Recurring concern

Failure to reliably develop and review risk-reduction plans

First to latest report 21 Aug 2013 — 2 Jun 2026

Reports that mention this concern
48
Times this concern has been raised
50
Stated actions linked to this concern
80

What this concern includes

Includes failures of the risk-reduction or safety-planning process where a required plan is missing, not implemented, not assessed for appropriateness, or changed or ended without the risk review needed to maintain effective protection.

What is not included
  • Excludes generic risk-assessment failures where no risk-reduction or safety plan is involved.
  • Excludes failures to implement unrelated organisational action plans, audit recommendations or post-incident actions.
  • Excludes failures of a separately named hazard-specific or end-to-end safety system where risk planning is only an incidental component.
  • Excludes clinical or operational outcomes where no deficiency in developing, reviewing or maintaining a risk-reduction plan is identified.

Reports and published responses 48 reports

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

  1. Worcestershire

    AI-generated summary

    Francis Leech · 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

    Francis Leech, who had advanced dementia and other significant medical conditions, died on 26 August 2024 after a decline following severe facial injuries inflicted by another care home resident. The principal concerns were that the resident’s aggressive behaviour and associated risks were not properly reflected in updated care and behavioural support plans, and that management and the subsequent internal investigation failed to identify or address these deficiencies.

    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 behavioural support plans to reflect aggression, risk and risk-reduction measures

    Wider context from the report

    “The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated. ”

    Source location

    Francis Leech · 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

    Conduct monthly audits of resident care and behavioural support plans.

    Verbatim wording from the response

    “The Home’s management and senior care team are principally responsible for the creation, review and amendment of resident care plans and Behavioural Support Plans. Following creation, resident care plans and Behavioural Support Plans are reviewed and updated on a monthly basis or as required in response to changing resident care needs. Support from an individual with dementia expertise is also available to the Home to draw upon as required.”

    Source location

    Response from Adept Care Homes (Bowood Court)
    Page 1 · response
    Published 21 August 2026

    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

    Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.

    Verbatim wording from the response

    “Following the conclusion of the Inquest into Mr Leech’s death, a further instruction was issued to the Home management and senior care team reaffirming the expectations in relation to the review and amendment of Behaviour Support Plans and the introduction of supporting risk assessments in reflection of lessons learnt. We would also note that a new Home Manager and Care Manager are now in place with oversight of the Home following the incident involving Mr Leech.”

    Source location

    Response from Adept Care Homes (Bowood Court)
    Page 2 · response
    Published 21 August 2026

    Open published response

  2. Essex

    AI-generated summary

    Katharine Emma Corrigan · 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

    Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.

    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 maintain collaborative, complete and accurate risk assessments and care plans

    Wider context from the report

    “6. Ms Corrigan’s risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early warning signs and triggers ii. Which mitigations were appropriate iii. Rationale as to why section 17 leaves were granted and/or rescinded b. With accurate risk information of her presentation and deterioration on the ward and with concerns raised by Family which were put in writing to the responsible clinician c. They contained inaccurate information on fire safety that had never been a part of her presentation . It was not understood where this had emanated from. d. That Ms Corrigan had tried to get rid of all her clothes and this was behaviour Ms Corrigan had previously displayed before attempting to end her life. e. That her mental health deteriorated in the days prior to her death and staff were concerned about the risks to herself due to her low mood. Nursing staff instigated the risk protocol such that Ms Corrigan should not have been able to access section 17 leave until reviewed by the multidisciplinary team and there was confusion about the Level of observations that had been put in place for Ms Corrigan on 21 July. Medical records and section 17 leave forms were not amended to ensure that staff could understand that due to her low mood with consequent risks, leave must not take place until a medical review. ”

    Source location

    Katharine Emma Corrigan · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  3. Essex

    AI-generated summary

    Abbigail Louise SMITH · 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

    Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

    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 up-to-date care plans and risk assessments for significant self-harm risk

    Wider context from the report

    “10. There were no up-to-date care plans and risk assessments in place for Abbi during her detention and when she was discharged to the community on 14 February 2022 to mitigate a known significant risk. Abbi had tied multiple tight ligatures during her 11-day admission under detention of the Mental Health Act and her usual clothing removed on 4 February due to her risks, the precise date her clothing was returned, and the rationale was not recorded. ”

    Source location

    Abbigail Louise SMITH · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.

