Recurring concern

Inadequate multi-agency safeguarding coordination

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First reported 18 Dec 2013•Latest report 5 Mar 2026

Definition

What this concern includes

Includes failures of the dedicated multi-agency safeguarding coordination process, including delayed or absent strategy meetings, inadequate case coordination, and failures to share relevant information when safeguarding risks require joint action.

Not included

Excludes generic communication, record-keeping or staffing deficiencies not explicitly tied to multi-agency safeguarding coordination.
Excludes single-agency assessments, treatment decisions or operational failures unless they concern the multi-agency safeguarding coordination process.
Excludes coordination for non-safeguarding services or general discharge planning unless the report explicitly links it to safeguarding risk.

Reports: 24
Individual concerns: 26
Date range: 2013–2026
Stated actions: 48

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care9

Home Office4

National Police Chiefs’ Council3

NHS England3

Birmingham and Solihull Mental Health NHS Foundation Trust2

College of Policing2

Crown Prosecution Service2

Department for Education2

Greater Manchester Police2

Metropolitan Police Service2

Ministry of Housing, Communities and Local Government2

Ministry of Justice2

Pennine Care NHS Foundation Trust2

Surrey and Borders Partnership NHS Foundation Trust2

Sussex Police2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

5 Mar2026
East London
Concerns raised1
1. Absence of multi-agency risk assessment and risk management
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.

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

Caroline Adeyelu · 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

Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Absence of multi-agency risk assessment and risk management
Wider context from the report
“1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided. ”
Source location
Caroline Adeyelu · Prevention of Future Deaths report
Page 3 · concerns
Open source report
4 Aug2025
Surrey
Concerns raised1
1. Lack of a system for joint ambulance and mental health emergency plans
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review emergency mental health care pathways across Surrey, Sussex and Kent to establish a partnership framework for ambulance responses to suicidality.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
Respondent positions 4
1. Position
  The Healthcare Professionals Line is considered sufficient for safe, situation-specific multi-agency decisions instead of relying on previously prepared joint plans.
  Stated by Surrey and Borders Partnership NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
  Stated by Epsom and St Helier University Hospitals NHS TrustOutside remit
2. Position
  Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
  Stated by Epsom and St Helier University Hospitals NHS TrustRedirects responsibility
3. Position
  The Surrey Safeguarding Board will lead the Safeguarding Adults Review, with the organisation participating.
  Stated by NHS Southwest London Integrated Care BoardRedirects responsibility
AI-generated summary

Tracey Ostler · 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

Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.

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 a system for joint ambulance and mental health emergency plans
Wider context from the report
“Multi Agency Safeguarding Plans Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service 8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care. 9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies. 10. No system currently exists in Surrey to create such plans. 11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive. 12. The psychiatric evidence was that she would be likely to lack capacity. 13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die. 14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community. 15. I therefore remain concerned that such a death could occur again. ”
Source location
Tracey Ostler · Prevention of Future Deaths report
Page 6 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review emergency mental health care pathways across Surrey, Sussex and Kent to establish a partnership framework for ambulance responses to suicidality.

Verbatim wording from the response
“• To work with partners in Surrey, Kent and Sussex to further inform and develop shared decision-making pathway”

Source location
Response from NHS South East Coast Ambulance Service
Page 4 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Healthcare Professionals Line is considered sufficient for safe, situation-specific multi-agency decisions instead of relying on previously prepared joint plans.

Verbatim wording from the response
“The use of the Healthcare Professionals Line (HCPL) is crucial in ensuring appropriate and safe multi agency decision making. A joint plan, prepared at an earlier juncture, cannot be relied upon to enable the ambulance service, or other professionals, to make decisions in emergency or crisis situations.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 2 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.

Verbatim wording from the response
“Epsom and St Helier University Hospitals NHS Trust is an acute trust, offering inpatient physical healthcare services at Epsom Hospital and St Helier Hospital. For patients within our locality, mental health services are provided by Surrey and Borders Partnership NHS Foundation Trust (‘SABP’). Whilst we are not commissioned to provide care for patients who do not have physical health needs, we acknowledge and are mindful of the situation that is faced across the country where the demand for mental health services far exceeds the availability. We work collaboratively with our partners in SABP to provide care for patients whilst they remain in the Trust. I welcome the opportunity to respond to your concerns on behalf of the Trust.”

Source location
Response from Epsom General Hospital
Page 2 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.

Verbatim wording from the response
“NHS Surrey Heartlands ICB (‘the ICB’) is the responsible ICB for the geographical area in which the Trust sits. It is responsible for commissioning the mental health care provision for the population within its geographical area.”

