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. Inner West London

    AI-generated summary

    Mrs Elsie Leaver · 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

    Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.

    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

    Omission of pertinent psychiatric history from GP summaries

    Wider context from the report

    “1. That the GP summary did not contain pertinent psychiatric history that would have assisted the hospital clinicians to identify Mrs Leaver’s depression and specifically her suicidality. ”

    Source location

    Mrs Elsie Leaver · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. East London

    AI-generated summary

    Donna Neill · 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

    Donna Neill was found deceased at home on 10 December 2018 after an overdose involving medication prescribed to her husband. The report identified that the risk of her taking medication not prescribed to her was not fully assessed, documented, or managed, and that no risk management plan was put in place.

    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 identified medication-taking risks in mental health records

    Wider context from the report

    “A clear risk was raised at the CPA meeting on the 4th December 2018. This was the risk of Donna taking medications prescribed to her husband. This risk was not documented in the Trust’s mental health records, not fully assessed and no risk management plan was put in place to protect Donna from harm. The absence of a risk assessment and management plan was not identified as a failing within the Trust’s internal investigation report and no steps have been taken by the Trust to improve the systems in place. ”

    Source location

    Donna Neill · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Exeter and Greater Devon

    AI-generated summary

    Archi Johnson · 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

    Archi Johnson, who had a history of depression, self-harm and suicidal ideation, was admitted voluntarily to a hospital ward on 5 November 2019 after reporting intrusive thoughts of taking his own life. He was found hanging on 7 November 2019; concerns were raised that information about a previous similar suicide attempt was not clearly recorded or shared, which may have affected decisions about his risk level, observation level and the removal of potentially dangerous ligature items.

    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 clearly record and make relevant previous incidents known to those responsible for care

    Wider context from the report

    “1.Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared: a)Two types of risk assessments were completed, with no system to ensure that important information is present on both; b) The previous incident in which Archi had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care; c) Those responsible for his care accepted that the above incident was one of which they would have wanted to have knowledge; d) The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items. ”

    Source location

    Archi Johnson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Freeda GLAUSIUSZ · 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

    Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.

    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 crisis-line calls in the medical record

    Wider context from the report

    “1. I was shocked when I listened to the recording of the call that █ ████████ made to the crisis line the day before his daughter died. The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis. In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled. The clinician then made no note of the call in the medical records, even retrospectively. I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts. • This is not the first time that I have made a PFD report to ELFT about its crisis line. • Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record. He said that he had made a note on a piece of paper, but he did not now have that piece of paper. • When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance. ”

    Source location

    Freeda GLAUSIUSZ · 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 medical-records training for senior nurses and Trust managers on record keeping, observations and retrospective entries.

    Verbatim wording from the response

    “To address this matter, medical records training for all senior nurses was provided on 24 November 2021 to all senior nurses and managers at the Trust. The focus of the training was good record keeping, observations and retrospective record keeping.”

    Source location

    Response from East London NHS Foundation Trust
    Page 4 · response
    Published 22 June 2023

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Azra Parveen HUSSAIN · 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

    Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

    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 significant family concerns and patient accounts

    Wider context from the report

    “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs. ”

    Source location

    Azra Parveen HUSSAIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. West Sussex

    AI-generated summary

    James Kenneth Herbertson · 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

    James Kenneth Herbertson took his own life after being struck by a train near Crawley train station on 10 April 2019. Concerns included unsuitable discharge accommodation and failures to recognise and act on signs of a mental health relapse, including not referring him to the crisis team or providing additional support.

    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

    Inadequate recording of deterioration in mental health presentation

    Wider context from the report

    “a) It was clear that James’ Mental health was deteriorating on the visit by the lead practitioner on 8th April 2019. This change in presentation was discussed at the Multidisciplinary meeting on 9th April 2019 but was not adequately recorded. He was placed in “Red Zone”. It was clear from the evidence that there was a lack of understanding by individual staff as to what actions they should be taking following a service user being placed in “Red Zone”. ”

    Source location

    James Kenneth Herbertson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Oxfordshire

    AI-generated summary

    LISA MARIE THOMPSON · 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

    Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.

