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. West Sussex, Brighton and Hove

    AI-generated summary

    Miles Ethan Hurley · 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

    Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a documented LDS mental health plan for custody

    Wider context from the report

    “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite. a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care. b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody. c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody. c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment. d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody. d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present. e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality. ”

    Source location

    Miles Ethan Hurley · Prevention of Future Deaths report
    Page 6 · concerns

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of formal police documentation of family concerns about mental health deterioration

    Wider context from the report

    “2. Lack of relevant Documentation by the Police Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making. ”

    Source location

    Miles Ethan Hurley · Prevention of Future Deaths report
    Page 5 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete and regularly review detainee risk assessments and care plans, recording changing physical or mental health information and responding to identified risks.

    Verbatim wording from the response

    “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).”

    Source location

    Response from Sussex Police
    Page 3 · response
    Published 29 July 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Record custody risks and concerns discussed with Liaison and Diversion staff on the detainee’s risk assessment and care plan.

    Verbatim wording from the response

    “LDS Nurses will proactively triage detainees listed on the Custody White Board between 08:00hrs and 20:00hrs. This is a virtual white board accessed via NICHE which LDS nurses can independently access at any time. It contains details of all detainees in each Custody Centre. A Professional Discussion will be held between the LDS Nurse and Principal Sergeants to identify assessments that may need to be prioritised.”

    Source location

    Response from Sussex Police
    Page 4 · response
    Published 29 July 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

    Add information received from detainees’ families to the custody care plan so concerns are formally recorded and addressed.

    Verbatim wording from the response

    “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).”

    Source location

    Response from Sussex Police
    Page 3 · response
    Published 29 July 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

    Police Custody Healthcare services are responsible for developing and delivering mental health care plans for detainees in crisis.

    Verbatim wording from the response

    “This is also covered in my response to points 4 and 5 below. The responsibility for the care of those in mental health crisis, requiring the development and delivery of a ‘care plan,’ rests with the Police Custody Healthcare (PCHC) service, who will be able to respond more fully to this point.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 29 July 2024

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The NPCC is unable to comment on the mental health plan referred to in the case.

    Verbatim wording from the response

    “b) The NPCC is unable to make comment on the mental health plan referred to in this case.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 29 July 2024

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Kieran Lavin · 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

    Kieran Lavin, who had experienced worsening depression and suicidal thoughts, died after leaving a mental health unit with his wife for transport to another facility. Shortly afterwards, on the M5 motorway, he exited the vehicle and was struck by vehicles. The principal concerns were that critical suicide-risk information was not recorded or recorded promptly, and that the transport risk assessment and guidance for family transport were inadequate.

    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 critical suicide risk information completely and promptly

    Wider context from the report

    “1. Critical suicide risk information was not recorded at all or not recorded in a timely manner. On 10/12/23, the experienced nurse did not record at all in the 'suicide' box on the 'level 1 – risk screening' the first report of suicidal ideation via road traffic collision. She described this omission as an error and the likely explanation was that she was the only nurse working on a very busy shift. On 11/12/23, the experienced nurse did not in a timely manner record in the ‘suicide’ box on the ‘level 1 – risk screening’ the second report of suicidal ideation via road traffic collision received by 11am. She said the likely explanation for not updating the ‘suicide’ box until 8:51pm (and after the nurse-in-charge made his transport risk formulation) was that she was the only nurse working on a very busy shift. The experienced Nurse-in-Charge did not record at all the transport risk formulation saying that was not his usual practice. The Patient Safety Manager said long standing trust policy required clinicians to record key information as soon as possible. I am not persuaded this long standing policy is sufficient by itself to remove the risk in the future of critical suicide risk information not being recorded at all or in a timely manner given three experienced nurses within 24 hours failed to follow the policy. ”

    Source location

    Kieran Lavin · 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

    Review and revise Psychiatric Decisions Unit handover standards to require urgent information to be documented and communicated before transport, discharge and other significant decisions.