    Verbatim wording from the response

    “Management Teams and staff also have access to an electronic Trust dashboard which is specific to each ward and provides a full oversight of relevant ward information about their current patients (including records, risk assessments and care plans), this supported the identification of any record gaps that can then be promptly addressed. These are printed on a daily basis for staff.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    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 and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.

    Verbatim wording from the response

    “In the interests of safety and based on risk assessment, it is noted that Abbi was issued with anti-ligature clothing during her admission (with her clothes being returned after discharge); during this time her attempts at ligatures were reduced.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    Open published response

  4. Essex

    AI-generated summary

    Abigail Louise SMITH · 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

    Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.

    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 appropriate care plans and risk assessments for known self-harm risk

    Wider context from the report

    “3. Abbi at times had to be physically and chemically restrained due to the level of distress and harm to herself. During her admissions Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom. There were no appropriate care plan and risk assessments to mitigate a significant known risk. ”

    Source location

    Abigail Louise SMITH · 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

    Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.

    Verbatim wording from the response

    “I understand that the Court has been provided with an updated copy of the Trust’s Policy for Enhanced Supervision and Engagement. This policy strengthens our assessment and guidance for patients requiring enhanced supervision as per the attached tool.”

    Source location

    Response from Mid & South Essex NHS Foundation Trust
    Page 2 · response
    Published 13 August 2026

    Open published response

  5. East London

    AI-generated summary

    Somtera Bibi · 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

    Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.

    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 relapse prevention or risk management plan developed with the patient and family members

    Wider context from the report

    “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour. Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically: (i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family (ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020 (iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened (iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members (v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members (vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse ”

    Source location

    Somtera Bibi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and strengthen risk assessment and management processes, including clinical-recording-system changes and staff training.

    Verbatim wording from the response

    “16. The Trust has a large piece of work underway reviewing and strengthening risk assessment and management processes. This will involve changes to our clinical recording system as well as staff training. This is intended to create processes that are more focused on risk formulation, based on current factors and historical risk. For clarity, these processes would always be expected to involve the service user and also family/carers where this is relevant.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

    Open published response

  6. West Sussex, Brighton and Hove

    AI-generated summary

    Amy Clare CHAPMAN · 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

    Amy Clare Chapman, who was experiencing a mental health crisis and assessed as at high risk of suicide, was admitted to the Haven Unit at Millview Hospital on 23 March 2025. On 27 March, she was permitted to leave the unit twice without adequate checking of her records, family contact, or documentation, and later jumped from a bridge, dying from her injuries. The principal concerns included insufficient risk assessment and planning for trips out, failures to read and record notes, inadequate family involvement, uncertainty over care and safety plans, and gaps in training, alerts, checklists, and auditing.

    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

    Uncertainty about when formal safety plans or care plans should be completed

    Wider context from the report

    “5. I am concerned about what seems to be a lack of certainty concerning when formal safety plans (and/or care plans) should be completed. An informal one on admission followed by a full one after 24 hours seems reasonable, but the process and expectations ought to be clarified. ”

    Source location

    Amy Clare CHAPMAN · 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

    Update the Haven Operational Policy to clarify care-plan timing and require recorded care planning from admission.

