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. Birmingham and Solihull

    AI-generated summary

    Paul Price · 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 Price had a history of depression and anxiety, and was found outside his room on 04/06/18 after falling from a window; he was pronounced deceased at hospital, with the medical cause of death recorded as multiple injuries. Concerns included delays in communicating mental-health assessment information to his GP, incompatible IT systems, and a failure to return a call about concerns for his wellbeing.

    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 mental health information

    Wider context from the report

    “2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up. ”

    Source location

    Paul Price · Prevention of Future Deaths report
    Page 1 · 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

    Invest in electronic recording, listening devices, and hybrid mail to support timely GP correspondence.

    Verbatim wording from the response

    “1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.”

    Source location

    Paul-Price-Response
    Page 2 · response
    Published 19 September 2018

    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 disputes that its computer systems were down on 1 June 2018; it attributes the missed message to staff error.

    Verbatim wording from the response

    “3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.”

    Source location

    Paul-Price-Response
    Page 2 · response
    Published 19 September 2018

    Open published response

  2. Blackpool and the Fylde

    AI-generated summary

    Adam James Carter · 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

    Adam James Carter died on 10 September 2017 after absconding from The Harbour mental health facility during escorted leave and falling from the fifth floor of a car park. The principal concern was inadequate record keeping about Adam’s risks, leave arrangements, leave authorisation and assessment before leave, which could affect staff decisions about patient safety.

    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 and clearly formulate patient risks in the medical records

    Wider context from the report

    “The concern relates to record keeping. During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following: • Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: - aggression and violence; - self harm; - suicidal behaviour; - absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. • He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave. • He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion). • He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records. If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health. It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result. I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Adam James Carter · 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

    Prompt nursing teams to reassess patients’ risks and mental state immediately before leave and document the decision in clinical records.

    Verbatim wording from the response

    “Once leave has been agreed by the Multi Disciplinary Team, the nursing team on each ward will be prompted to fully consider the patients risks and state of mind immediately prior to the patient taking this leave, and reminded to document their up to date decision in the clinical record.”

    Source location

    2018-0226-Response-by-Lancashire-Care-NHS-Trust
    Page 1 · response
    Published 23 September 2018

    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 actions’ impact in a clinical audit, then review findings and provide feedback through team clinical supervision.

    Verbatim wording from the response

    “The impact of the above actions will be included in a clinical audit in January 2019. Matrons and ward managers will then review the findings from these audits and feed the results back during clinical supervision with their teams.”

    Source location

    2018-0226-Response-by-Lancashire-Care-NHS-Trust
    Page 2 · response
    Published 23 September 2018

    Open published response

  3. Surrey

    AI-generated summary

    Henry James Heselton · 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

    Henry James Heselton died by hanging in a field off Down Lane, Guildford, on 28 September 2016. The report identified concerns about unclear electronic mental health records and poor communication between mental health teams and his general practitioner, which meant relevant information was not available to inform clinical judgement.

    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 relevant mental health history in care plans

    Wider context from the report

    “1. The electronic mental health records were unclear. Vital information about Mr Heselton’s mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information was not easy to extract for professionals needing to find information about a patient in a crisis. ”

    Source location

    Henry James Heselton · 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

    Implement collaborative My Safety & Crisis Plans with regular completion and update prompts, including after significant risk changes.

    Verbatim wording from the response

    “The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors; demographic, background, clinical history, psychological and psychosocial factors and current context. The clinical assessment of these factors leads to a management plan which will include a ‘My Safety & Crisis Plan’ (a collaborative approach to safety planning). This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen when there is a significant change in risk.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response

  4. Black Country

    AI-generated summary

    Mr Colin Johns · 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

    Mr Colin Johns, a 71-year-old man with a history of low mood, alcohol dependency and previous self-harm, was discharged home after presenting with suicidal thoughts and requesting psychiatric admission. He subsequently took an overdose of co-codamol and died after being found collapsed at home. Concerns included inadequate communication and history-taking about self-harm attempts and insufficient efforts to find a suitable inpatient bed.

    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 self-harm and access-to-medication risks

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inadequate communication and history taken as part of the assessment process by the MHLS nurse. Specifically there were failures to record the fact he had attempted to strangle/suffocate himself whilst in the A and E department and gain entry to the drugs trolley. ”

    Source location

    Mr Colin Johns · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. South London

    AI-generated summary

    Julia Jane MacPherson · 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

    Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

    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 or missing records of consent discussions for off-licence mental health medication

    Wider context from the report

    “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

    Source location

    Julia Jane MacPherson · Prevention of Future Deaths report
    Page 1 · 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

    Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.

    Verbatim wording from the response

    “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.”

    Source location

    2018-0298-Oxleas-NHS-Foundation-Trust
    Page 2 · response
    Published 19 January 2019

    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 ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.

    Verbatim wording from the response

    “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.”

    Source location

    2018-0298-Oxleas-NHS-Foundation-Trust
    Page 2 · response
    Published 19 January 2019

    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

    Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.

