Recurring concern

Unreliable recording of safety-critical mental health information

First to latest report 18 Aug 2014 — 27 May 2026

Reports that mention this concern
51
Times this concern has been raised
54
Stated actions linked to this concern
61

What this concern includes

Includes failures in mental health or related care processes to accurately record, update or retain clinically or safety-relevant mental health information, including risk history, significant concerns, care-relevant objections and other information needed by staff making later decisions.

What is not included
  • Excludes generic clinical or care record deficiencies where the information is not specifically mental health or mental-health-risk information.
  • Excludes failures to communicate or share accurately recorded information where the recording process itself was reliable.
  • Excludes failures in mental health assessment, treatment, referral or follow-up where no deficiency in recording safety-critical mental health information is identified.
  • Excludes routine administrative information and non-safety-relevant mental health notes.

Reports and published responses 51 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    Abbigail Louise SMITH · 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

    Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

    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 record the timing and rationale for returning usual clothing after ligature risk

    Wider context from the report

    “10. There were no up-to-date care plans and risk assessments in place for Abbi during her detention and when she was discharged to the community on 14 February 2022 to mitigate a known significant risk. Abbi had tied multiple tight ligatures during her 11-day admission under detention of the Mental Health Act and her usual clothing removed on 4 February due to her risks, the precise date her clothing was returned, and the rationale was not recorded. ”

    Source location

    Abbigail Louise SMITH · 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

    Review and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.

    Verbatim wording from the response

    “In the interests of safety and based on risk assessment, it is noted that Abbi was issued with anti-ligature clothing during her admission (with her clothes being returned after discharge); during this time her attempts at ligatures were reduced.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    Open published response

  2. Essex

    AI-generated summary

    Abigail Louise SMITH · 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

    Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after unsuccessfully trying to suspend herself, and was pronounced dead at 00:08 on 16 February 2022 from compression of the neck. The report describes concerns about failures in mental-health care, including inaccurate records and diagnosis information, inadequate adjustments for autism and learning difficulties, medication-management problems, and discharge from detention without an effective plan to mitigate a known and immediate risk of suicide.

    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 accurately record changes in mental health diagnosis in discharge summaries

    Wider context from the report

    “1. Abbi spent most of her adult life detained and over 18 months in a specialist Tier 4 mental hospital having been transferred there by her local mental health trust. The Tier 4 specialist team agreed that Abbi did not have a personality disorder. This was a significant change for Abbi and was not accurately set out in the discharge summary. ”

    Source location

    Abigail Louise SMITH · Prevention of Future Deaths report
    Page 3 · 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 record changes in mental health diagnosis in Psychology records

    Wider context from the report

    “2. Objectively and subjectively Abbi had appeared to respond positively to Clozapine medication with which she was compliant such that Abbi was discharged back to the care of her local community mental health Trust . The medical records and documentation contained significant cutting and pasting and the change of mental health diagnosis was not contained within the Psychology records. ”

    Source location

    Abigail Louise SMITH · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. City of London

    AI-generated summary

    Tony Montana Duncan · 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

    Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.

    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 document risk assessments

    Wider context from the report

    “2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being completed. ”

    Source location

    Tony Montana Duncan · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  4. Essex

    AI-generated summary

    Resmije Ahmetaj · 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

    Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.

    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

    Incomplete mental health care records

    Wider context from the report

    “(4) The mental health Trust record-keeping did not contain all relevant information relating to the care and treatment there were omissions relating to symptoms and potential signs of deterioration and compliance with medication. ”

    Source location

    Resmije Ahmetaj · 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

    Take forward MDT learning on documenting and escalating inconsistencies between clozapine assays, adherence reports and clinical stability.

    Verbatim wording from the response

    “On reflection, while the management of this case was consistent with current guidance, there are learning points regarding communication and escalation. Specifically, inconsistencies between assay findings, patient-reported adherence, and clinical stability should have been explicitly documented and escalated to the consultant psychiatrist at an earlier stage. Doing so would have provided additional assurance around risk management and strengthened the therapeutic dialogue with the patient. This learning is being taken forward by the MDT.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 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 the Record Keeping Safety Improvement Programme to improve documentation-related patient safety through learning and regular review.

