20 Mar 2026 Luke Owen ASHCROFT · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 1
Failure to ensure reliable telephone access after CSU cell lockdown View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Luke Owen ASHCROFT · Prevention of Future Deaths report
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Report summary
Luke Ashcroft was admitted to Lincoln County Hospital from HMP Lincoln after being found unconscious in his cell in the Care and Separation Unit. His death was confirmed on 1 July 2020, with the post-mortem finding hypoxic brain injury consistent with ligature application. The inquest identified concerns about missed healthcare opportunities, inadequate information sharing and risk mitigations, shortcomings in the ACCT plan, and failures to carry out required observations; it also raised concerns about the safety and availability of corded telephone access in the unit.
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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 Failure to ensure reliable telephone access after CSU cell lockdown
Wider context from the report “My concerns are twofold.
Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the clear and obvious risks of self harm posed by the provision of a corded telephone, secured at one end, suspended at head height in a cell commonly occupied by prisoners, who may seek to self harm. I was told that the cell J109 had no ligature points and that the door was fitted with anti ligature fittings. As a consequence, that was the only method of securing telephone access. That same issue may extend to other cells in the CSU. Whether at head height or otherwise, the provision of a corded phone may well be an issue in potential cases of self harm and appears incongruous in comparison with other steps taken to ensure safety within that cell. The risks of an inmate utilising that cord in an act of self harm are self evident.
Secondly, the mechanism of provision of telephone access on CSU appears to require a prisoner requesting such provision before the cells are locked down . Thereafter, whilst a request can be made by a prisoner, telephone provision may depend upon the availability of additional officers to attend whilst the cell is unlocked and the telephone provided . That is not certain to take place. Given the proper availability to prisoners in crisis of freephone access to Samaritans and similar services, the possible absence of a handset to access such services is a matter of concern.
” Source location Luke Owen ASHCROFT · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review current Care and Separation Unit telephony arrangements.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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Concerns raised 1
Failure to answer a sufficient proportion of 111 and Blue Light Line calls View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Patricia Genders · Prevention of Future Deaths report
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Report summary
Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.
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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 Failure to answer a sufficient proportion of 111 and Blue Light Line calls
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered . That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Source location Patricia Genders · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in local urgent and emergency mental health infrastructure, including crisis cafes, crisis houses, places of safety, emergency departments and crisis lines.
Verbatim wording from the response “There has also been investment into a range of wider local mental health urgent and emergency care infrastructure schemes, including:” Source location Response from Department for Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review local system plans for suitable 111-service investment and provide feedback on required improvements.
Verbatim wording from the response “Alongside this, local system plans will be reviewed by NHS England’s regional leads to determine whether there is suitable investment in 111 services, where capacity constraints exist. This review will run from December 2025 – March 2026. Regional leads will provide feedback to organisations on the plans and discuss areas of improvement required within the plans.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor delivery of Sussex mental health-crisis improvement plans through joint ICB and provider oversight meetings.
Verbatim wording from the response “Sussex Partnership NHS Foundation Trust (SPFT) and Sussex ICB have set out a series of actions to deliver improvements in the care provided to people in mental health crisis. NHS England is monitoring the delivery of these plans through joint ICB and provider oversight meetings. These plans do include reference to increased capacity in 'blue light' and 111 services, alongside the delivery of 24/7 crisis response services. Should the Coroner require further information regarding this, SPFT and Sussex ICB would be best placed to provide this.” Source location Response from NHS England
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29 Jun 2022 Paul Alexander Meadows · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Unavailability of practitioners to answer received calls View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Suffolk and North East Essex Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
NHS Suffolk and North East Essex Integrated Care Board
Repurposed the First Response Service and transitioned access to NHS 111 option 2 to refocus crisis response.
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NHS Suffolk and North East Essex Integrated Care Board
Provided additional funding for voluntary, community and social enterprise partners to increase crisis-team capacity and target frequent service users.
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NHS Suffolk and North East Essex Integrated Care Board
Continue working with NSFT to reduce team vacancies and improve the crisis-service offer in Suffolk.
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Department of Health and Social Care
Maintain delivery of 24/7 urgent mental health helplines established during the pandemic.
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Department of Health and Social Care
Expand and diversify the types of mental health workforce roles available.
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Department of Health and Social Care
Invest £111 million in 2021/22 to grow the mental health workforce.
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Paul Alexander Meadows · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Alexander Meadows was found dead at home on 4 August 2021 after taking a Codeine overdose, against a background of physical health difficulties and deteriorating mental health. The report identified concerns that his mental health crisis was not recognised by the First Response Service on 3 August 2021 and that there was no onward referral for urgent or emergency intervention. It also identified broader concerns about the time available to practitioners to gather information and properly triage and risk assess callers, linked to workload and recruitment pressures.
