not proving to be fully effective at this time. The CCG/ICB is therefore working on a series of learning events with both TEWV and service users at present whilst considering how services ought to be commissioned and delivered moving forwards, whilst also looking at more immediate and interim arrangements based on the findings in the regulation 28 notice and from direct discussions and queries with service users.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
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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 Examine immediate and interim arrangements for autism-related therapy in light of the Regulation 28 notice and service-user discussions.
Verbatim wording from the response “has a dual diagnosis of autism spectrum disorder and some other mental health condition; TEWV should be in a position to deliver adjusted services to support their needs. The level of requests for additional therapy for those with autism diagnosis suggests that this is not proving to be fully effective at this time. The CCG/ICB is therefore working on a series of learning events with both TEWV and service users at present whilst considering how services ought to be commissioned and delivered moving forwards, whilst also looking at more immediate and interim arrangements based on the findings in the regulation 28 notice and from direct discussions and queries with service users.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
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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 Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Verbatim wording from the response “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Response from TEWV
Open published response
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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 Deliver autism-awareness and trauma-informed training addressing reasonable adjustments, autism-related trauma and staff understanding of autistic people’s needs.
Verbatim wording from the response “The Trust Board have received training in this essential work so that they are better informed, they remain committed to ensuring that it is embedded into clinical journey and subsequent underpinning practice to seek to understand patient needs. Across the Trust we are delivering autism awareness training to our clinical staff with a focus on how to make reasonable adjustments for autistic people so that they can access and benefit from services. Additionally, we are focussing on avoidance of trauma in this training so the potential to traumatise autistic people is reduced. We humbly accept that if everybody (including staff) understood autism better, then trauma such as Zoe experienced would be reduced.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 revised risk-assessment and safety-planning tools with associated multidisciplinary training, including autism-specific suicide-risk content.
Verbatim wording from the response “As a Trust we do take very seriously our responsibility to ensure that our patients have the most robust multidisciplinary risk assessment facilitated by trained and competent staff. The safety summary is the Trust’s risk assessment tool, and a significant amount of work has been undertaken by the Trust in respect of improving the quality of risk assessments, across both inpatient and community settings to ensure that full and up to date information is included as part of the risk assessment. The harm minimisation training supports an individualised and needs-led approach to risk assessment, and this includes people with Autism and their specific needs. In order to drive this work forward, a Trust-wide quality improvement event was held in August 2021 the Trust Clinical Advisory Group commenced work in reviewing harm minimisation training.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Provide autism training, supervision and consultation for clinical and non-clinical staff on risk, diagnosis, needs and holistic care planning.
Verbatim wording from the response “Additionally, we offer as a trust a full day Understanding Autism Training which has a focus on risk assessment for autistic people, diagnosis and associated risks and needs. This training is further consolidated through the offering of individual Autism supervision and consultation for clinical staff.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Require registered providers to ensure staff receive role-appropriate learning disability and autism training.
Verbatim wording from the response “We know that having the right workforce with the right skills and training to support autistic people is crucial in ensuring a person receives safe and appropriate care and support. This is why, from 1 July 2022, registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role.” Source location Response from Department of Health and Social Care
Open published response
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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 the National Autism Strategy while considering effective mechanisms, including empowering local systems to improve outcomes.
Verbatim wording from the response “You may also wish to know that, on 21 July 2021, we published the refreshed National Autism Strategy, which aims to improve the lives of autistic people by addressing health inequalities and improving access to public services.² Actions within the strategy include improving health and care professionals’ understanding of autism. We remain committed to implementing the strategy and are considering the most effective mechanisms to achieve this, including empowering local systems to deliver improved outcomes for autistic people.” Source location Response from Department of Health and Social Care
Open published response
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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 Fund autism training for staff working in adult mental health inpatient settings.