Source location
Response from Epsom General Hospital
Page 2 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Surrey Safeguarding Board will lead the Safeguarding Adults Review, with the organisation participating.

Verbatim wording from the response
“I can assure you that we are committed to ensuring the learning and improvements are embedded moving forward. As Ms Ostler was a Surrey resident, rather than a South West London resident, we have engaged with Surrey Heartland ICB and have been made aware that a Safeguarding Adult Review (SAR) will be led by the Surrey Safeguarding Board, which we will fully engage with.”

Source location
Response from NHS South West London Integrated Care Board
Page 1 · response
Published 13 August 2025
Open published response
20 Feb2025
Cumbria
Concerns raised1
1. Failure to adopt a multiagency safeguarding approach
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Continue delivering multi-agency self-neglect training across the partnership, including training for the GP practice.
  Stated by Northumberland Children and Adults Safeguarding PartnershipStated in progress
2. Action
  Introduce a multi-agency risk management framework within six months for earlier intervention and referrals involving adults with complex needs and serious-risk concerns.
  Stated by Northumberland Children and Adults Safeguarding PartnershipStated planned
AI-generated summary

Janet Scott · 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

Janet Scott, who had schizophrenia and diabetes and was at serious risk of self-neglect, was found unresponsive at home on 28 March 2023 after concerns about her living conditions and welfare had been raised. She died in hospital on 30 March 2023 after developing sepsis. The report identified missed opportunities to provide assistance and a failure to activate multi-agency safeguarding procedures, raising concern that safeguarding referrals may not be made when agencies assume others are already aware.

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 adopt a multiagency safeguarding approach
Wider context from the report
“(1) Although individual agencies referred me to training they had provided to staff since Ms Scott's death, I also received evidence that, for instance, the GP surgery might not raise a safeguarding referral if the same circumstances were repeated because social services had already been informed. This leads me to be concerned that the message that 'safeguarding is everyone's responsibility' has not been taken on board. I am concerned that future cases will occur in which a multiagency approach is not adopted or that individuals will not make safeguarding referrals because they assume that other agencies are already aware of the issue. ”
Source location
Janet Scott · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue delivering multi-agency self-neglect training across the partnership, including training for the GP practice.

Verbatim wording from the response
“tool for use by practitioners and outlines suggested responses depending upon the level of risk and harm identified. The policy emphasises the importance of a person-centred approach as well as the need to balance autonomy with protection and a duty of care, which was highlighted in the review of Ms Scott’s death. Multi-agency training has been delivered across the partnership to increase awareness of the policy, and training will continue throughout 2025 including with Ms Scott’s GP practice in July 2025.”

Source location
Response from Northumberland Children's and Adults Safeguarding Partnership
Page 2 · response
Published 27 February 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce a multi-agency risk management framework within six months for earlier intervention and referrals involving adults with complex needs and serious-risk concerns.

Verbatim wording from the response
“Multi-agency Risk Management (MARM) Framework NCASP will introduce a multi-agency risk management framework within 6 months, which will set out a shared commitment across agencies who work with risk in Northumberland and will provide practice guidance to practitioners who are working with adults who have multiple and complex needs and are at risk of serious harm or abuse. This framework will support professionals to provide earlier multi-agency intervention than traditional safeguarding procedures and encourage referrals for low level concerns before they become significant and critical.”

Source location
Response from Northumberland Children's and Adults Safeguarding Partnership
Page 3 · response
Published 27 February 2025
Open published response
7 Feb2025
Mid Kent and Medway
Concerns raised3
1. Delays in convening multi-agency safeguarding meetings
2. Failure to provide agencies with access to all relevant cross-sector safeguarding information
3. Lack of a mechanism to convene urgent multi-agency safeguarding meetings
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 5
1. Action
  Deliver the national rollout of reforms to family help, multi-agency child protection and family group decision-making, including multi-agency child protection teams.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Deliver system-wide learning events on provider learning, family perspectives and inter-agency working following children’s and young people’s suicides.
  Stated by NHS Kent and Medway ICBStated completed
3. Action
  Develop a system-wide improvement plan addressing agency information sharing, risk assessments and decision-making.
  Stated by NHS Kent and Medway ICBStated planned
1. Action
  Implement the Kent and Medway Care Record to enable inter-agency access to health and social care records.
  Stated by NHS Kent and Medway ICBStated completed
2. Action
  Continue work supporting use of the Kent and Medway Care Record across relevant services.
  Stated by NHS Kent and Medway ICBStated in progress
Respondent positions 3
1. Position
  Actions taken by the Integrated Care Board, social services and local authority fall outside the national policy or programme remit.
  Stated by NHS EnglandOutside remit
1. Position
  The Integrated Care Board is responsible for providing a separate system-level response detailing local actions taken.
  Stated by NHS EnglandRedirects responsibility
2. Position
  No direct education interface with the Kent and Medway Care Record is currently planned because County Council front-door teams provide an alternative information-sharing route.
  Stated by NHS Kent and Medway ICBExisting arrangements considered sufficient
AI-generated summary

