Recurring concern

Unreliable care-planning processes

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First reported 1 Aug 2013•Latest report 2 Jun 2026

Definition

What this concern includes

Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.

Not included

  • Excludes standalone procedural instructions, treatment steps, extubation plans and immediate deterioration-management plans unless the source explicitly identifies them as part of the person's formal care plan.
  • Excludes organisational improvement plans, staffing plans and operational contingency plans.
  • Excludes discharge planning, risk assessment, family involvement or generic records when that separate control is the concern and formal care-plan reliability is not directly asserted.
Reports
120

Distinct published reports

Individual concerns
141

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
200

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care14
Care Quality Commission9
Sussex Partnership NHS Foundation Trust9
Essex Partnership University NHS Foundation Trust7
NHS England7
Ministry of Justice5
Avon and Wiltshire Mental Health Partnership NHS Trust4
Barts Health NHS Trust4
Norfolk and Suffolk NHS Foundation Trust4
North East London NHS Foundation Trust4
Birmingham and Solihull Mental Health NHS Foundation Trust3
Central and North West London NHS Foundation Trust3
Hc-One Limited3
HM Prison and Probation Service3
Office of the Chief Coroner3

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Nottinghamshire

    AI-generated summary

    Norma Lockton · 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

    Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the death.

    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 update general health and mobility care plans

    Wider context from the report

    “3. The lack of recognition of Norma’s changing health and mobility needs, leading to no change in her general health and mobility care plans ”

    Source location

    Norma Lockton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. North East Kent

    AI-generated summary

    PAUL HILLS · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to update mental health care plans

    Wider context from the report

    “2. Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour. ”

    Source location

    PAUL HILLS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    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 care plan was updated and risk levels were reviewed, contrary to the concern that neither had been updated as risk escalated.

    Verbatim wording from the response

    “Sgt Hills’ care plan was updated on a number of occasions and his risk levels were being reviewed. However, the records of this case were not to the standard expected. Sgt Hills’ initial care plan, dated October 2019, formed the basis for treatment. Within a Department of Community Mental Health, subsequent updating of the care plan is part of the overall treatment record, which clinicians document on a review/assessment template. On this template, there is a section for recording any updates to the care plan, or to confirm the extant care plan, as well as assessment of risks, clinical reasonings and any prescribed medication.”

    Source location

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

    Open published response
  3. Manchester South

    AI-generated summary

    Mary Brady · 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

    Mary Brady, who had vascular dementia and lived in a care home, was found unresponsive after being left unobserved in a communal area. A used pair of latex gloves was removed from her airway, and she died shortly after midnight on 11 March 2019. Concerns included accessible open waste baskets, improper disposal and insufficient escalation of used gloves, and failures to document and risk-assess her previous ingestion of non-food items or update her care plan.

    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 update care plans following identified mouthing risks

    Wider context from the report

    “3. Mrs Brady had been seen putting foreign non-food items in her mouth by staff. These instances had not been appropriately documented and risk assessed. The level of risk she presented was not fully understood as a result and her care plan was not updated. ”

    Source location

    Mary Brady · 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

    Existing CQC regulatory action and continued monitoring are considered sufficient to reduce further risks at the care home.

    Verbatim wording from the response

    “You issued your report to the Care Quality Commission (CQC) and Departmental officials have made enquiries with the CQC on the regulatory activity in relation to this incident. I am therefore aware that following a review of the circumstances of Mrs Brady’s death; information provided by the registered provider and the action it has taken; and the findings of a CQC inspection conducted in February 2019, the CQC is satisfied that sufficient action has been taken to reduce further risks within the Balmoral Care Home and that there was insufficient evidence that a breach of the Regulations¹ had occurred. The CQC’s response to your report provides further detail on its considerations in relation to this case.”

    Source location

    2020-0105-Response-from-the-Department-of-Health-and-Social-Care.pdf
    Page 1 · response
    Published 5 June 2020

    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

    Registered providers and service managers are responsible for safe care, local risk assessments and mitigating environmental and other risks.

    Verbatim wording from the response

    “Registered providers and managers of services are expected to ensure they are delivering care safely and doing all they can to mitigate risks through the conduct of local risk assessments (including for example, assessing environmental risks such as those associated with open wastebaskets). Providers are expected to plan care in line with good practice standards, such as guidance issued by the National Institute for Health and Care Excellence (NICE), and relevant professional and regulatory bodies.”