Verbatim wording from the response “In the context of the NHS Long Term Plan, initiatives have been undertaken by NHS England that are of relevance to the issues raised following Zoe’s death. This includes one off funding made in 2021/2022 for future improvements, to include:” Source location Response from NHS England
Open published response
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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 Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Verbatim wording from the response “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
Open published response
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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 Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
Verbatim wording from the response “Our new patient recording information system (CITO) will not only allow a greater clarity around active and discounted diagnoses but will importantly also support patient access to their own records improving mutual understanding and effective” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Obtain specialist autism support for community teams to review care quality and reasonable adjustments, while monitoring uptake.
Verbatim wording from the response “Within the North Yorkshire teams, and across the trust supervision and support is being sought by the generic community teams on a case-by-case basis from clinical experts, who have an appropriate level of expertise to check and challenge the quality of care being provided. This is not only in relation to the specific care and treatment pathway for the individuals concerned, but also looks at the ability and understanding of the team to provide reasonable adjustments when working with patients who have an autism diagnosis or who present with such traits. This sits alongside the training that is being delivered to local teams to increase knowledge and understanding of these issues.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Fund projects improving sensory environments in mental health hospitals through environmental changes, staff training and patient-experience learning.
Verbatim wording from the response “• £4 million for a range of projects across the country to improve the sensory environment of mental health hospitals. There were 40 projects across the country aimed at environmental changes to accommodate sensory needs of autistic people in mental health inpatient settings. The projects delivered changes to the physical environment and/or training for staff on the sensory needs of autistic people and/or learning from the experiences of patients.” Source location Response from NHS England
Open published response
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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 Develop a sensory-friendly resource pack for health trusts and Integrated Care Systems.
Verbatim wording from the response “The University of Reading were also been asked to develop a sensory assessment tool for use in mental health hospitals and we commissioned the National Development Team for Inclusion (NDTi) to develop Ten Sensory Friendly Ward Principles as part of the “It’s Not Rocket Science” work; see here for details. The Ten Principles are focused on the, often quite small, changes needed to ward environments to improve the sensory environment for autistic people. The principles were used to inform the development and delivery of the sensory projects programme in 2021/2022 so that projects had to demonstrate how the principles were used. We are currently developing a sensory friendly resource pack for health Trusts and Integrated Care Systems (ICSs).” Source location Response from NHS England
Open published response
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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 Develop and embed an autism-informed care-planning process with evaluation and sustainability work for person-centred holistic plans.
Verbatim wording from the response “As a trust we offer a full day Understanding Autism training for both clinical and non-clinical staff, which has a focus on developing holistic plans of care for autistic people and reflects diagnosis and associated risks and needs. This is consolidated through the offering of individual autism supervision and consultation for clinical staff. The utilisation of supervision and consultation has increased over the last twelve months ensuring that care plans consider the needs of the autistic patient. Work is actively taking place to ensure that Autistic people’s needs can be reflected within the new care planning process.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Adopt nationally recommended collaborative care planning using holistic, individualised recovery plans based on the DIALOG model.
Verbatim wording from the response “We are adopting the nationally recommended changes to care planning to ensure that this is more collaborative and focussed on holistic needs with individualised recovery plans based on the DIALOG model. Increasingly, across the system, we
████████
████████” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
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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 Communicate learning from Zoe’s death and subsequent inquiries, including the need to validate or review EUPD diagnoses, to relevant clinical and senior medical staff.
Verbatim wording from the response “5) Learning from Zoe’s death and the subsequent inquiries has already been communicated by the patient safety team, and most recently the need to be validating or reviewing any diagnosis of EUPD has been highlighted by the medical director to a meeting of all senior medical staff (1st June 2022).” Source location Response from TEWV
Open published response
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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 Communicate learning from Zoe’s death and inquiries, including the need to validate or review EUPD diagnoses, to clinical and senior medical staff.