Ella Louise Murray · 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

Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in convening multi-agency safeguarding meetings
Wider context from the report
“(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change. (4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position. ”
Source location
Ella Louise Murray · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide agencies with access to all relevant cross-sector safeguarding information
Wider context from the report
“(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change. (4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position. ”
Source location
Ella Louise Murray · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a mechanism to convene urgent multi-agency safeguarding meetings
Wider context from the report
“(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home. (2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home. Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home. Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today. ”
Source location
Ella Louise Murray · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver the national rollout of reforms to family help, multi-agency child protection and family group decision-making, including multi-agency child protection teams.

Verbatim wording from the response
“As part of this, the Government’s Families First Partnership programme is delivering the national rollout of reforms to family help, multi-agency child protection and family group decision-making, including delivery of MACPTs. The programme guide sets out the responsibilities of the MACPT members, including to facilitate better communication and information sharing among practitioners and agencies. This is available at: Families First Partnership programme - GOV.UK”

Source location
2025-0182 Response from Department of Health and Social Care
Page 2 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver system-wide learning events on provider learning, family perspectives and inter-agency working following children’s and young people’s suicides.

Verbatim wording from the response
“As part of the ICBs response to a number of suicides of children and young people during 2023, a series of learning events have taken place. The first focused on North East London Foundation Trust (NELFT - our children and young people mental health services provider) and their learning as an organisation. The second focused on the patients’ and their families’ perspective to ensure their voices were engaged as part of wider learning. The third focused on system wide/inter agency working in November 2024. This event will culminate in a system wide improvement plan that will include a focus on agency information sharing, risk assessments and decision making among others. Work on a shared risk protocol across system partners has already commenced.”

Source location
Response from Kent and Medway Integrated Care Board
Page 4 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a system-wide improvement plan addressing agency information sharing, risk assessments and decision-making.

Verbatim wording from the response
“As part of the ICBs response to a number of suicides of children and young people during 2023, a series of learning events have taken place. The first focused on North East London Foundation Trust (NELFT - our children and young people mental health services provider) and their learning as an organisation. The second focused on the patients’ and their families’ perspective to ensure their voices were engaged as part of wider learning. The third focused on system wide/inter agency working in November 2024. This event will culminate in a system wide improvement plan that will include a focus on agency information sharing, risk assessments and decision making among others. Work on a shared risk protocol across system partners has already commenced.”

Source location
Response from Kent and Medway Integrated Care Board
Page 4 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Kent and Medway Care Record to enable inter-agency access to health and social care records.

Verbatim wording from the response
“In addition, Kent & Medway ICB has implemented the Kent and Medway Care Record (KMCR), which supports inter agency access to health and social care records. The level of visibility recommended is largely in place, although continued work to support use of the system is ongoing. There are no current plans to have a direct interface between education and the KMCR, but Kent County Council front door teams, who act as a single point of contact for requests for support at an intensive level or above for children, young people and families, ensuring these requests are directed to the appropriate service for ongoing support”

Source location
Response from Kent and Medway Integrated Care Board
Page 4 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue work supporting use of the Kent and Medway Care Record across relevant services.

Verbatim wording from the response
“In addition, Kent & Medway ICB has implemented the Kent and Medway Care Record (KMCR), which supports inter agency access to health and social care records. The level of visibility recommended is largely in place, although continued work to support use of the system is ongoing. There are no current plans to have a direct interface between education and the KMCR, but Kent County Council front door teams, who act as a single point of contact for requests for support at an intensive level or above for children, young people and families, ensuring these requests are directed to the appropriate service for ongoing support”

Source location
Response from Kent and Medway Integrated Care Board
Page 4 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Actions taken by the Integrated Care Board, social services and local authority fall outside the national policy or programme remit.

Verbatim wording from the response
“My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy or programme remit. It would not be appropriate at this juncture for NHS England to provide comment on actions taken by Kent & Medway Integrated Care Board, Kent Social Services or the Local Authority involved in Ella’s care.”

Source location
Response from NHS England
Page 1 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Integrated Care Board is responsible for providing a separate system-level response detailing local actions taken.