    Source location

    2020-0105-Response-from-the-Department-of-Health-and-Social-Care.pdf
    Page 2 · response
    Published 5 June 2020

    Open published response
  4. Black Country

    AI-generated summary

    Edna May Davenport · 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

    Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

    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 increased observation arrangements in written records or care plans

    Wider context from the report

    “(1) During the course of the inquest, I heard evidence that buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck. The family were told that as a result, observations of the deceased had been increased to every 15 minutes day and night. There was no evidence of this in any written records or care plan and no evidence of alternative arrangements in her care plan being made to enable the deceased to call for assistance from her room should it be needed given her disabilities; ”

    Source location

    Edna May Davenport · Prevention of Future Deaths report
    Page 2 · 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

    Failure to include resident bedroom-door preferences in care plans

    Wider context from the report

    “(3) I also heard in evidence that the deceased preferred to have her bedroom door left open but this did not form part of her care plan and there was no evidence as to when the door was in fact left open, or when it was closed, or indeed whether the door was open when the other resident was found in the deceased’s room; ”

    Source location

    Edna May Davenport · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. West Sussex

    AI-generated summary

    John Ashley · Prevention of Future Deaths report

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

    Report summary

    John Ashley took his own life while suffering a deterioration in his mental illness, according to the inquest conclusion. The report identified concerns about failures to update his care and treatment plan, record and share key information, review his deterioration and medication non-compliance, and provide adequate clinical oversight and cover arrangements.

    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 update Care and Treatment Plans when mental health deteriorates

    Wider context from the report

    “1. Mr Ashley’s Care and Treatment Plan was not updated when his mental health deteriorated. ”

    Source location

    John Ashley · 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

    Revise care plan formats and processes to improve care standards.

    Verbatim wording from the response

    “The Trust is continuing to monitor compliance with care plans, risk assessments and supervision and since autumn last year, we have revised our care plan and risk assessment formats/processes, updated our policies and training programme to improve standards of care.”

    Source location

    2020-0071-Sussex-Partnership-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 8 April 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue monitoring compliance with care plans, risk assessments and supervision through performance reporting and audits.

    Verbatim wording from the response

    “The Trust monitors performance in each of these areas and there are individual performance dashboards for each team within the Carenotes system that allow clinicians to monitor their own performance when they log onto the system. Team Leaders and other managers also have access to team/service based reports through our "Report Manager" performance system and these provide an audit function and allow managers to have an overview of team performance.”

    Source location

    2020-0071-Sussex-Partnership-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 8 April 2020

    Open published response
  6. South London

    AI-generated summary

    Billy James Jenkins · 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

    Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.

    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 develop robust plans addressing protective factors and harm minimisation

    Wider context from the report

    “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. ”

    Source location

    Billy James Jenkins · 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

    Strengthen community mental-health assessment oversight, including further face-to-face assessment where diagnoses differ and monthly quality audits.

    Verbatim wording from the response

    “Following this incident we have taken further measures to ensure the assessment of patients within the community mental health team are robustly managed in order to ensure that the MDT has sufficient information to review an assessment and to ensure that where there is any disparity in diagnosis that a further face to face assessment is conducted. The operational team manager is monitoring this practice through discussions in Team meetings, supervisions and MDT case discussions.”

    Source location

    2020-0068-Response-from-Oxleas-NHS-Foundation-Redacted
    Page 2 · response
    Published 27 March 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish a Trust-wide rolling programme delivering STORM and DICES training on suicide prevention, risk assessment, safety planning and risk management.

    Verbatim wording from the response

    “In order to further support staff we have instigated a Trust wide rolling programme of training for mental health community teams. This consists of STORM, a two day suicide prevention programme which offers skills based training in risk assessment and safety planning. Also we have rolled out DICES an evidence based approach to assess and manage risks. The checklist provided during this training support the formulation of risk in the risk assessment utilised by the Team. The training supports staff to notice and assess any risks present, manage the risk”

    Source location

    2020-0068-Response-from-Oxleas-NHS-Foundation-Redacted
    Page 2 · response
    Published 27 March 2020

    Open published response
  7. Manchester South

    AI-generated summary

    Wayne Lee Millett · 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

    Wayne Lee Millett, a detained patient at The Priory Hospital, Cheadle, had treatment-resistant schizophrenia treated with Clozapine and died there on 13 February 2019 after escalating abdominal symptoms, collapse and complications including pseudo-obstruction of the small bowel. The report raised concerns that the Care Plan was not followed, that the Priory’s investigation and quality-assurance processes were inadequate, and that care-plan compliance and Clozapine-related monitoring had not been sufficiently reviewed.