    Verbatim wording from the response

    “The Trust has continued with a Record Keeping Safety Improvement Programme (SIP). This SIP program is focusing on improving patient safety in respect of documentation specifically. The approach will be to support continuous learning and improvement and regular review.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 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 clinical record-keeping guidance defining the characteristics of a good clinical record.

    Verbatim wording from the response

    “To further support staff the Trust has developed a new Clinical record keeping guidance to help guide staff on what is a good clinical record.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 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

    Discuss case-related record-keeping requirements with service leads and task service managers with reinforcing their importance to staff.

    Verbatim wording from the response

    “Additionally we can confirm that discussions have been undertaken with service leads with regards to record keeping in respect of this particular case and highlighting importance of timely and detailed record keeping. Service Managers were tasked to emphasise the importance of this service staff.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 4 · response
    Published 14 August 2025

    Open published response

  5. Cornwall and Isles of Scilly

    AI-generated summary

    Callum James Hargreaves · 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

    Callum James Hargreaves, who had a history of substance misuse and housing instability, was found dead in the sea on 20 January 2024 after being removed from a cliff edge and assessed under the Mental Health Act the previous day. The principal concerns were that the rationale for not pursuing a short-term admission was not recorded, and that clinicians did not further explore or test Callum’s refusal to allow his mother to be informed of his discharge. The report also noted that the Nearest Relative’s details appeared not to have been completed on the MH 1.

    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 record the rationale for mental health assessment decisions

    Wider context from the report

    “I accepted independent expert evidence that the mental health act assessment had been thorough and appropriately concluded there were no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term admissions to manage a period of crisis in a patient presenting with complex PTSD/EUPD, that was not indicated here. It was identified that the rationale for reaching that decision was not recorded in the notes. This is a matter I have taken up separately with those responsible for the AMHP. 1) It was accepted in evidence that, owing to the decisions made by Callum, there were only limited options available to the clinicians. Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected. Additionally, the possibility of prescribing additional Diazepam was correctly discounted once it became evident Callum was already sourcing illicitly more than could be prescribed safely. 2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she had been (wrongly) advised by police that her son would be detained and was safe. There was no evidence that this decision by Callum was explored or tested by the clinicians – instead it simply appeared to have been accepted by the clinicians without further enquiry. The independent expert was of the view that in a situation like this, where the assessing team had very few ‘levers’ available to it, Callum’s mother was potentially one that could and should have been explored further. It was noted that GMC guidance allows for further enquiry, specifically that 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent. It was noted that the Nearest Relative’s details appeared not to have been completed on the MH 1. Again, this is a matter that has been brought to the attention of those responsible for the AMHP. ”

    Source location

    Callum James Hargreaves · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Cornwall and Isles of Scilly

    AI-generated summary

    Callum James Hargreaves · 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

    Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.

    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 record the rationale for decisions not to detain following mental health assessments

    Wider context from the report

    “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024. 1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes. 2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so. The Nearest Relative details on the MH 1 form were not completed. The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further. You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded. ”

    Source location

    Callum James Hargreaves · 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

    Transfer Mental Health Act assessment recording from RIO to Mosaic to enable inclusion in the audit programme.

    Verbatim wording from the response

    “From the 14th of May 2025, the local authority has been proactively implementing a change in where Mental Health Act (MHA) assessments are recorded. This is a departure from the current practice of recording on the health database (RIO) to recording on the Adult Social Care database (Mosaic). This change will allow us to incorporate MHA assessments into our audit programme, thereby supporting improved quality and consistency in documentation and recording.”

    Source location

    Response from Cornwall Council (Care and Wellbeing)
    Page 3 · response
    Published 9 June 2025

    Open published response

  7. Essex

    AI-generated summary

    DAVID WAYNE BENNETT · 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

    David Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.

    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 accurately record contact and suicidal ideation in mental health records

    Wider context from the report

    “(3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the System One Records with suicidal ideation not recorded. ”

    Source location

    DAVID WAYNE BENNETT · 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 focused SystmOne training on recording suicidal ideation and review template completion fields with Mental Health Practitioners.