Verbatim wording from the response “5) Learning from Zoe’s death and the subsequent inquiries has already been communicated by the patient safety team, and most recently the need to be validating or reviewing any diagnosis of EUPD has been highlighted by the medical director to a meeting of all senior medical staff (1st June 2022).” Source location Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
Open published response
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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 TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
Verbatim wording from the response “This is therapy which is beyond that which TEWV can provide as the primary mental health provider. That does not change the expectation that TEWV be in a position to make appropriate adjustments to their mental health support for those with any neuro development diagnosis. By this we mean that we would expect TEWV to be in a position to support those with a mental health condition even where they have a diagnosis of autism spectrum disorder however it is recognised by the CCG/ICB that there may be cases where there is additional specialist input required. This is when IFR requests are made. The CCG/ICB accepts that this is becoming more frequent and the reasons for this are not clear but are sufficient for the CCG/ICB to be considering the commissioning pathway for this type of therapy.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
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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 In North Yorkshire, autism assessment and support are commissioned from services outside the Trust.
Verbatim wording from the response “• In North Yorkshire the commissioned service for assessment and support is external to the Trust and so the numbers are correspondingly less in terms of those waiting for an assessment.” Source location Response from TEWV
Open published response
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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 Autism assessment and support in North Yorkshire are commissioned from services external to the Trust.
Verbatim wording from the response “• In North Yorkshire the commissioned service for assessment and support is external to the Trust and so the numbers are correspondingly less in terms of those waiting for an assessment.” Source location Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialist autism assessment and adapted psychological interventions require individual funding and are usually delivered by The Retreat.
Verbatim wording from the response “We acknowledge that commissioning arrangements which are currently led by The Clinical Commissioning Group, are complex and provided by multiple organisations. The current position is that Adult Autism diagnostic services are commissioned through The York Retreat for York and North Yorkshire and are commissioned through TEWV for Durham and Tees Valley.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pandemic-related disruption to services was outside the control of the CCGs, TEWV and the Retreat Centre.
Verbatim wording from the response “Unfortunately the disruption to services caused by the Covid-19 pandemic was out of the control of the CCGs, TEWV and the Retreat (Tuke) Centre. That said, as the Retreat (Tuke) Centre was not providing core services to Zoe; there would be an expectation that she would be kept safe utilising core mental health services provided by TEWV. This should have meant that Zoe's core mental health care would have been provided by TEWV and risk assessed by them however as TEWV had adapted their model of care delivery for Zoe it may be that this was not appreciated in the usual practice of community mental health services.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
12 Mar 2022 Samuel Alban Stanley · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1
Diagnostic-only commissioning for children with autism and learning disabilities without an overt mental health diagnosis View source
This report raised 8 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.
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AI-generated summary
Samuel Alban Stanley · 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
Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.
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 Diagnostic-only commissioning for children with autism and learning disabilities without an overt mental health diagnosis
Wider context from the report “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death. The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis .
” Source location Samuel Alban Stanley · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £2.1 million in local neurodevelopmental services to improve provision for children and young people.
Verbatim wording from the response “In terms of the commissioning of services, the CCG actively works with partners across the health system to ensure gaps do not exist and that pathways are in place to cater for the presentations and needs of the local communities it serves. NELFT are commissioned to provide more than just diagnostic services including psychological and psychosocial interventions, but the CCG acknowledge that mental health services are under extreme pressure, with increasing referrals that have significantly peaked during and post pandemic. Therefore, the CCG is actively working with NELFT to ensure that services are developed to meet the needs of all children and young people and to identify areas where the service offer can be strengthened and have increased significant levels of investment to help address this.” Source location Response from Kent and Medway Clinical Commissioning Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NELFT to develop children’s mental health services and strengthen the service offer for children and young people.
Verbatim wording from the response “In terms of the commissioning of services, the CCG actively works with partners across the health system to ensure gaps do not exist and that pathways are in place to cater for the presentations and needs of the local communities it serves. NELFT are commissioned to provide more than just diagnostic services including psychological and psychosocial interventions, but the CCG acknowledge that mental health services are under extreme pressure, with increasing referrals that have significantly peaked during and post pandemic. Therefore, the CCG is actively working with NELFT to ensure that services are developed to meet the needs of all children and young people and to identify areas where the service offer can be strengthened and have increased significant levels of investment to help address this.” Source location Response from Kent and Medway Clinical Commissioning Group
Open published response
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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 NELFT was commissioned to provide psychological and psychosocial interventions, not solely autism and learning-disability diagnostic services.