    Verbatim wording from the response

    “Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 2019

    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

    Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.

    Verbatim wording from the response

    “We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.”

    Source location

    2018-0298-Response-by-CQC
    Page 2 · response
    Published 19 January 2019

    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 circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.

    Verbatim wording from the response

    “We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 2019

    Open published response

  6. Inner North London

    AI-generated summary

    Songul BOZDAG · 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

    Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.

    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 need for a care plan approach on the computer system

    Wider context from the report

    “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016. 2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory. 3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error. 4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system. 5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis. These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life. ”

    Source location

    Songul BOZDAG · 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 monthly supervision for all care coordinators, covering care-plan delivery, reviews, CPA status and record-keeping, with regular compliance audits.

    Verbatim wording from the response

    “The key system for monitoring the ongoing support provided to service users by a care coordinator is monthly supervision. This had not been robustly undertaken within the CMHT and I am pleased to report that this is now working in line with Trust procedures with all care coordinators receiving monthly supervision. Standing agenda items in supervision include CPA status, delivery of the care plan including monitoring of visits and medical reviews and the standard to record keeping. Regular audits are being undertaken to maintain a robust oversight on the process and also actively respond to any gaps in the system in a timely way and to provide assurance that staff are working to agreed record keeping standards and practice.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    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 internal monitoring processes to identify gaps in CPA reviews and regular contact.

    Verbatim wording from the response

    “In addition to the above a review of internal monitoring process has been undertaken to assure the Trust that systems are sufficiently robust and will flag up any cases where service users on CPA are not being seen regularly or reviewed by their consultant. Teams have access to live reports which allows real time activity by the Team and can be drilled down to provide data on an individual service user. The Team administrator also sends out weekly prompts around key performance indicators to the Operational Team Lead and this includes activity for patients on CPA.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    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 teams with live activity reports and weekly performance prompts covering CPA patients.

    Verbatim wording from the response

    “In addition to the above a review of internal monitoring process has been undertaken to assure the Trust that systems are sufficiently robust and will flag up any cases where service users on CPA are not being seen regularly or reviewed by their consultant. Teams have access to live reports which allows real time activity by the Team and can be drilled down to provide data on an individual service user. The Team administrator also sends out weekly prompts around key performance indicators to the Operational Team Lead and this includes activity for patients on CPA.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    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 London Borough of Tower Hamlets is handling formal processes addressing the care coordinator’s conduct, with Trust support.

    Verbatim wording from the response

    “Before setting out the steps that the Trust is taken in relation to improving systems I would like to reassure you that the issues highlighted in relation to the conduct of the care co-ordinator. One of the first actions taken was an audit of the care coordinators case load to ascertain if she was working to agreed record keeping standards and practice. The gaps in the care that she provided to Ms Bozdag are currently being dealt with by her employer, the London Borough of Tower Hamlets, through formal processes with the full support of the Trust and the individual in question is not working with patients whilst these processes are ongoing.”

    Source location

    Response from East London NHS Foundation Trust
    Page 1 · response
    Published 25 September 2017

    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

    Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.

    Verbatim wording from the response

    “With the systems that are now implemented at the CMHT I hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns.”

    Source location

    Response from East London NHS Foundation Trust
    Page 2 · response
    Published 25 September 2017

    Open published response

  7. County Durham and Darlington

    AI-generated summary

    Thomas Whitfield · 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

    Thomas Whitfield was a voluntary patient at Farnham Ward, Lanchester Road Hospital, and was found hanging in his room on the morning of 28 July 2016, shortly after being re-assessed by his Consultant Psychiatrist. The concerns included whether information from his sister about perceived suicide risk was communicated and recorded, and the absence of monitoring or recording of telephone calls that might have clarified what was said.

    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 family concerns about suicide risk in the Paris notes

    Wider context from the report

    “The deceased’s sister made a statement advising that she had spoken to hospital staff alerting them to the risk that she perceived her brother had of suicide. Her statement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk. Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the patient. A Consultant Psychiatrist gave evidence that if he had been aware of such family concerns it would have affected his risk assessments. There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns. Many calls now are recorded for monitoring and training purposes and had such calls being so monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time. There is CCTV in the hospital, which can be viewed after an event to clarify what did/not happen. ”

    Source location

    Thomas Whitfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Inner North London

    AI-generated summary

    John 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

    John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.

    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 self-harm or suicide assessments

    Wider context from the report

    “1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had. It appears she may benefit from additional training and/or supervision. ”

    Source location

    John WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Staffordshire South

    AI-generated summary

    Annabel Mae LEWIS · 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

    Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.

    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 risk, contact details, appointment information and follow-up arrangements

    Wider context from the report

    “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded. There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life. The time period between referral and initial contact and attempted follow up appears considerable. No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements. The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging. Annabel might well have benefitted had she been offered a more proactive service. ”

    Source location

    Annabel Mae LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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-capacity documentation at discharge

    Wider context from the report

    “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete. ”

    Source location

    Derek LEE · 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