    Verbatim wording from the response

    “The quality and standards of the handover process in the PDU will be reviewed, with particular attention to ensuring that critical information is documented and communicated before key decisions, such as patient transport, are made. The handover process will also be revised to establish clear standards that require the documentation and communication of urgent information prior to any significant decisions, including patient discharge.”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 2 · response
    Published 9 August 2024

    Open published response

  3. Rutland and North Leicestershire

    AI-generated summary

    Christopher Henrik LARSEN · 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

    Christopher Henrik Larsen, a 52-year-old man, was found hanging at his home in Leicestershire on 6 January 2023 and died before a planned mental health triage call. Concerns included inadequate documentation and decision-making in multidisciplinary team meetings, inaccurate interpretation of risk information, insufficient risk assessment and discharge planning, and weaknesses in the serious incident investigation and learning process.

    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 MDT meeting decision making and risk downgrading rationale

    Wider context from the report

    “1. Multi-Disciplinary Team (“MDT”) Meetings I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen. It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients. The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information. There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.” At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting. ”

    Source location

    Christopher Henrik LARSEN · 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

    Implement the revised MDT template and pre-MDT referral process to clarify referrals and capture clinical information, decisions, actions and owners.

    Verbatim wording from the response

    “As part of immediate learning and action taken relating to the concerns you have raised directly about the MDT meeting and documentation, we have reviewed and made substantial changes to the MDT template to be used for MDT meetings [Appendix 1]. In addition, after engagement with clinical staff and extended reflection on the death of Christopher Larsen, we have also implemented a process to provide further clarity on the reason for referral into the MDT meeting via pre-MDT sections to be completed on the MDT template. This template will be completed by the clinician who had the last clinical contact with the patient prior to the MDT meeting. The information captured in this template and the reason for the referral into the MDT meeting will be discussed with the patient at this clinical contact and will support the information captured within the patient’s notes and risk assessment.”

    Source location

    Response from Leicestershire Partnership NHS (2)
    Page 2 · response
    Published 14 June 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include a senior nurse clinician, medical colleagues and crisis-service members in MDT meetings to oversee and support the process.

    Verbatim wording from the response

    “The MDT meeting attendance has also been reviewed to include a senior nurse clinician to oversee the process along with medical colleagues and other members of the crisis service. The MDT meeting will utilise the information within the pre-MDT template and the most recent Core assessment, Risk assessment and the contemporaneous clinical notes to inform the clinical discussions. The discussions within the MDT will be captured in real-time in the MDT template and the outcomes, decisions and actions agreed and documented; the MDT template forms part of the patient notes and will be immediately available.”

    Source location

    Response from Leicestershire Partnership NHS (2)
    Page 2 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct monthly audits of MDT processes and documentation, share feedback with staff, review outcomes through quality governance, and undertake additional six-month senior scrutiny.

    Verbatim wording from the response

    “To provide assurance to the Directorate senior clinical team, audits will be undertaken monthly to ensure the processes and documents are being completed fully and to the standards expected. Feedback from the audits will be shared with the staff involved via their weekly meeting to ensure they are aware of areas requiring improvement. The outcomes of the audit will be reviewed within the Directorate Quality and Safety Governance meeting, with evidence of learning shared; this will be monitored monthly. In addition, the Chief Nurse and Medical Director will review the audits, sample of decisions and outcomes of the new process in six months to provide additional assurance and scrutiny.”

    Source location

    Response from Leicestershire Partnership NHS (2)
    Page 2 · response
    Published 14 June 2024

    Open published response

  4. Cornwall and Isles of Scilly

    AI-generated summary

    Sally Poynton · 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

    Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.