Verbatim wording from the response “3. Concern that there was a lack of psychosocial and psychological therapies offered in this case. This was compounded by the information shared that NELFT may not have been commissioned to provide anything other than a diagnostic service for those presenting with autism and learning disabilities rather than an overt mental health issue.” Source location Response from Kent and Medway Clinical Commissioning Group
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PFD Monitor interpretation Commissioners are responsible for ensuring locally appropriate health and social care services, including services for people with complex needs.
Verbatim wording from the response “You may wish to know that under the Equality Act (2010), health and social care organisations must make reasonable adjustments to ensure that disabled people are not disadvantaged. Commissioners are responsible for ensuring the provision of services based on the local needs of their population, including for people with learning disabilities, mental health problems and complex physical needs. Commissioners should take into consideration any relevant guidance, such as those published by the National Institute for Health and Care Excellence in designing their local services.” Source location Response from Department of Health and Social Care
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31 Jan 2022 OSKAR MILES NASH · Prevention of Future Deaths report Surrey
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Concerns raised 1
Lack of mandatory Autism training for child mental health referral triage staff View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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OSKAR MILES NASH · 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
Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of mandatory Autism training for child mental health referral triage staff
Wider context from the report “The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I have been told that the triaging process is now undertaken by an “Access and Advice Team” but I am concerned that there continues to be no requirement for the staff in that Team to undertake relevant Autism training on a mandatory basis .
” Source location OSKAR MILES NASH · Prevention of Future Deaths report
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory Autism Awareness training to CYPS staff, initially prioritising the Access and Advice Team.
Verbatim wording from the response “Our response
A new “Autism Awareness” half-day training course, provided by the Association for Psychological Therapies (APT), has been added to the mandatory training matrix for all CYPS staff. The course is designed to raise staff’s knowledge and awareness of the importance of autism and covers issues such as:” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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PFD Monitor interpretation The Secretary of State for Health and Social Care will address mandatory learning disability and autism training under Concern 12.
Verbatim wording from the response “There were clearly failings in Oskar’s case. We recognise that the current special education and disability system, established through the Children and Families Act 2014, does not consistently deliver the services needed by children and young people and their families. That is why we have undertaken a comprehensive review of how the system has evolved since 2014 and how it can be made to work best for all families, ensuring quality of provision is the same across the country. In doing so we have placed a clear focus on the importance of joined-up support, working in collaboration with the Department of Health and Social Care (and the Secretary of State for Health and Social Care, will be writing to you with regard to mandatory training in learning disability and autism (Concern 12)).” Source location 2022-0031-Response-from-Department-for-Education_Published
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25 Mar 2021 Sean Daniel FEGAN · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to account for autistic presentation when understanding mental health needs View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sean Daniel FEGAN · 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
Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to account for autistic presentation when understanding mental health needs
Wider context from the report “6. Autism awareness – I was concerned that Mr Fegan’s presentation acted as a barrier to a proper understanding of his mental health needs . In line with his autism diagnosis, he did not present in a socially typical way of expressing his feelings and emotions in a demonstrative manner, but rather ‘jumped’ to his view about what treatment he required, namely prescriptions. This was misunderstood by professionals on more than one occasion .
” Source location Sean Daniel FEGAN · Prevention of Future Deaths report
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore shared learning with clinicians, teams and the family from Mr Fegan’s case.
Verbatim wording from the response “Nevertheless we acknowledge that at this point in time he had had a previous admission of some length and more information could have been obtained from his GP about his current mental health, and more consideration could have been given to the details pertaining to his previous admission into B2. The team have reflected over this, and consider that undertaking an assessment at this point would have enabled a clearer formulation to be developed with him, with a rounded consideration of the interplay between Mr Fegan’s ASD, substance misuse and any underlying mental illness, to inform a plan for him. The Clinical Director will explore opportunities for shared learning with other clinicians and teams from Mr Fegan’s story. This will also be explored in discussion with his family.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the established Neurodevelopmental Specialist Service to provide autism diagnosis, post-diagnostic support, training, assessment advice, care planning and crisis support.