    Verbatim wording from the response

    “Response: SystmOne has a template to complete to record the Mental Health Assessment and also a template for risk assessment for the primary care nurse to complete. On the risk assessment there are boxes to check for suicidal thought and self-harm. If these are checked a dialogue box opens up for further information to be added. If the patient is not suicidal there will not be any information recorded. Although SystmOne training is mandatory for it to be used, the Trust will now arrange ensuring training on how to use the system for recording suicidal ideation specifically as a focus. We can confirm that a training session for Basildon and Brentwood Mental Health Practitioners planned for the 29 April 2025, where fields for completion in the templates used on SystmOne will be reviewed to ensure all MHPs are proficient in using SystmOne.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    Open published response

  8. Sunderland

    AI-generated summary

    John Paul Hurst · 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

    John Paul Hurst, who had a history of paranoid schizophrenia and previous suicide attempts, was released from custody on 13 September 2021 after concerns had been raised about his mental health and risk of suicide. He was found near train tracks on 15 September 2021 and died from haemorrhage associated with severe injury to his right leg, consistent with impact with a train. The principal concern was that the electronic custody record inadequately documented the mental-health and suicide-risk concerns, and lacked detailed analysis and reasoning for the CJLD assessment conclusion.

    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 record detailed information about detained persons’ mental health concerns

    Wider context from the report

    “At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release risk assessment, the custody sergeant had been greatly assisted by the information recorded on the electronic custody record regarding the concerns that led to the mental health assessment and the assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted that the electronic custody record contained limited information about the concerns of police officers and John’s sister, and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion. I am concerned that the information on the electronic custody record was inadequate and lacked detail regarding the concerns for the detained person’s mental health, as identified by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental health services. In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion. ”

    Source location

    John Paul Hurst · 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

    Provide custody staff with instruction and learning on recording detainees’ mental-health concerns through the Custody Newsletter, Custody Compendium and direct reminders to Custody Sergeants.

    Verbatim wording from the response

    “I agree that it is important that custody officers record all relevant information and concerns expressed in relation to the mental health of a detainee. This is something which all custody officers should be aware of. In order to ensure that custody staff are aware of their obligations in this respect, following receipt of your report appropriate instruction and learning from this Inquest has been provided to custody staff via:”

    Source location

    Response from Northumbria Police
    Page 1 · response
    Published 24 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

    Review and update CJLD guidance for recording screening assessments, mental-health concerns, risks, clinical reasoning, referrals and handovers on electronic custody records.

    Verbatim wording from the response

    “The Trust has carried out a thorough review of the guidance provided to staff in relation to entering information onto the electronic custody record and the following changes have been embedded:”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS
    Page 2 · response
    Published 24 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

    Circulate the updated operating procedure and train CJLD staff on required electronic-record entries and verbal handover documentation.

    Verbatim wording from the response

    “The updated Local Operating Procedure was circulated to staff on 12 November 2024 via email, please see "Exhibit A". Team training also took place on the 13 November 2024 to discuss the updated guidance. During”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS
    Page 2 · response
    Published 24 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

    Conduct monthly random audits of every CJLD staff member’s screening records and discuss audit outcomes in monthly clinical supervision to monitor implementation.

    Verbatim wording from the response

    “In addition, CJLD Clinical Leads have been given express permission by the Northumbria Police (Superintendent responsible for Custody), to audit Trust staff entries into the electronic custody record provided the reason for accessing the record is documented. Clinical Audit of CJLD screening documentation and will be carried out by CJLD Clinical Leads monthly for every staff member. Three random samples are selected for each staff member each month. Audit includes records made on both ECR and RiO. Audit outcomes are and will be discussed in monthly Clinical Supervision.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS
    Page 3 · response
    Published 24 October 2024

    Open published response

  9. Manchester South

    AI-generated summary

    Leslie Andrew Swindells · 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

    Leslie Andrew Swindells had a complex mental health background and, after his mental health deteriorated, was found unresponsive at home with self-inflicted puncture wounds to the neck. The concerns included assessment by a practitioner with limited mental-health training, lack of appropriate triage and escalation, failure to recognise and mitigate risk, telephone-based assessment, inadequate documentation, and unclear supervision arrangements.