    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 family-provided clinical timelines

    Wider context from the report

    “a) In-patient care at Longreach Hospital Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water. He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care. At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’ One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care. I felt there were a number of points of learning: i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest; ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult. It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s. iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices; iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard. v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob. vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics. ”

    Source location

    Sally Poynton · Prevention of Future Deaths report
    Page 4 · 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

    Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty

    Wider context from the report

    “a) In-patient care at Longreach Hospital Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water. He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care. At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’ One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care. I felt there were a number of points of learning: i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest; ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult. It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s. iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices; iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard. v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob. vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics. ”

    Source location

    Sally Poynton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Integrated Care Board is expected to respond to concerns about the specific care provided.

    Verbatim wording from the response

    “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.”

    Source location

    2024-0267 Response from Department of Health and Social Care
    Page 1 · response
    Published 20 May 2024

    Open published response

  5. Northumberland

    AI-generated summary

    Harry David HALL · 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

    Harry David Hall, who had a history of depression and recent suicidal ideation, was found dead in the rear garden of his home on 29 May 2023 after sustaining a self-inflicted traumatic head injury from a captive bolt gun. The principal concern was inadequate record keeping about the missed mental-health appointment and the lack of clarity about whether any assessment took place before his death; the report also noted delays in 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 record the reason for a missed appointment and whether an assessment was undertaken

    Wider context from the report

    “The deceased was seen by his General Practitioner on 27 March 2023 when he described ongoing suicidal ideation. His General Practitioner referred him to the 24-hour crisis team at 17.56 hours on 27 March 2023. The Initial Response Team ("IRT") provides 24 hour access to urgent mental health care and treatment. The IRT called the deceased at 22.37hrs on 27 March 2023 and I am told during which no immediate risks of self-harm were identified and although frequent thoughts of suicide were being experienced they were felt to be chronic in nature. The clinical decision was to not to refer on the Crisis Team and instead refer to the West Northumberland Community Treatment Team. There were two letters the first dated 31 March 2023 offering an appointment on 17 May 2023 and the second dated 4 April offering an appointment on 26 June 2023. I heard there was a ten week delay in appointments although that delay has since been rectified. The appointment on 17 May 2023 did not go ahead. No evidence was given as to why the appointment on the 17 May 2023 did not go ahead. There is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial information. It is speculation if the outcome would have been any different if the deceased had been seen prior to his death. I am concerned with regard to the record keeping at this time. ”

    Source location

    Harry David HALL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 a cancelled appointment lacked rationale and says assessment remained within the applicable 18-week timeframe.

    Verbatim wording from the response

    “There was therefore no cancelled appointment and therefore no omission of rationale for the perceived cancellation. Furthermore, as was explained in the hearing, Mr Hall would have been seen within the 18 week timeframe that was the appropriate benchmark at the time.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear
    Page 2 · response
    Published 9 May 2024

    Open published response

  6. Swansea and Neath Port Talbot

    AI-generated summary

    Nicholas Kim Harrison · 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

    Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.

    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 s.12 doctors’ assessment outcomes when patients are not admitted

    Wider context from the report

    “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur. ”

    Source location

    Nicholas Kim Harrison · 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

    Amend the AMHP assessment form to capture consultation views, reasons for non-consultation, earlier analysis, and doctors' individual views and detention-criteria conclusions.

    Verbatim wording from the response

    “vi. The AMHP assessment form is to be updated to include an additional section for the recording of the views of relevant others or reasons for not consulting with them, and AMHPs are to be directed/instructed to complete this section in as much detail as possible.”

    Source location

    Response from City and County of Swansea
    Page 4 · response
    Published 9 May 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

    Discuss with the Health Board the requirement for doctors to record their views and conclusions on the AMHP assessment form.

    Verbatim wording from the response

    “xi. The AMHP assessment form is to be amended so that the section referencing the doctors involved in the assessment process prompts the detailed recording of the doctors' individual views as to the individual's case and criteria for detention. The Council's Head of Adult Services has opened dialogue with Swansea Bay University Health Board's (hereafter "SBUHB") Service Group Director of Mental Health and Learning Disabilities with regard to the requirement for doctors to record their views/conclusions on the AMHP assessment form.”