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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 Unavailability of practitioners to answer received calls
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Source location Paul Alexander Meadows · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Repurposed the First Response Service and transitioned access to NHS 111 option 2 to refocus crisis response.
Verbatim wording from the response “• Suffolk and North East Essex Integrated Care System (ICS) and NSFT agreed to repurpose the FRS and transition to NHS111 option 2. This would refocus the service to revert to the ‘Crisis’ Response service that was initially planned. This change in April 2022, has seen a reduction in calls and abandonment rate and seen an improvement in call response times. It has also helped the team to spend more time with individuals who are accessing the service.” Source location Response from NHS Suffolk and North East Essex
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How this respondent action was interpreted
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PFD Monitor interpretation Provided additional funding for voluntary, community and social enterprise partners to increase crisis-team capacity and target frequent service users.
Verbatim wording from the response “• The amount of funding does not have a direct impact on how NSFT can successfully recruit to vacancies. The ICS has provided additional funding to create additional support from voluntary, community and social enterprise partner(s) to provide targeted help to individuals who access the First Response Service frequently. These approaches have helped to increase capacity for our crisis response teams to support more individual callers. It has also allowed the FRS to have a more focused community approach to reduce crisis situations.” Source location Response from NHS Suffolk and North East Essex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NSFT to reduce team vacancies and improve the crisis-service offer in Suffolk.
Verbatim wording from the response “• The ICS will continue to work with NSFT to reduce the number of vacancies in the team and continue to improve the offer for people who are experiencing a mental health crisis in Suffolk.” Source location Response from NHS Suffolk and North East Essex
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain delivery of 24/7 urgent mental health helplines established during the pandemic.
Verbatim wording from the response “Additionally, in 2021/22 we provided £500 million to accelerate our expansion plans. Of this, £110 million was used to expand adult mental health services, including investment in crisis services and maintaining the delivery of the 24/7 urgent mental health helplines stood up during in the pandemic.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand and diversify the types of mental health workforce roles available.
Verbatim wording from the response “Turning to your matter of concern regarding staff vacancies, we are fully committed to attracting, training and recruiting the mental health workforce of the future. Through our plans set out in ‘Implementing the Five Year Forward View for Mental Health’ and ‘Stepping Forward to 2020/2021: The mental health workforce plan for England’, we have expanded and diversified the types of roles that are available.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £111 million in 2021/22 to grow the mental health workforce.
Verbatim wording from the response “The NHS Mental Health Implementation Plan 2019/20–2023/24 sets out the need for the mental health workforce to grow by over 27,000 during this time frame, to support the expansion and transformation of NHS mental health services and give an extra two million people the mental health support they need. We invested £111 million in 2021/22 to grow the mental health workforce to deliver these ambitious commitments. Further, Health Education England and NHS England have been working with Integrated Care Systems (ICSs) to confirm plans to 2024. The aim is for every ICS to look at everything they can do to meet the Implementation Plan ambition, including through innovative service models, increasing supply, and improving retention and recruitment.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The service could not financially respond to the sudden increase in demand caused by its expanded remit.
Verbatim wording from the response “• Suffolk adequately funded the service from the outset but were not able to financially respond to the sudden increase caused by the request to make the service accessible to anyone with a mental health query. The Suffolk First Response Service was further advanced than the Norfolk equivalent service when the FRS went live in March 2020 and initially supported Norfolk calls too whilst the Norfolk service offer was further developed.” Source location Response from NHS Suffolk and North East Essex
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local commissioners are responsible for deciding service provision and ensuring services meet local population needs.
Verbatim wording from the response “With regards to differences in funding available to Norfolk and to Suffolk, NHS England is responsible for determining allocations of financial resources to Integrated Care Boards from April 2022. The allocations process uses a statistical formula to make geographic distribution fair and objective, so that it more clearly reflects local healthcare need and helps to reduce health inequalities. Local commissioners are responsible for decisions about the provision of services in their area and ensuring that they meet the needs of the local population.” Source location Response from Department of Health and Social Care
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4 Oct 2018 Stephen Peter Jackson · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to answer calls to mental health professionals View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Stephen Peter Jackson · 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 Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.
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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 Failure to answer calls to mental health professionals
Wider context from the report “3. Mr. Jackson wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls , the context would support this being a reference to mental health professionals.
” Source location Stephen Peter Jackson · Prevention of Future Deaths report
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.