Verbatim wording from the response
“Ella’s case includes learnings for teams across NHS England and local organisations, as well as more broadly. It is NHS England’s understanding that Kent and Medway Integrated Care Board will be responding to the Coroner separately with a system-level response detailing the local actions taken. NHS England will consider the ICB’s response in due course. My colleagues from national NHS England teams have also provided the below input.”

Source location
Response from NHS England
Page 2 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
No direct education interface with the Kent and Medway Care Record is currently planned because County Council front-door teams provide an alternative information-sharing route.

Verbatim wording from the response
“In addition, Kent & Medway ICB has implemented the Kent and Medway Care Record (KMCR), which supports inter agency access to health and social care records. The level of visibility recommended is largely in place, although continued work to support use of the system is ongoing. There are no current plans to have a direct interface between education and the KMCR, but Kent County Council front door teams, who act as a single point of contact for requests for support at an intensive level or above for children, young people and families, ensuring these requests are directed to the appropriate service for ongoing support”

Source location
Response from Kent and Medway Integrated Care Board
Page 4 · response
Published 16 April 2025
Open published response
14 Oct2024
Surrey
Concerns raised1
1. Failure of CAMHS staff to attend or engage with Core Group Meetings
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Cascade the importance of clinician engagement with Core Group meetings to community teams.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated planned
2. Action
  Request that Children’s Services copy Core Group meeting invitations to the Trust’s central Safeguarding team.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The Trust cannot monitor or arrange attendance for Core Group invitations it does not receive from Children’s Services in time.
  Stated by Surrey and Borders Partnership NHS Foundation TrustUnable to act
AI-generated summary

Locket Ure Williams · 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

Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of CAMHS staff to attend or engage with Core Group Meetings
Wider context from the report
“Concern 4 From the evidence I heard at the inquest hearing, it was apparent that staff within CAMHS did not always attend or engage with Core Group Meetings to which they were invited by children’s services. At the prevention of future deaths hearing, it was accepted that, for those children under Children’s Services, active involvement in Core Group Meetings by all agencies involved with the child was of real importance. This was so, because the meetings were the means by which information was shared by different agencies and an informed plan was made to protect the child’s life (including from suicide) and welfare. Failure by Trust staff to attend or otherwise to engage with the meetings, and the other agencies involved with the child, may therefore raise the risk to the child and undermine their protection. I was also told that there is an expectation that Trust staff should prioritise attendance / involvement in Core Group Meetings but, it seems, that no monitoring takes place to assess compliance with that expectation, including no systematic recording of the receipt of invitations to attend Core Group Meetings and no systematic recording of the response by the staff who have been invited, or otherwise. ”
Source location
Locket Ure Williams · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Cascade the importance of clinician engagement with Core Group meetings to community teams.

Verbatim wording from the response
“Attendance at Core Group meetings in respect of those supported by Children’s Services is mandatory. There is also an expectation that clinicians contribute to other safeguarding meetings, and local authority reviews of Education Health and Care Plans (“EHCP”). The Standard Operating Procedure (“SOP”) for our community teams requires that Care Plans include actions flowing from these meetings. Care Plans are recorded on SystmOne and accessible to any Trust clinician involved in the care of the child or young person.”

Source location
Response from Surrey and Borders Partnership NHS
Page 3 · response
Published 14 October 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Request that Children’s Services copy Core Group meeting invitations to the Trust’s central Safeguarding team.

Verbatim wording from the response
“The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.”

Source location
Response from Surrey and Borders Partnership NHS
Page 3 · response
Published 14 October 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust cannot monitor or arrange attendance for Core Group invitations it does not receive from Children’s Services in time.

Verbatim wording from the response
“The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.”

Source location
Response from Surrey and Borders Partnership NHS
Page 3 · response
Published 14 October 2024
Open published response
3 Jun2024
Birmingham and Solihull
Concerns raised1
1. Failure to invite police representatives to daily appraisal meetings
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Deliver missing-person training and provide flash cards reminding managers of coordination, police liaison and daily appraisal responsibilities.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
2. Action
  Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
  Stated by West Midlands PoliceStated in progress
Respondent positions 2
1. Position
  Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
  Stated by Home OfficeRedirects responsibility
AI-generated summary

Tcherno Bari · 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

Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.

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 invite police representatives to daily appraisal meetings
Wider context from the report
“(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’. ”
Source location
Tcherno Bari · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver missing-person training and provide flash cards reminding managers of coordination, police liaison and daily appraisal responsibilities.