    Verbatim wording from the response

    “Action has also been taken to ensure there is certainty about when a formal care and safety plan should be completed. The Haven Operational Policy has been updated (to be ratified imminently) to include the following specificity:”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 3 · response
    Published 29 June 2026

    Open published response

  7. Birmingham and Solihull

    AI-generated summary

    Kiefer Kiam Bolangi Fraser-Phillips · 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

    Kiefer Kiam Bolangi Fraser-Phillips, who had treatment-resistant paranoid schizophrenia and several physical health conditions including sleep apnoea, was found deceased in bed at a mental health unit on 18 September 2025. The post-mortem medical cause of death was recorded as sudden unexplained death in schizophrenia. Concerns included incomplete recording of therapeutic observations because of Wi-Fi problems and the absence of a care plan addressing physical health risks associated with his medication and sleep apnoea.

    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 care plans addressing identified physical healthcare risks

    Wider context from the report

    “2. Many patients with enduring mental health conditions on long term medication will have significant physical health conditions due to the side effects of the medication. These often include considerable weight gain, and in Mr Fraser-Phillips' case sleep apnoea and the associated risk of position asphyxia. There was no care plan in place to address these risks. Consideration needs to be given to ensuring patients with significant physical healthcare needs have adequate care plans in place to address any risks identified. ”

    Source location

    Kiefer Kiam Bolangi Fraser-Phillips · 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 Dialog+ Care Planning across inpatient services to document physical-health risks, mitigation actions and review plans.

    Verbatim wording from the response

    “Care Planning Improvements: Implementation of Dialog+ Care Planning”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 3 · response
    Published 17 April 2026

    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 ward-level Dialog+ audits, including checks that physical-health risks have documented action plans and follow-up, with feedback to clinical teams.

    Verbatim wording from the response

    “Audit and Assurance Framework”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 3 · response
    Published 17 April 2026

    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 and audit Inpatient MDT standards to support follow-up of actions identified in physical-health action plans.

    Verbatim wording from the response

    “7. In response to the Coroner’s concerns, the Trust has strengthened its Audit and Assurance Framework for Dialog+ Care Planning at ward level. This framework includes: - Routine ward-level audits of Dialog+ care plans - Specific checks that relevant domains are being appropriately used, including the Physical Health domain - Assurance that identified physical health risks are clearly reflected in the action plan, with proportionate and documented follow-up arrangements - Feedback to clinical teams and incorporation of findings into local quality improvement activity”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 3 · response
    Published 17 April 2026

    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

    Share learning from the case across inpatient teams on medication-related physical-health risks and documenting risks such as sleep apnoea, obesity and positional asphyxia.

    Verbatim wording from the response

    “Learning and Prevention of Future Risk”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 4 · response
    Published 17 April 2026

    Open published response

  8. Buckinghamshire

    AI-generated summary

    Barry HARMER · 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

    Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to reinforce safety plans during waits for beds

    Wider context from the report

    “(2) At the Inquest there was variable evidence as to the operation of the daily Patient Flow Meetings, during which patients requiring beds would be matched to availability based on individual needs. Communication to families of issues or obstructions to bed availability and reinforcement of safety plans during any period of wait for a bed should be a central feature of these daily meetings. ”

    Source location

    Barry HARMER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Bedfordshire and Luton

    AI-generated summary

    Mohammed Ashraful Islam CHOUDHURY · 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

    Mohammed Ashraful Islam CHOUDHURY, aged 26, died at hospital on 11 January 2023 after being attacked and stabbed by another resident at his supported accommodation. The concerns included inadequate management of the other resident’s known risks, lack of a multidisciplinary plan after he stopped taking medication, and withdrawal of medication support without checking with his GP that prescriptions were being obtained.

    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

    Absence of an MDT plan to address anti-psychotic depot medication non-concordance

    Wider context from the report

    “(i) The risks identified in respect of ████████ on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022. (ii) There was no MDT plan to address the significant development of ████████ non-concordance with his anti-psychotic depot medication from mid-September 2022. (iii) Despite knowing that ████████ lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not). ”

    Source location

    Mohammed Ashraful Islam CHOUDHURY · 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

    Reinforce medication non-concordance policies and procedures requiring weekly MDT discussion and comprehensive electronic-record documentation of missed depot injections or adherence concerns.