    Source location

    Response from City and County of Swansea
    Page 4 · response
    Published 9 May 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

    Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.

    Verbatim wording from the response

    “It is not within the Council's remit to respond to all of the matters of concern set out by His Majesty's Coroner in the Report, and it is appropriate that the Council responds to the first and second matters of concern. I shall address each in turn:”

    Source location

    Response from City and County of Swansea
    Page 1 · response
    Published 9 May 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

    SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.

    Verbatim wording from the response

    “This is a matter of concern for SBUHB and NHS Wales to primarily address, but the Council wishes to comment specifically in relation to access to its systems by Section 12 doctors.”

    Source location

    Response from City and County of Swansea
    Page 5 · response
    Published 9 May 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.

    Verbatim wording from the response

    “I note the report has been sent to the UHB and the City and County of Swansea for a response and action and I expect them to provide responses within your timescale that address the concerns raised. I am issuing a separate Welsh Government response to ensure lines of accountability are clear. I take the concerns raised in the report very seriously and I would like to set out the actions being taken.”

    Source location

    Response from Welsh Government
    Page 1 · response
    Published 9 May 2024

    Open published response

  7. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Ryan John EVANS · 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

    Ryan John EVANS died after being found hanging in the communal area of his accommodation on 3 April 2018. The concerns included that, despite evidence of self-harm and suicidal ideation, no mental health assessment was carried out at hospital, and that mental health information and referrals were not effectively documented or communicated during his time in police custody.

    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 suicidal ideation identified during emergency department care

    Wider context from the report

    “An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self-harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded. The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital. These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.” Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation. The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’ I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again. The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment. ”

    Source location

    Ryan John EVANS · 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

    Update Emergency Department digital triage to ask all patients about mental health or self-harm within 15 minutes of arrival.

    Verbatim wording from the response

    “In response to this NICE guideline and additional guidance from the Royal College of Emergency Medicine (RCEM), ‘Mental Health in Emergency Department’s – A Toolkit for Improving care’, April 2021, the Trust has now updated its digital triage assessment of all patients attending the Emergency Department to include a mandatory question about a patient’s history of mental health and/or self-harm. This question is asked of all patients attending the Emergency Department within 15 minutes of their arrival regardless of the reason for their presentation.”

    Source location

    Response from Frimley Health
    Page 2 · response
    Published 8 January 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

    Store Emergency Department triage and mental health assessment forms electronically in the patient record, with Psychiatric Liaison access.

    Verbatim wording from the response

    “Both the initial Emergency Department triage and the mental health assessment form are now held electronically on the Trust’s electronic patient record, to which the Psychiatric Liaison services team have access. This means that, if necessary, a patient’s entire medical record can be referred to by Psychiatric Liaison services.”

    Source location

    Response from Frimley Health
    Page 4 · response
    Published 8 January 2024

    Open published response

  8. Manchester North

    AI-generated summary

    Teresa Chmielek · 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

    Teresa Chmielek took her own life at home on 17 June 2023, after a referral to mental health services concerning her suicide risk was rejected without contact or a face-to-face review. The concerns included failure to identify or recognise the reported recent suicide attempt, lack of meaningful multidisciplinary discussion and direct contact, inadequate referral arrangements and documentation, and the absence of procedures and auditing for referral decisions.

    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 suicide attempts in screening MDT notes

    Wider context from the report

    “(1) The notes made by the SPoE Nurse for use during discussion at the screening MDT meeting did not include any reference to the report of a recent suicide attempt and the Court was not satisfied that the risk of suicide had been identified or recognised by the SPoE Nurse ”

    Source location

    Teresa Chmielek · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Jack FARRINGTON · 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

    Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.