Verbatim wording from the response
“On 25 June 2024 there was a training session put together which was attended by Clinical Service Managers, Nurse Managers, Matrons, Ward Managers for the in-patient wards and the Home Treatment Team Managers. During the session this inquest was used as a training tool and staff were reminded of their professional responsibilities, particularly around the co-ordination with police and daily meetings. Flash cards were provided to ensure that CSM’s are reminded of what they should be doing when patients go missing.”

Source location
Response from BSMHFT
Page 2 · response
Published 6 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.

Verbatim wording from the response
“BSMHFT and send an appropriate staff member, as required. The WMP missing persons policy will be updated to reflect this.”

Source location
Response from West Midlands Police
Page 4 · response
Published 6 June 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.

Verbatim wording from the response
“Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.”

Source location
Response from DHSC
Page 1 · response
Published 6 June 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.

Verbatim wording from the response
“As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.”

Source location
Response from the Home Office
Page 1 · response
Published 6 June 2024
Open published response
13 Mar2024
Birmingham and Solihull
Concerns raised1
1. Failure to coordinate interagency release management and share critical information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 20
1. Action
  Hold monthly strategy meetings monitoring first-night accommodation and whether released prisoners’ whereabouts are known to community services.
  Stated by G4SStated completed
2. Action
  Record travel-warrant destinations and email them to the OMU group for communication to relevant offender managers and agencies.
  Stated by G4SStated completed
3. Action
  Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.
  Stated by G4SStated completed
1. Action
  Continue streamlining internal data recording so information is shared through the national prisons IT system, DPS.
  Stated by G4SStated in progress
2. Action
  Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated planned
3. Action
  Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated planned
4. Action
  Implement an improved referral and discharge procedure through the updated standard operating protocol.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
5. Action
  Approach SystemOne to discuss the feasibility of adding a local field for community mental health team information.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
6. Action
  Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.
  Stated by Swansea Bay University Local Health BoardStated completed
7. Action
  Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.
  Stated by Swansea Bay University Local Health BoardStated completed
8. Action
  Provide documented discharge summaries and comprehensive handovers to primary care, general practitioners, patients and, with consent, probation officers.
  Stated by Swansea Bay University Local Health BoardStated completed
9. Action
  Use weekly discharge information, prison NOMIS access and a Governor Grade officer at Single Point of Access meetings to verify release dates.
  Stated by Swansea Bay University Local Health BoardStated in progress
10. Action
  Continue updating ViSOR records for each individual so information can be shared across agencies.
  Stated by West Midlands PoliceStated completed
11. Action
  Work with agencies to clarify key roles and systems, improve information sharing and management, and protect the public.
  Stated by West Midlands PoliceStated planned
12. Action
  Visit managed offenders after prison release regardless of their MAPPA process status.
  Stated by West Midlands PoliceStated completed
13. Action
  Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.
  Stated by West Midlands PoliceStated planned
14. Action
  Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.
  Stated by HM Prison and Probation ServiceStated completed
15. Action
  Continue reviewing and refining MAPPA practices to improve interagency working and risk-information sharing.
  Stated by HM Prison and Probation ServiceStated in progress
16. Action
  Reinforce the statutory information-sharing requirement for MAPPA duty-to-cooperate agencies.
  Stated by HM Prison and Probation ServiceStated completed
17. Action
  Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 7
1. Position
  G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.
  Stated by G4SOutside remit
1. Position
  HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.
  Stated by G4SRedirects responsibility
2. Position
  G4S cannot implement changes to streamline IT systems used by HMPPS, the NHS and third-party providers.
  Stated by G4SUnable to act
3. Position
  Issues concerning information sharing on NDelius should be addressed to HMPPS.
  Stated by G4SRedirects responsibility
4. Position
  National Systemone interface issues must be addressed by other Interested Parties, although the Trust is exploring a local amendment.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustRedirects responsibility
5. Position
  A unified prison interagency IT system cannot be implemented because the Health Board lacks the necessary power.
  Stated by Swansea Bay University Local Health BoardUnable to act
6. Position
  Liaison with MAPPA is the Offender Management Unit’s responsibility, while the Responsible Authority must notify Health and arrange relevant meetings.
  Stated by Swansea Bay University Local Health BoardRedirects responsibility
AI-generated summary

Jacob Michael Nicholas BILLINGTON · 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

Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.

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 coordinate interagency release management and share critical information
Wider context from the report
“1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community. ”
Source location
Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Hold monthly strategy meetings monitoring first-night accommodation and whether released prisoners’ whereabouts are known to community services.

Verbatim wording from the response
“• Monthly strategy meetings at the prison show consistently high (c 90%) levels of prisoners released from custody are housed on the first night of their release, so that their whereabouts immediately post release is known to relevant community services.”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Record travel-warrant destinations and email them to the OMU group for communication to relevant offender managers and agencies.

