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. Manchester South

    AI-generated summary

    Sandra Brotherton · 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

    Sandra Brotherton was killed at her home on 31 December 2014, shortly after returning from hospital. The inquest heard that she had been the predominant and effectively sole carer for a person with a dual diagnosis of paranoid schizophrenia and Asperger’s Syndrome, who had been alone at home during her hospital stay. Concerns included the lack of a clearly discussed contingency plan, inadequate documentation and sharing of care-plan information with the Personal Assistant, difficulty obtaining an urgent psychiatric appointment, and insufficient follow-up after Sandra requested that he be rehoused immediately.

    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 objections to sharing confidential medical information

    Wider context from the report

    “2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a lack of capacity, this should be recorded. ”

    Source location

    Sandra Brotherton · 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

    Require Care Coordinators to assess risk-based information sharing with Personal Assistants and document this in wellbeing care plans.

    Verbatim wording from the response

    “Care Coordinators within Stockport Community Services have been reminded that in line with the CPA policy, version 12, where a Personal Assistant is in place with individual service users, the Care Coordinator will assess the need to share information with the PA based on risk. This must form part of the wellbeing care plan.”

    Source location

    2016-0400-Response-by-Pennine-Care-NHS-Trust
    Page 2 · response
    Published 26 February 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

    Disseminate and deliver a briefing on Personal Assistant involvement in care planning and information-sharing records.

    Verbatim wording from the response

    “To share the learning highlighted in this regulation a 7 minute briefing regarding the involvement of a PA in care planning processes has been developed and has been shared with all community based mental health teams in the Trust. The briefing recommends that where a Personal Assistant is integral to the Mental Health Service”

    Source location

    2016-0400-Response-by-Pennine-Care-NHS-Trust
    Page 2 · response
    Published 26 February 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

    Discuss adding Personal Assistant care-planning and information-sharing guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.

    Verbatim wording from the response

    “To be discussed at the Tier 4 meeting to discuss adding guidance as an addendum to current operational policy for each community based team.”

    Source location

    2016-0400-Response-by-Pennine-Care-NHS-Trust
    Page 3 · response
    Published 26 February 2017

    Open published response

  2. Manchester City

    AI-generated summary

    Nicholas Patrick SULLIVAN · 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 Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.

    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 reception checklist for identifying and recording mental health and self-harm or suicidal ideation information

    Wider context from the report

    “5.1 Whilst recognising that Emergency Departments can by busy, reception staff did not work to a short bullet point pro-forma checklist which identifies issues of mental disorder/conditions and check and record important background issues, such as self-harming behaviour or suicidal ideation. This information is vital to record and should trigger urgent triage/mental health assessment. ”

    Source location

    Nicholas Patrick SULLIVAN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Preston and West Lancashire

    AI-generated summary

    Andrew Gus PEEBLES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.

    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 referrals concerning psychiatric state in the medical record

    Wider context from the report

    “(7) on referral on 25 May 2013 by and RGN who was concerned about Mr Peebles psychiatric state to two RMNs no record was made in the medical record of any such referral having taken place and no referral or assessment did subsequently take place ”

    Source location

    Andrew Gus PEEBLES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · 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

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    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 assessment of mood and suicidal thoughts during prison triage

    Wider context from the report

    “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts. ”

    Source location

    Samuel Rodney Darren BLAIR · 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

    Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.

    Verbatim wording from the response

    “Response: We refer you to the response provided by BEH-MHT as these concerns are relating to their services rather than the services of Care UK.”

    Source location

    2016-0196-Response-by-Care-Uk
    Page 1 · response
    Published 19 May 2016

    Open published response

  5. Worcestershire

    AI-generated summary

    Stephen Martin ADAMS · 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

    Stephen Martin ADAMS was being cared for by the Home Treatment Team of Worcestershire Health and Care NHS Trust when he died by suicide by hanging at his home. The inquest identified that the suicide-risk assessment section of a Mental Health Liaison Team risk assessment document had not been completed, and that risk assessment was instead inferred from the worker’s actions.