    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 formally review care plans for patients prescribed Clozapine

    Wider context from the report

    “4) It is a matter of concern that, notwithstanding the cause of death identified on Post Mortem Examination and despite nearly a year having passed since Mr Millett’s death, the organisation has yet to formally review the care plans of all patients prescribed Clozapine, with a view to ensuring each relevant patient has in place a clear plan for monitoring of potential side-effects of the medication, which gives clear and authoritative direction to staff as to how to act if serious complications are suspected. It is a particular matter of concern that this step has not been taken, given the evidence heard from the Peripatetic Director of Clinical Services which suggested this would be a straightforward measure to accomplish, and one which could be completed within 28 days. ”

    Source location

    Wayne Lee Millett · 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

    Complete the 2020 formal audit of patient care plans and analyse its results.

    Verbatim wording from the response

    “Please note there are systems in place which ensure that patient care plans are regularly audited. These systems include Ward Managers and the Director of Compliance at each hospital having a responsibility for undertaking regular “spot-checks” by way of completing the monthly Quality Walk Rounds during which the care records of patients are reviewed and evaluated. Our Healthcare Division Quality Team also undertakes a formal annual audit of care plans. The 2020 audit was unfortunately delayed due to the Covid-19 pandemic but was completed last month with the audit results currently being analysed.”

    Source location

    2020-0031-Response-from-Priory_Redacted
    Page 2 · response
    Published 26 February 2020

    Open published response
  8. West Yorkshire Eastern

    AI-generated summary

    Adam Alexander Bojelian · Prevention of Future Deaths report

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

    Report summary

    Adam Alexander Bojelian had profound disabilities and was hospitalised for approximately 17 months before being taken to a hospice on the eve of his death on 24 March 2015. The report identified concerns about the absence of individual nurses’ training records and the lack of a formal written care plan during much of his hospital stay, despite his complex medical needs.

    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 create formal written care plans for patients with complex medical needs

    Wider context from the report

    “(2) Formal Written Care Plans The evidence taken at the inquest revealed that despite the complex medical needs of this child, no formal written care plan was created for the period he was in hospital, from September 2013 to January 2015 (15 months). It was assumed all the clinicians involved would glean sufficient information from a review of his notes. The absence of a plan meant that aspects of his treatment were not exposed as being controversial (and disputed by his parents). An example of this related to hydrocortisone therapy. In complex cases, a comprehensive care plan would provide both parents and clinicians with a basis upon which to obtain a second opinion from an independent source in the event of a dispute, as occurred repeatedly in this case. ”

    Source location

    Adam Alexander Bojelian · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  9. Manchester South

    AI-generated summary

    Julie Helen Taylor · 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

    Julie Helen Taylor, who had Down syndrome and significant learning disabilities, died at Stepping Hill Hospital on 23 September 2018 from pneumonitis following a chicken pox virus infection contracted while awaiting discharge. The concerns included inadequate reasonable-adjustment planning, lack of best-interests meetings and documented decision-making, poor communication between agencies, limited access to suitable learning-disability beds and support, information-sharing difficulties, and delayed recognition of chicken pox.

    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 interagency communication to produce a clear and effective care plan for people with learning disabilities

    Wider context from the report

    “3. Prior to her admission to the acute hospital there had been on-going discussion about her deteriorating condition and where her care needs could more effectively be met. The inquest heard that both in the community and subsequently in the acute setting there was a need for improved communication between agencies /professionals to ensure a clear, consistent and effective plan was put in to meet the needs of those with a learning disability. In her case it was recognised at the end of July that a learning disability acute bed would be beneficial. Driving that forward was limited by a number of factors including communication between agencies involved; ”

    Source location

    Julie Helen Taylor · 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

    Publish an evidence review of care co-ordination for people with learning disabilities, focused on health and wellbeing.