Verbatim wording from the response
“• At HMP & YOI Parc, a member of the cashiers team issues a travel warrant for each prisoner shortly before they are released from custody. The cashier previously recorded on CMS, the prison’s central electronic messaging system, the fact that a travel warrant had been issued. The cashier now records where the travel warrant has been issued to, and, in addition, sends an email to a new OMU email group, which includes healthcare admin and the Heads of Offender Management, to indicate that a travel warrant has been issued with details of where the travel warrant has been issued to. This email is automatically received by all offender managers within OMU. This information is then communicated to the Community Offender Manager and any other individuals/agencies involved with the prisoner.”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.

Verbatim wording from the response
“• Whilst Community Offender Managers have responsibility for the coordination of release planning, notice was given by email to all offender managers within HMP & YOI Parc that they must notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode. When doing so, they must provide any information relating to a prisoner’s intentions in terms of where they are going on the day of release. This will assist the Community Offender Manager to effectively manage the prisoner’s release, and to coordinate and link in with other external agencies believed by the Community Offender Manager to be relevant to coordinate interagency working.”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue streamlining internal data recording so information is shared through the national prisons IT system, DPS.

Verbatim wording from the response
“The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.

Verbatim wording from the response
“The Deputy Medical Director chaired an initial scoping meeting in response to these issues identified by the PFD on 10th April 2024, culminating in agreement on 3 primary areas of focus:”

Source location
Response from BSMHFT
Page 1 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.

Verbatim wording from the response
“3. Interface between Prison In-reach and the CMHT- A comprehensive review of the current interaction process between the Prison In-reach team and the CMHT is planned. This will involve a detailed gap analysis to determine areas needing strengthening. We aim to develop a clear plan to enhance this interface, thereby improving continuity of care and ensuring that individuals receive the necessary support as they transition from prison to community-based services.”

Source location
Response from BSMHFT
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement an improved referral and discharge procedure through the updated standard operating protocol.

Verbatim wording from the response
“In the meantime we can offer you assurances that since the events that culminated in Mr Billington’s death the Trust has improved the structure and supervision surrounding the prison discharge coordinator roles, such that the practitioners have weekly supervision with opportunity to escalate cases of concern, and an improved system of referrals and discharge procedures, reflected in the updated standard operating protocol. This means that in the event of a similar situation occurring again, there would be sufficient structure to ensure and support the flexibility in service provision to prevent such an individual falling between services, even where they had been discharged from active multiagency management by MAPPA.”

Source location
Response from BSMHFT
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Approach SystemOne to discuss the feasibility of adding a local field for community mental health team information.

Verbatim wording from the response
“Systemone Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.”

Source location
Response from BSMHFT
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.

Verbatim wording from the response
“• Formal hand over of care is received from the transferring Community Mental Health Team (CMHT) or previous prison via a formal meeting”

Source location
Response from Swansea Bay University Health Board
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.

Verbatim wording from the response
“Discharge to Community”

Source location
Response from Swansea Bay University Health Board
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide documented discharge summaries and comprehensive handovers to primary care, general practitioners, patients and, with consent, probation officers.

Verbatim wording from the response
“A Formal discharge meeting is also held between the MHIR and Primary Care Teams when patients / prisoners within the prison setting are being discharged from secondary care services (MHIR) back to primary care services within the prison. This meeting includes a full”

Source location
Response from Swansea Bay University Health Board
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use weekly discharge information, prison NOMIS access and a Governor Grade officer at Single Point of Access meetings to verify release dates.

Verbatim wording from the response
“• On a weekly basis the MHIR Team are sent the discharge information of prisoners from the Offender Management Unit (OMU). We don’t request travel warrant information as the travel warrant is only issued on the day of travel. We also now have access to the prison NOMIS system which we didn’t previously (training for use is being rolled out to the whole team with 50% already achieved). This system is updated by the Resettlement Team and OMU regarding release dates. These layered approaches help to avoid the risk of the team not being aware of relevant information”

Source location
Response from Swansea Bay University Health Board
Page 4 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue updating ViSOR records for each individual so information can be shared across agencies.

Verbatim wording from the response
“Visor is the shared IT system accessible to numerous agencies. West Midlands Police will ensure we continue to update Visor records for each individual to ensure information can be shared across agencies.”

Source location
Response from West Midlands Police
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with agencies to clarify key roles and systems, improve information sharing and management, and protect the public.

Verbatim wording from the response
“We will work with all agencies to understand key roles and systems to better share information, manage individuals and protect the public.”