    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 documentation of mental health assessment content

    Wider context from the report

    “7. The documentation of the practitioner was poor and did not reflect the content of the conversation which had been recorded and was available to the inquest. ”

    Source location

    Leslie Andrew Swindells · 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

    Provide paper copies of clinical templates for use when electronic templates are inaccessible.

    Verbatim wording from the response

    “We recognise the concerns that you have raised into the documentation concerning Mr Swindells' appointment with the Assistant Practitioner. We have outlined at Section Two above the changes which were introduced to the standard templates utilised by Assistant Practitioners in their mental health and depression reviews. In addition to this, to ensure that accurate contemporaneous records are kept of all appointments with patients, clinicians have also been provided with hard copies of the templates to be used if they are unable to access the clinical system templates due to IT issues.”

    Source location

    Response from GTD Healthcare
    Page 8 · response
    Published 17 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

    Concerns about care and documentation should be addressed by the provider, rather than NHS England or the CQC.

    Verbatim wording from the response

    “Upon review, many concerns fall within the remit of the provider and their responsibility as an employer to meet the fundamental standards set out in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 17 October 2024

    Open published response

  10. Worcestershire

    AI-generated summary

    Oliver Davies · 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

    Oliver Davies died by suicide by hanging in his cell at HMP Hewell on 31 December 2022. The concerns included delayed and incomplete mental health assessment, failures to share relevant information about his self-harm and suicide risk, inadequate prioritisation and follow-up by the mental health care coordinator, and failures to keep him informed about healthcare and appointments.

    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 highlight recent mental-health and self-harm risk information in medical records for clinical assessment

    Wider context from the report

    “1) Oliver had been at HMP Hewell since 20.10.22. He was a man with long-standing mental health issues, for whom this was a first experience of custody. After a steady deterioration in his mental state, a mental health referral on 17.11.22 led to a belated mental health examination conducted by a registered learning disability nurse on 6.12.22. In the week leading up to the nurse’s assessment: (a) A prison officer had made an urgent TAG mental health referral on 30.11.22, citing concerns that Oliver was experiencing active thoughts of self-harm or suicide, and that he (the officer) had “mild concerns” about intentional self-harm, and there were “definite indicators” of unintentional self-harm; and (b) Oliver himself had submitted a healthcare application form asking to see a doctor, saying that he was “extremely depressed”, his anxiety was “really high” and he was “not coping at all, please help”; These important events were not highlighted on Oliver’s SystmOne medical record, and so the nurse conducting the assessment 6.12.22 was not aware of either of these important recent events, and did not take them into account when assessing Oliver; ”

    Source location

    Oliver Davies · 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

    Ensure TAG referrals and healthcare applications are added to and visible in SystmOne.

    Verbatim wording from the response

    “There is also now, a clear process for the management of TAG referrals and Healthcare applications ensuring that they are added to and visible in SystmOne.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · 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

    Reinforce reviewing recent electronic patient-record activity before assessment or intervention through incident-meeting messages, governance dissemination, management reminders and supervision.

    Verbatim wording from the response

    “The importance of staff familiarising themselves with recent clinical activity from the electronic patient record has been highlighted to all Inclusion staff as part of the key messages that arise from our monthly Health in Justice Serious Incident Meeting.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · 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

    Document patient concerns in SystmOne so subsequent staff can identify raised concerns and plan care and treatment to mitigate risk.

    Verbatim wording from the response

    “Following Mr Davies death, all MPFT colleagues at HMP Hewell have participated in specific clinical supervision focused on the importance of listening to and responding to prisoner concerns. To further support this, the team holds daily team meetings, monthly business meetings, weekly healthcare huddles, and weekly Safety Intervention Meetings (SIM) meetings; all of which have recorded minutes where prisoners' concerns are addressed. Information from the SIM meetings is disseminated to care coordinators via email, ensuring that tasks arising from these discussions can be actioned promptly. All patient concerns are documented on SystmOne by the person who is notified of the concern so that anyone looking at the”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · response
    Published 14 October 2024

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026