    Verbatim wording from the response

    “Both the second⁴ and the third⁵ annual LeDeR reports highlighted the importance of care co-ordination. We committed to publishing an evidence review of care co-ordination for people with learning disability, focused on health and wellbeing. Once this work is complete, we will be better placed to understand how this can be used to inform how care co-ordination is delivered across the health and social care sector for people with a learning disability, particularly in relation to developing guidance.”

    Source location

    2019-0454-Response-from-the-Department-of-Health-and-Social-Care
    Page 3 · response
    Published 7 January 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Improve timely discharge-summary publication, targeting delivery within 48 hours and performance above the Trust’s 95% standard.

    Verbatim wording from the response

    “It is recognised that effective communication between the hospital and community settings is pivotal in ensuring a seamless transition of care. Consistent timely publication of the discharge summary within 48 hours of”

    Source location

    2019-0454-Response-from-Greater-Manchester-Health-and-social-Care-Partnership-Redacted
    Page 3 · response
    Published 7 January 2020

    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 local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.

    Verbatim wording from the response

    “I am advised by NHS England and NHS Improvement that Ms Taylor’s death is currently being reviewed under the LeDeR process and I expect the local NHS to reflect on the findings of the review and take action to address any failings in the care provided locally for people with a learning disability. I have also asked officials to bring your report to the attention of the National Director for Learning Disabilities, Ray James, who is leading work nationally to improve services for people with learning disabilities and/or autism.”

    Source location

    2019-0454-Response-from-the-Department-of-Health-and-Social-Care
    Page 2 · response
    Published 7 January 2020

    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

    Community care matters in Derbyshire fall outside the Greater Manchester Health and Social Care Partnership’s remit.

    Verbatim wording from the response

    “You have also identified a number of areas regarding community care in Derbyshire. As Derbyshire does not fall under the remit of the Greater Manchester Health and Social Care Partnership we are unable to provide a response to those issues.”

    Source location

    2019-0454-Response-from-Greater-Manchester-Health-and-social-Care-Partnership-Redacted
    Page 2 · response
    Published 7 January 2020

    Open published response
  10. East London

    AI-generated summary

    Sammi Higgins · 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

    Sammi Higgins had mental health conditions and a deteriorating mental state, including voices telling her to harm herself. On 3 February 2018, after presenting to mental health services following an overdose and self-harm and being discharged without weekend mental health support, she ingested a fatal combination of alcohol and tablets. Concerns included the absence of an overarching care plan or key-worker, failures in communicating and implementing a medication change, and lengthy delays in accessing psychotherapy.

    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 overarching care plans for service users whose care requirements exceed brief intervention

    Wider context from the report

    “1. Sammi was cared for under the Access Assessment and Brief Intervention Team (AABIT). She was under the care of this team for almost three years. Her care requirements went beyond "brief intervention". Whilst under the care of this team, Sammi had no overarching care plan. No-one was appointed to oversee Sammi’s care. The evidence at the Inquest revealed that doctors working within the team were not aware of the possibility of service users under the AABIT having an overarching care plan or of service users having a key-worker assigned to them. ”

    Source location

    Sammi Higgins · 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

    Issue a reminder to maintain an up-to-date overarching care plan for every patient receiving AABIT care.

    Verbatim wording from the response

    “6. Reminder – Care planning Action: A reminder will be issued for a care plan template for each patient to be updated to ensure that the overarching care plan is up to date at all times when the service users are receiving care which meets their needs. Deadline: 31.01.2020 Lead: ████████, Operational Lead AABIT”

    Source location

    Response from North East London NHS Foundation Trust
    Page 5 · response
    Published 13 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Produce and discuss monthly RIO reports demonstrating compliance with care and crisis plans on the correct pathway.

    Verbatim wording from the response

    “7. Audit – care/crisis management plan compliance Action: A RIO report demonstrating compliance with care plan/crisis plan on correct RIO pathway will be produced monthly basis and discussed at the AABIT team meeting. Deadline: 31.01.2020 Lead: ████████, Operational Lead AA BIT”

    Source location

    Response from North East London NHS Foundation Trust
    Page 5 · response
    Published 13 December 2019

    Open published response
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Data last updated 7 September 2026