Source location
Response from West Midlands Police
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Visit managed offenders after prison release regardless of their MAPPA process status.

Verbatim wording from the response
“Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer will try to visit a managed offender when they are released from prison, regardless of the status of the MAPPA process.”

Source location
Response from West Midlands Police
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.

Verbatim wording from the response
“This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.”

Source location
Response from West Midlands Police
Page 4 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.

Verbatim wording from the response
“For a prisoner to still be detained in custody at the point of sentence expiry is usually as a result of them having been recalled to custody. This means they remain the responsibility of the Probation Community Offender Manager (COM) until the point of release at the sentence end date (SED). There is no statutory authority for Probation supervision of a prisoner released into the community at SED. The sharing of information prior to release into the community in an effective manner with relevant agencies is therefore of paramount importance. The Probation Service West Midlands has a practice document which sets out the expectations for Practitioners when cases are being released at SED. This document has been revised and reissued to all staff and embedded in development sessions delivered by the Regional Quality Team.”

Source location
Response from HMPPS
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue reviewing and refining MAPPA practices to improve interagency working and risk-information sharing.

Verbatim wording from the response
“MAPPA arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.”

Source location
Response from HMPPS
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reinforce the statutory information-sharing requirement for MAPPA duty-to-cooperate agencies.

Verbatim wording from the response
“MAPPA arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.”

Source location
Response from HMPPS
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.

Verbatim wording from the response
“NHS-England are commissioned to provide healthcare in Prisons. The sharing of information between health in custody and health in the community is a core feature of the nationally rolled out NHS-England Reconnect Service. West Midlands Probation Service has actively promoted the Reconnect Service with Probation Practitioners in recent months to ensure they are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community.”

Source location
Response from HMPPS
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.

Verbatim wording from the response
“In addition, G4S has no power to influence the management of release of prisoners from, and/or to ensure interagency working at, private prisons operated by other providers or HMPPS operations.”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.

Verbatim wording from the response
“HMPPS has responsibility for provision and operation of resettlement services. Such resettlement services at HMP & YOI Parc are commissioned by HMPPS from external providers who are based within the prison to facilitate resettlement services for prisoners approaching release from custody. G4S is not party to the procurement or placement of resettlement services within HMP & YOI Parc or the direct delivery of these services. G4S’ focus is on ensuring alignment and integration with third party service providers to ensure effective interagency working.”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
G4S cannot implement changes to streamline IT systems used by HMPPS, the NHS and third-party providers.

Verbatim wording from the response
“The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Issues concerning information sharing on NDelius should be addressed to HMPPS.

Verbatim wording from the response
“The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service”

Source location
Response from G4S Care Justice Services (UK) Ltd
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
National Systemone interface issues must be addressed by other Interested Parties, although the Trust is exploring a local amendment.

Verbatim wording from the response
“Systemone Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.”

Source location
Response from BSMHFT
Page 3 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
A unified prison interagency IT system cannot be implemented because the Health Board lacks the necessary power.

Verbatim wording from the response
“Swansea University Health Board recognise that there is not a shared database for interagency working in place across England and Wales prison establishments to enable the transfer and access to key information by agencies coordinating the discharge of high risk individuals.”

Source location
Response from Swansea Bay University Health Board
Page 2 · response
Published 19 March 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Liaison with MAPPA is the Offender Management Unit’s responsibility, while the Responsible Authority must notify Health and arrange relevant meetings.

Verbatim wording from the response
“In respect of MAPPA, Swansea Bay University Health Board undertake the role of a ‘Duty to Cooperate Agency’ with Probation, HMP and the Police as the Responsible Authority – it is the Responsible Authority’s responsibility to inform Health if a MAPPA eligible individual is scheduled for discharge and ensure we are invited to relevant meetings to coordinate release / discharge management. The MHIR Team liaise directly with the prison based Offender Management Unit and not directly with MAPPA. Liaison with MAPPA is the responsibility of the Offender Management Unit.”

Source location
Response from Swansea Bay University Health Board
Page 3 · response
Published 19 March 2024
Open published response
18 Apr2023
South London
Concerns raised1
1. Lack of a single effective global focus for consolidating and retrieving cross-agency risk information
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Patrick Soames · 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

Patrick Soames died by suicide on 21 June 2021 after a final month involving repeated serious self-harm, including cutting, medication overdose and excessive alcohol misuse, with multiple hospital attendances. The principal concerns were that information about his risk was fragmented across NHS Trusts, police forces, local authorities and geographical areas, with no effective system to consolidate or flag his recent self-harm history nationally.