    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 suicide risk assessment in risk assessment documents

    Wider context from the report

    “(1) It emerged during the inquest that the Risk Assessment document completed by the Mental Health Liaison Team worker was not complete in as much as the box indicating the assessment of suicide risk had not been completed. The witness indicated that many workers do not complete this box and the assessment of risk is to be extrapolated from the actions taken by the worker. No where on the document is the assessment of risk to be found. ”

    Source location

    Stephen Martin ADAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Derby and Derbyshire

    AI-generated summary

    Louise Sharon Henry · 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

    Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

    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 GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information

    Wider context from the report

    “4. That GPs do not appreciate the use that can be made of the Special Patient Note facility and Right Care plan facility on the EMIS system operated by GPs. I heard evidence that key information relating to patients and in particular mental health patients can be updated on to the Special Patient Note facility and the Right Care Plan facility by GPs and used to record risk relapse triggers and indicators for patient’s with mental health difficulties and risk of suicide/ self harm. This enables Out of Hours Services such as those operated by Derbyshire HealthCare United to access key risk information when they are called out of hours when the GP and the full GP records with this key information is not available. There appears to be action that can be taken by NHS England through the Clinical Commissioning Groups to educate GPs as to this facility. ”

    Source location

    Louise Sharon Henry · 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

    Review the PARIS discharge-letter format after the audit and determine necessary changes.

    Verbatim wording from the response

    “11. On completion of the audit, a review of the discharge letter format available within the PARIS system will take place and it will be amended accordingly. New templates will be configured which will alert GPs to information they should enter onto the ‘special patient notes’ facility.”

    Source location

    2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
    Page 6 · response
    Published 16 January 2015

    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

    Remind practices to use Special Patient Notes and Right Care Plans for patients with mental health conditions.

    Verbatim wording from the response

    “I have been asked to remind you about the use of Special Patient Notes and, where available, Right Care Plans particularly in relation to patients with mental health conditions following a Regulation 28 report to prevent future deaths from the Coroner’s Office.”

    Source location

    2015-0013-Response-by-NHS-England
    Page 1 · response
    Published 16 January 2015

    Open published response

  7. Wiltshire and Swindon

    AI-generated summary

    Elizabeth Godwin · 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

    Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.

    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 assess, record and monitor the urgency of mental health assessments

    Wider context from the report

    “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS: a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment. b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored. c) As to how that information is shared with other agencies involved in the care of that patient. d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it. e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail. I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns. ”

    Source location

    Elizabeth Godwin · 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

    Amend the mental health assessment matrix so similar self-harm presentations trigger amber-risk classification and mental health assessment before Emergency Department discharge.

    Verbatim wording from the response

    “A retrospective review has confirmed that Mrs Godwin was correctly assessed, utilising the Mental Health Assessment Matrix available at the time, as being of low risk, the amendment to the Matrix ensures that future patients, who present with a similar history to that of Mrs Godwin, would flag as an “amber” risk and would receive an assessment by a mental health professional before leaving the Emergency Department.”

    Source location

    2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 1 · response
    Published 19 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a PCLS referral pathway using a standard operating procedure, telephone triage and a triage decision-support tool.

    Verbatim wording from the response

    “When an individual is referred to our services a triage process is undertaken to establish the urgency with which an assessment is required. The Trust has developed a Standard Operating Procedure for Primary Care Liaison Services, (PCLS), which outlines the process for receiving referrals and carrying out a phone triage system to establish risk and therefore urgency of response. All referrals are now made through the PCLS.”

    Source location

    2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 2 · response
    Published 19 June 2015

    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

    Set response-time standards for urgent and routine assessments and record triage outcomes in electronic patient records.

    Verbatim wording from the response

    “The Trust has developed a triage tool to support decision making in PCLS. The response to urgent referrals is addressed in the Trust Access to Mental Health Care Assessment and Treatment General Policy. All urgent assessments should be carried out within 4 hours by the Intensive Support team. Those requiring face to face routine assessment will be seen by PCLS workers within an appropriate time frame indicated by the triage process, with an expected maximum of 4 weeks.”

    Source location

    2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 2 · response
    Published 19 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Record referral and assessment times and monitor significant delays in Mental Health Act assessments.

    Verbatim wording from the response

    “In the event of a Mental Health Act Assessment the AMHP would conduct a risk assessment to determine the urgency and proceed to set up the mental health act assessment. The AMHP service record the time of referrals and the time of assessments and monitor any significant delays between the two.”

    Source location

    2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 2 · response
    Published 19 June 2015

    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

    Existing policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.

    Verbatim wording from the response

    “The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.”

    Source location

    2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 1 · response
    Published 19 June 2015

    Open published response

  8. Wiltshire and Swindon

    AI-generated summary

    Richard Jeffrey Jones · 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

    Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record information obtained from mental health patients, including perceived risk and assessment urgency

    Wider context from the report

    “I am concerned in particular as to the following matters : a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment. b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency. c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care. ”

    Source location

    Richard Jeffrey Jones · 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 College of Emergency Medicine mental health risk assessment tool for ED suicide and self-harm risk assessment and urgency documentation.

