Recurring concern

Unreliable safeguarding response after suspected overdose

First to latest report 28 Oct 2015 — 19 May 2021

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
6

What this concern includes

Includes failures of controls specifically dedicated to responding to a suspected or confirmed overdose, including recognition, investigation, risk-assessment updates, assessment of intentions or drug access, safeguarding action, policy application and learning from the event.

What is not included
  • Excludes general medication prescribing, quantity, administration or review failures where no overdose-triggered safeguarding response is identified.
  • Excludes generic self-harm or suicide-risk management concerns not specifically triggered by a suspected or confirmed overdose.
  • Excludes generic incident investigation or organisational learning deficiencies unless they concern the overdose-response process.
  • Excludes clinical treatment failures during overdose care when no overdose-related safeguarding or risk-management deficiency is identified.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester North

    AI-generated summary

    Liam Kenyon · 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

    Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to update risk assessments after a suspected overdose

    Wider context from the report

    “4. In addition following him being found unconscious due to a suspected overdose the Court heard his risk assessment should have been updated and this was not done. ”

    Source location

    Liam Kenyon · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Oxfordshire

    AI-generated summary

    LISA MARIE THOMPSON · 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

    Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.

    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 and risk assessments with material overdose information and information from clinical reviews and contacts

    Wider context from the report

    “Evidence was heard that: (1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020 (2) The care plans and risk assessments at the mental health Trust were not updated: (a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication. (b) the two most recent overdoses were not recorded (c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out. (d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist (e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator ”

    Source location

    LISA MARIE THOMPSON · 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

    Maintain current risk assessments and care plans for Care Programme Approach patients and share them with patients and families as appropriate.

    Verbatim wording from the response

    “The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:”

    Source location

    2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
    Page 2 · response
    Published 27 May 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review electronic care-record processes for recording and reviewing risk formulations and assessments, including family views and best-practice family involvement.

    Verbatim wording from the response

    “The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:”

    Source location

    2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
    Page 2 · response
    Published 27 May 2021

    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

    Embed multidisciplinary team care-plan reviews for patients at risk of suicide.

    Verbatim wording from the response

    “The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:”

    Source location

    2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
    Page 2 · response
    Published 27 May 2021

    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

    Have the Quality Improvement team consider family involvement, enhanced risk formulation and suicide-risk assessment within thematic improvement work.

    Verbatim wording from the response

    “To that end, the Trust has a Quality Improvement team² who are dedicated to working with our local teams to continually improve the quality of our services. Our Chief Nurse has asked the Quality Improvement team to ensure areas of improvement relating to this tragic serious incident are considered alongside other themes identified from the thematic review, in particular:”

    Source location

    2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
    Page 3 · response
    Published 27 May 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include risk-assessment and care-plan quality in Trust audits during the coming year.

    Verbatim wording from the response

    “Please be assured that this work is a high priority for the Trust. Trust audits in the coming year will include looking at the quality of risk assessments and care plans. We have also included safety planning questions into our CPA and Essential Standards audits. I also hope it will help to inform you about work being carried out if I attach the Trust’s Action Plan record (“C”).”

    Source location

    2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
    Page 3 · response
    Published 27 May 2021

    Open published response

  3. Leicester City and South Leicestershire

    AI-generated summary

    Ahmedreza Fathi · 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

    Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.

    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 overdose-related intentions and inappropriate drug access for safeguarding purposes

    Wider context from the report

    “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt. ”

    Source location

    Ahmedreza Fathi · Prevention of Future Deaths report
    Page 5 · 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 investigate suspected overdose events and apply learning outcomes

    Wider context from the report

    “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt. ”

    Source location

    Ahmedreza Fathi · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  4. County Durham and Darlington

    AI-generated summary

    Kevin Anthony Forster · 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

    Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.

    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 healthcare and discipline staff to know the overdose policy and prescribed response

    Wider context from the report

    “2. Healthcare staff were unaware of what, if any, drugs policy was in place at the time. A policy known as a “Drugs Overdose Policy” which had, in various guises been in operation since 2008 included a definition of overdose as the “purposeful or accidental act of ingesting an amount of a drug or substance that may cause harm to health”. As such, the ingestion of unknown drugs is de facto harmful to health and would constitute an overdose which should lead to the triggering of the Overdose Policy. Both discipline and healthcare staff were unaware of the policy, the “overdose” definition and the prescribed steps which should then ensue. ”

    Source location

    Kevin Anthony Forster · 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

    Update, approve, introduce and distribute the Substance Misuse Policy to healthcare staff.

    Verbatim wording from the response

    “After G4S took over the contract in April 2015, it became clear to me that the situation relating to the “Drugs Overdose” policy required clarification. The previous policy was too rigid and did not allow specialist practitioners to exercise their expertise and manage individuals as safely and appropriately as possible. I therefore updated the Substance Misuse policy. The draft policy document was submitted to and approved by the G4S Clinical Governance Lead, prior to formal introduction and implementation at the prison. Once approved, the Substance Misuse Policy was introduced to all healthcare staff. A copy of the policy was sent by email to every member of healthcare staff.”

    Source location

    2015-0453-Response
    Page 2 · response
    Published 28 October 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026