    Verbatim wording from the response

    “Response: The Trust has reviewed and reinforced its operational policy and standard operating procedures regarding medication non-concordance. These now require that missed depot injections or concerns about adherence be formally discussed in the weekly multidisciplinary team (MDT) meeting and documented comprehensively in the electronic patient record.”

    Source location

    Response from East London Foundation Trust
    Page 1 · response
    Published 8 January 2026

    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 depot-medication compliance auditing and weekly monitoring, with findings reported through local and Directorate governance and escalated where required.

    Verbatim wording from the response

    “An audit cycle has been embedded into routine practice to ensure compliance with these standards. A retrospective review conducted during 2024-2025 examined 275 service users on depot within Luton”

    Source location

    Response from East London Foundation Trust
    Page 1 · response
    Published 8 January 2026

    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

    Formalise MDT risk oversight for medication non-adherence through risk-register inclusion, weekly RAG review, senior multidisciplinary attendance and recording of decisions and responsible clinicians.

    Verbatim wording from the response

    “Response: The MDT has reflected on this learning and strengthened processes accordingly. Where a service user misses a depot injection or demonstrates medication non-adherence, the matter is now formally raised within the weekly MDT and added to the MDT risk register where appropriate. All MDT meetings are attended by the team Consultant, Operational Lead, Depot Clinic Lead, Care Coordinator, Psychologist, Occupational Therapist and wider MDT members. Risk is reviewed, RAG rated, and monitored weekly until resolved or stabilised. Managers and senior clinicians have reiterated the requirement that all discussions, decisions and responsibilities are clearly recorded in the electronic clinical system, including the named clinician responsible for agreed actions.”

    Source location

    Response from East London Foundation Trust
    Page 2 · response
    Published 8 January 2026

    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

    Strengthened medication non-concordance procedures, auditing, monitoring and training are considered sufficient; no further action is required.

    Verbatim wording from the response

    “Response: The Trust has reviewed and reinforced its operational policy and standard operating procedures regarding medication non-concordance. These now require that missed depot injections or concerns about adherence be formally discussed in the weekly multidisciplinary team (MDT) meeting and documented comprehensively in the electronic patient record.”

    Source location

    Response from East London Foundation Trust
    Page 1 · response
    Published 8 January 2026

    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

    Weekly MDT review, risk-register oversight, escalation and documented accountability are considered sufficient; no further action is required.

    Verbatim wording from the response

    “Response: The MDT has reflected on this learning and strengthened processes accordingly. Where a service user misses a depot injection or demonstrates medication non-adherence, the matter is now formally raised within the weekly MDT and added to the MDT risk register where appropriate. All MDT meetings are attended by the team Consultant, Operational Lead, Depot Clinic Lead, Care Coordinator, Psychologist, Occupational Therapist and wider MDT members. Risk is reviewed, RAG rated, and monitored weekly until resolved or stabilised. Managers and senior clinicians have reiterated the requirement that all discussions, decisions and responsibilities are clearly recorded in the electronic clinical system, including the named clinician responsible for agreed actions.”

    Source location

    Response from East London Foundation Trust
    Page 2 · response
    Published 8 January 2026

    Open published response

  10. North Yorkshire and York

    AI-generated summary

    Victoria Anne 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

    Victoria Anne Taylor’s mental health deteriorated between May and October 2024, involving suicidal ideation, self-harm and binge drinking. She was reported missing on 1 October 2024, and her body was recovered from the River Derwent on 22 October 2024. The principal concerns were that mental health services did not offer a treatment pathway addressing reported childhood trauma, provided limited safety planning, and did not suggest or convene a multi-agency approach despite knowing that several agencies were involved.

    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 safety plans to provide additional support responsive to identified needs

    Wider context from the report

    “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor. ”

    Source location

    Victoria Anne TAYLOR · Prevention of Future Deaths report
    Page 1 · 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