    Verbatim wording from the response

    “Since the death of Mr Jones, and following review of the case in collaboration with AWP, an immediate action taken by SFT Emergency Department was to implement a new mental health risk assessment tool as recommended by the College of Emergency Medicine. This tool provides a more accurate assessment of the risk of suicide or self harm than the SADPERSON score we were previously using. It enables clinical staff to risk assess patients and document their findings prior to referring the patient to the mental health team with an indication of the appropriate urgency for their response. (Mr Jones fell within the low risk category using the old and new tools). The tool is”

    Source location

    2015-0068-Response-by-Salisbury-NHS-Trust
    Page 1 · response
    Published 20 February 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a mental health referral proforma to record risk, assessment timeframe, accepting practitioner and agreed actions for out-of-hours referrals.

    Verbatim wording from the response

    “To ensure robust recording of information to the out-of-hours AWP service a proforma will be generated for clinician use. This will include information such as the assessed level of risk as per the mental health risk assessment tool, the agreed timeframe for assessment, the name of the accepting mental health practitioner, and any other agreed actions from the telephone referral conversation. The proforma will safeguard against any misunderstandings between an ED clinician to an AWP”

    Source location

    2015-0068-Response-by-Salisbury-NHS-Trust
    Page 2 · response
    Published 20 February 2015

    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

    Incorporate the mental health referral proforma into the upgraded ED electronic system for electronic transfer and storage by the end of 2015.

    Verbatim wording from the response

    “mental health worker and vice versa. Once completed, the information will then be faxed or emailed to an agreed secure number or address for AWP to place with the AWP patient record, and the original will be held within the ED patient record at SFT. This will be incorporated within the ED upgraded electronic system by the end of the year so that it can be transferred and stored electronically.”

    Source location

    2015-0068-Response-by-Salisbury-NHS-Trust
    Page 3 · response
    Published 20 February 2015

    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 a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.

    Verbatim wording from the response

    “Your report was considered by our Critical Incident Review Group, which is chaired by my Medical Director, ████████ on 2 March 2015. It was decided that to best explore the issues you have raised, we should conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces. This will enable staff from the different agencies to collaborate and identify the best solutions to the problems you have raised concerns about, to include a review of any relevant policies and procedures.”

    Source location

    2015-0068-Response-by-Avon-Wiltshire-Mental-Health-NHS-Trust
    Page 1 · response
    Published 20 February 2015

    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

    Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.

    Verbatim wording from the response

    “DH will continue their discussions with MoD and NHSE on this issue and these discussions will address the specific concerns you have raised in your report. Unfortunately, PHE are not in a position to advise on this matter further.”

    Source location

    2015-0068-Response-by-Public-Health-England
    Page 1 · response
    Published 20 February 2015

    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 Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.

    Verbatim wording from the response

    “I am aware you have also written to the Department of Health (DH), and I understand that DH, the Ministry of Defence (MoD) and NHS England (NHSE) work closely together to ensure that service personnel receive the right health services. These organisations are also aware of the need for effective patient note transfer between the MoD and the NHS.”

    Source location

    2015-0068-Response-by-Public-Health-England
    Page 1 · response
    Published 20 February 2015

    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 mental health providers named in the report are expected to comment on the particular case and address concerns locally.

    Verbatim wording from the response

    “Finally, I have been advised that the mental health providers named in your report are expected to provide comment on the detail of this particular case and to address your concerns from their local perspective.”

    Source location

    2015-0068-Response-by-Public-Health-England
    Page 2 · response
    Published 20 February 2015

    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

    Local mental health providers are expected to address the specific case and concerns from their local perspective.

    Verbatim wording from the response

    “Firstly, I would expect the mental health providers named in your report to provide comment on the detail of this particular case and to address your concerns from their local perspective.”

    Source location

    2015-0068-Response-by-Department-of-Health2
    Page 1 · response
    Published 20 February 2015

    Open published response

  9. Inner North London

    AI-generated summary

    Andrew Elliot FROST · 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

    Andrew Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of crisis team records to capture valuable information received during referrals

    Wider context from the report

    “2. The crisis team’s records did not reflect some valuable information that was passed to them. For example, that police and paramedics were with Mr Frost at the time of the GP’s call. This information was communicated by the GP and by Mr Frost’s partner. If the crisis team had considered this information, they could have advised Mr Frost’s partner he should tell the paramedics that the crisis team were not coming out that day, which may have assisted paramedics’ decision making. ”

    Source location

    Andrew Elliot FROST · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Surrey

    AI-generated summary

    Katherine Liana Bonaventura · 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

    Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment 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

    Failure to record the outcome of mental state assessments after inpatient leave

    Wider context from the report

    “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.” It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area. It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return. It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit. ”

    Source location

    Katherine Liana Bonaventura · 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