    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 recent medication overdoses

    Wider context from the report

    “Evidence was heard that: (1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020 (2) The care plans and risk assessments at the mental health Trust were not updated: (a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication. (b) the two most recent overdoses were not recorded (c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out. (d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist (e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator ”

    Source location

    LISA MARIE THOMPSON · 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

    Have the Quality Improvement team consider family involvement, enhanced risk formulation and suicide-risk assessment within thematic improvement work.

    Verbatim wording from the response

    “To that end, the Trust has a Quality Improvement team² who are dedicated to working with our local teams to continually improve the quality of our services. Our Chief Nurse has asked the Quality Improvement team to ensure areas of improvement relating to this tragic serious incident are considered alongside other themes identified from the thematic review, in particular:”

    Source location

    2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
    Page 3 · response
    Published 27 May 2021

    Open published response

  8. North East Kent

    AI-generated summary

    PAUL HILLS · 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

    Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.

    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 disclosures relevant to mental health risk

    Wider context from the report

    “4. His risk assessment was not up-to-date and his disclosures during April were not documented. ”

    Source location

    PAUL HILLS · 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

    Improve clinical record keeping to ensure care plans, risk assessments and clinical reasoning are documented clearly and electronically.

    Verbatim wording from the response

    “Sgt Hills’ risk was assessed by treating clinicians in Department of Community Mental Health, London, and as a result he was offered a face-to-face appointment. Following discussion with Sgt Hills, who was concerned about attendance in person, a telephone appointment was agreed as an alternative. We agree that the factors his clinicians considered in proceeding with telephone consultations should have been documented more clearly. Steps have now been taken to ensure better record keeping. This is covered in more detail below, in the response to your matters of concern 2 and 4.”

    Source location

    2020-0247-Response-from-MP-MOD-Redacted.pdf
    Page 2 · response
    Published 29 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

    Strengthen senior-clinician oversight of record-keeping quality and regularly review clinicians whose performance falls below the required standard.

    Verbatim wording from the response

    “More broadly, steps have been taken to ensure that Senior clinicians focus on the quality of record keeping and, should the performance of any treating clinician fall below the expected standard, that person’s performance will be reviewed regularly until the required quality is achieved. To support this, Defence Primary Healthcare is currently updating its guidance on the delivery of mental healthcare to ensure clinicians, Departments of Community Mental Health and Regions have the support they require and can be held to account for their adherence to clinical policy.”

    Source location

    2020-0247-Response-from-MP-MOD-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    Open published response

  9. Exeter and Greater Devon

    AI-generated summary

    Stuart Michael CLARK · 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

    Stuart Michael CLARK died shortly after being recovered from a canal on 3 October 2017, after entering the water wearing a rucksack filled with weights. During a hospital admission before his death, he disclosed that he was a vulnerable adult and a suicide risk, but this was not escalated or followed by an assessment of his risk of self-harm or suicide. The report identified that senior clinical staff were not directly informed and that the relevant medical record entry was not available to other staff at the time.

    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 recording clinically significant disclosures in medical notes

    Wider context from the report

    “(1) The evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Canpere) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk. This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent, plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services. Senior clinical staff were not directly informed of the disclosure. The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide, and if appropriate she would have referred him to the mental health services. The nurse made an entry in the medical records; however, the medical notes were not made up until the end of the day and therefore the information was not available to the other staff at the relevant time. ”

    Source location

    Stuart Michael CLARK · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Manchester West

    AI-generated summary

    Karl Qolf Jamil Englemak Cassimjee · 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

    Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.

    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 interim deterioration advice and action information

    Wider context from the report

    “1. Brief circumstances of matter of concern a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital); b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner; c. The assessment, as recorded by the Registrar was accepted to be sub-optimal; d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team. e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim). f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account. ”

    Source location

    Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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