Verbatim wording from the response “A Neurodevelopmental Specialist Service (NeSS) is now established, from 1st April 2021, to offer diagnosis and post-diagnostic support for autistic people. NeSS will provide training and development of competence in mental health services to support assessment, care planning, advice, and crisis support for autistic people with mental health conditions in the community. Advice can be sought in relation to complex referral decision making involving individuals with autism as a diagnosis.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit a dedicated speech and language therapist to support autistic people in community crisis.
Verbatim wording from the response “The Trust is also strengthening the support provided to people with autism in crisis by recruiting a speech and language therapist dedicated to work with autistic people in crisis in the community, by making use of the additional funding that will be made available from NHS England. There is an ongoing mental health division wide steering group for autism that brings together clinical and non-clinical colleagues to clarify treatment pathways for autistic people and share good practice within the mental health division.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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PFD Monitor interpretation Provide additional training on autism-spectrum-disorder presentations for Crisis Resolution Home Treatment staff.
Verbatim wording from the response “The Crisis team has since been enhanced and expanded to allow for the increasing number of patients on its caseload, and there will be more training available specifically relating to ASD presentations as outlined in paragraph one and six.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot and plan Trust delivery of tiered mandatory learning-disability and autism training for health and social-care staff.
Verbatim wording from the response “The ████████ mandatory training in learning disability and autism is being piloted from April 2021 for all health and social care staff. This training will be delivered in three tiers: Tier 1: autism awareness, Tier 2: for all clinicians and Tier 3, for advanced specialists. There is an ongoing national pilot on the delivery of this training. The Trust’s Learning and Development teams are involved in planning delivery of this training within the Trust in line with national recommendations. As mentioned earlier the Trust has the Neurodevelopment Steering group established with a working group in place, including AMH and NeSS, with the aim of developing and enhancing the clinical care pathways.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the established Neurodevelopmental Case Discussion Forum for clinicians to present complex cases and obtain advice.
Verbatim wording from the response “Also established is the Neurodevelopmental Case Discussion Forum, facilitated by an experienced clinician in the NeSS service, where clinicians can bring complex cases to present and discuss, and obtain advice.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate learning from the autism-deaths review into training and future service developments.
Verbatim wording from the response “The service has also undertaken work around learning from deaths of individuals with autism, part of which is the Learning from Autism Deaths Thematic Review. The learning from this will be included in training and future service developments.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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PFD Monitor interpretation The referral decision was jointly and carefully considered using available information, although additional GP information could have improved the assessment.
Verbatim wording from the response “At the time the decision was made, it was made in joint approach with the commissioned service for drug and alcohol support, Change, Grow, Live (CGL), who were present at the time, and with the benefit of his substance misuse notes. The prescriber and the consultant were also there and considered the referral carefully. Whilst the patient own clozapine and melatonin to be considered it is felt unlikely that these particular drugs would have been prescribed given his risks, particularly given the addictive potential of clonazepam. Melatonin is not licensed for use in adults, it is a grey drug on the Area Prescribing Committee, as the evidence for benefit is too limited.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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Concerns raised 1
Failure to recognize suicidal ideation that may be masked by autistic spectrum conditions View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Jeff David ANTWIS · 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
Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognize suicidal ideation that may be masked by autistic spectrum conditions
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider review.
” Source location Jeff David ANTWIS · Prevention of Future Deaths report
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Shropshire Community Health NHS Trust was responsible for investigating care because it provided CAMHS services in Shropshire at the relevant time.
Verbatim wording from the response “As identified in your letter South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not providing CAMHS services within Shropshire at the time of Jeff’s death therefore South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not in a position to have carried out an investigation into the care of Jeff prior to his death. The Serious Incident Investigation presented at the inquest was carried out by Shropshire Community Health NHS Trust who were providing CAMHS services in Shropshire in January 2017.” Source location 2017-0392-Response
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Includes deficiencies in mental health assessment and care that are specifically linked to misunderstanding, failing to recognise or failing to adapt to autistic presentation or needs, including dedicated recognition, diagnostic formulation, communication and care-planning failures.