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 a single effective global focus for consolidating and retrieving cross-agency risk information
Wider context from the report
“1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself). 2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours. 3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it. 4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up. 5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history. ”
Source location
Patrick Soames · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Nov2020
Manchester South
Concerns raised1
1. Poor information sharing and joint risk recognition across statutory agencies
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Conduct district safeguarding-team deep-dive reviews and circulate domestic abuse, child-protection and adults-at-risk triage expectations.
  Stated by Greater Manchester PoliceStated completed
2. Action
  Establish a specific safeguarding-team triage training course incorporating information-sharing guidance.
  Stated by Greater Manchester PoliceStated in progress
Respondent positions 1
1. Position
  Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
AI-generated summary

Alfie Gildea · 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

Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report
“12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken. ”
Source location
Alfie Gildea · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct district safeguarding-team deep-dive reviews and circulate domestic abuse, child-protection and adults-at-risk triage expectations.

Verbatim wording from the response
“GMP's Public Protection Governance Unit has conducted a deep-dive review into the standards used in the triage process of six district safeguarding teams, including information sharing between agencies. The purpose of the review was to understand the methodology and information considered as part of the triage decision making process and how this was recorded. This review identified good practice and areas for development moving forward. Triage expectations for domestic abuse, child protection, and adults at risk have been circulated to districts to set out the standards expected during triage. Moving forward, the Public Protection Governance Unit is working with the People and Development Branch to establish a specific triage training course which will include guidance on information sharing.”

Source location
2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Page 7 · response
Published 24 December 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a specific safeguarding-team triage training course incorporating information-sharing guidance.

Verbatim wording from the response
“GMP's Public Protection Governance Unit has conducted a deep-dive review into the standards used in the triage process of six district safeguarding teams, including information sharing between agencies. The purpose of the review was to understand the methodology and information considered as part of the triage decision making process and how this was recorded. This review identified good practice and areas for development moving forward. Triage expectations for domestic abuse, child protection, and adults at risk have been circulated to districts to set out the standards expected during triage. Moving forward, the Public Protection Governance Unit is working with the People and Development Branch to establish a specific triage training course which will include guidance on information sharing.”

Source location
2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Page 7 · response
Published 24 December 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

Verbatim wording from the response
“I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

Source location
2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
Page 1 · response
Published 24 December 2020
Open published response
9 Nov2020
Surrey
Concerns raised1
1. Failure to involve general practitioners in MARAC meetings
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 1
1. Action
  Assist Surrey Police with its detailed review of MARAC workings.
  Stated by Surrey County CouncilStated in progress
Respondent positions 1
1. Position
  Surrey Police, as MARAC lead agency and chair, is responsible for reviewing and improving MARAC workings; Surrey County Council will assist.
  Stated by Surrey County CouncilRedirects responsibility
AI-generated summary

Name not published · 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

The deceased died at home on 29 November 2017 after consuming considerable amounts of alcohol and cocaine and hanging herself with a ligature. Concerns included limited communication between the MARAC process and her general practitioner about domestic abuse risks and safeguarding measures, and the GP not being informed about her children being removed from her care and subsequent care proceedings, or the associated mental health stressors.

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 involve general practitioners in MARAC meetings
Wider context from the report
“3. ████████ general practitioner was not invited to contribute to the MARAC meetings held in July and August 2017. General Practitioners are not routinely invited to MARAC meetings. ”
Source location
Name not published · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Assist Surrey Police with its detailed review of MARAC workings.

Verbatim wording from the response
“Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.”

Source location
Response to Surrey coroner area - Prevention of future deaths report
Page 1 · response
Published 7 October 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Surrey Police, as MARAC lead agency and chair, is responsible for reviewing and improving MARAC workings; Surrey County Council will assist.

Verbatim wording from the response
“Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.”

Source location
Response to Surrey coroner area - Prevention of future deaths report
Page 1 · response
Published 7 October 2022
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Absence of multi-agency risk assessment and risk management

Concerns raised1

Lack of a system for joint ambulance and mental health emergency plans

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure to adopt a multiagency safeguarding approach

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

Concerns raised3

Delays in convening multi-agency safeguarding meetings

Failure to provide agencies with access to all relevant cross-sector safeguarding information

Lack of a mechanism to convene urgent multi-agency safeguarding meetings

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure of CAMHS staff to attend or engage with Core Group Meetings

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

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

Concerns raised1

Failure to invite police representatives to daily appraisal meetings

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 1

Respondent positions 4

Actions described in response 2

Actions described in response 5

Respondent positions 3

Actions described in response 2

Respondent positions 1

Actions described in response 2

Respondent positions 2