    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 securely store and share Queen Alexandra Hospital mental health records

    Wider context from the report

    “There were records kept during Jack’s presence at Queen Alexandra Hospital which were either not stored or had been lost prior to the inquest. This significantly hampered the investigation and restricted the information available to the jury. I accept that the location of patients with mental health issues whilst awaiting transfer to a mental health unit has changed since Jack’s death. I also understand that mental health nursing records are now kept within an Enhanced Care Plan but this is still a paper format and therefore the risk of inadequate information sharing and failing to store records remain. ”

    Source location

    Jack FARRINGTON · 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

    Replace paper-based clinical observation forms with electronic forms feeding directly into SystmOne, including tablet procurement and ward testing.

    Verbatim wording from the response

    “The Mental Health Service continues to record various clinical observations on paper-based forms, which are scanned into SystmOne. This includes therapeutic engagement and observations, physical observations, food and fluid charts. The service is working towards replacing the paper-based forms with an electronic form that feeds directly into SystmOne, and I am pleased to report that work is on track and planned to be implemented by 01st April 2024. The Service’s Clinical Matron has visited departments within Southern Health NHS Foundation Trust to view the system in use and is meeting regularly with Solent NHS Trust Information Specialist to ensure this will be ready to implement on time. This change also involves the procurement of tablets to record the information on, which will be tested in all areas of the wards.”

    Source location

    Response from Solent NHS Trust
    Page 2 · response
    Published 13 November 2023

    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

    Locate mental health nursing records within the Enhanced Care Plan for patients awaiting mental health placement.

    Verbatim wording from the response

    “As noted by the coroner, the Trust continues to work to improve its processes regarding the care and documentation of the care of patients with mental health needs. Patients awaiting mental health placement are predominantly cared for in the Acute Medical Unit (AMU) with the recent introduction of the mental health nursing records being located within the Enhanced Care Plan.”

    Source location

    Response from Portsmouth Hospitals University NHS Trust
    Page 4 · response
    Published 13 November 2023

    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 temporary staff and partner mental health teams with electronic access to document assessments and care plans in Oceano.

    Verbatim wording from the response

    “Within the ED, bank and temporary members of staff are provided with a temporary ICT login, and a login for Oceano allowing for electronic documentation of patient assessment and delivery of care. Our partner organisations, Solent NHS Trust, and Southern Health Foundation Trust mental health teams, also now have access to Oceano allowing them to input their assessments and plan of care directly into the Trust’s ICT system negating the need for paper records.”

    Source location

    Response from Portsmouth Hospitals University NHS Trust
    Page 4 · response
    Published 13 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.

    Verbatim wording from the response

    “The Trust fully agrees that the current hybrid between paper and electronic records creates greater complexity and inefficiency, impacting the ability of the multidisciplinary teams to locate all necessary information for each patient. The ambition of PHU and similar NHS Trusts who have not already done so is to move to a true paper free Electronic Patient Record (EPR). We are working with the Integrated Care Board (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time.”

    Source location

    Response from Portsmouth Hospitals University NHS Trust
    Page 4 · response
    Published 13 November 2023

    Open published response

  10. Inner West London

    AI-generated summary

    Mr Oleg Khala · 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 Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.

    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 patients' mental health history by CATT

    Wider context from the report

    “1. The generic, tick-box style of history recording by CATT which does not paint a full and proper picture of the mental health of the patient, especially compared to the assessments of psychiatric liaison, are such that risk may be unrecorded and under appreciated by CATT and patients thus be put at risk. ”

    Source location

    Mr Oleg Khala · 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

    Deploy enhanced documentation practices to support coordinated care.

    Verbatim wording from the response

    “As part of the implementation of this we have developed and are deploying standardized protocols, enhanced documentation practices, and regular training sessions to promote effective coordinated care by any named clinician involved in patient care. These measures aim to mitigate potential risks and ensure that patients receive the highest quality of care in a coordinated manner.”

    Source location

    Response from West London NHS Trust
    Page 3 · response
    Published 10 July 2023

    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