Concerns raised 1
Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Kirsty Clare TAYLOR · Prevention of Future Deaths report
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Report summary
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
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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 Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway
Wider context from the report “2. Evidence before this inquest indicated that SHFT has recognised that the mental health provision for those with personality disorders must move towards an individual, therapeutic and trauma-informed approach , which is both compassionate and recovery focused. It is evident that the 'Personality Disorder Pathway' currently being developed is an important step towards that aim, enabling practitioners and services to take a more holistic and person-centred approach, reducing risk and improving outcomes. I am aware that SHFT have been encouraged to review and further develop the Pathway. I am concerned that that must occur, and at pace .
” Source location Kirsty Clare TAYLOR · Prevention of Future Deaths report
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PFD Monitor interpretation Implement the new Personality Disorder and Complex Trauma model through an approved phased plan.
Verbatim wording from the response “In order to ensure that the Trust responded to this combination of local analysis and national and international developments, a new model has subsequently been developed over the past year for all services working with people who have Personality Disorder and Complex Trauma.” Source location Response from Southern Health NHS Foundation Trust
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PFD Monitor interpretation Roll out the Personality Disorder and Complex Trauma model through a steering board and six implementation workstreams.
Verbatim wording from the response “A programme Steering board and 6 workstreams have formed to ensure a structured roll out and oversight of the implementation plans. One of the workstreams is the Families and Carers Support workstream and the Trust would again very much welcome Kirsty’s family to participate in this. ████████ will be in touch with them about this shortly as we recognise that their generous offer to give their time to support these changes will be invaluable.” Source location Response from Southern Health NHS Foundation Trust
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PFD Monitor interpretation Develop inpatient tools supporting patients with Personality Disorder.
Verbatim wording from the response “A further workstream which is focussed on the in-patient pathway has as one of its strands the development of tools to support patients with a Personality Disorder should they be admitted to hospital. This group includes among its membership experts by experience with neurodiversity and the Trust fully recognises the need for the whole pathway to be accessible for this patient group.” Source location Response from Southern Health NHS Foundation Trust
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PFD Monitor interpretation Deliver whole-system trauma-informed training and cultural change across relevant organisations.
Verbatim wording from the response “As part of embedding the trauma-informed approach¹ the Trust is involved in a whole system piece of work to ensure that wherever an individual or family touches our services they will experience a trauma-informed response. This is a large-scale piece of work involving training and cultural change across a range of organisations. Connected to this and as part of the NHS England Mental Health, Learning Disability and Autism Quality” Source location Response from Southern Health NHS Foundation Trust
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PFD Monitor interpretation Maintain three recruit-to-train posts and provide further training for existing staff delivering evidence-based interventions.
Verbatim wording from the response “As part of the new Personality Disorder and Complex Trauma model, the Trust is seeking to increase access for individuals to evidence-based interventions, aligning with the national agenda on increasing access for individuals with severe mental illness. Funding received for ‘recruit to train’ posts is enabling this to happen.” Source location Response from Southern Health NHS Foundation Trust
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PFD Monitor interpretation Develop the clinical psychology workforce through an apprenticeship scheme and 48 Clinical Associate in Psychology roles.
Verbatim wording from the response “A separate measure taken to mitigate the national shortage of psychology staff has seen the Trust developing a new workforce and running an apprenticeship scheme with Plymouth University to develop Clinical Associates in Psychology (CAPS). Since 2022, the Trust has developed 48 CAPS across the organisation (3 cohorts of 16).” Source location Response from Southern Health NHS Foundation Trust
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PFD Monitor interpretation Develop and run an expanded Family Connections programme for families of people with complex emotional needs, including neurodiversity.
Verbatim wording from the response “Whilst we were initially only able to offer this in the Trust to a small sub-set of families whose relative was receiving a particular combination of interventions, we have sought to expand this. A new Family Connections model has been developed and has been run by Clinical Associates in Psychology (part of our new workforce expansion described in 2 above) for other family members with good outcomes.” Source location Response from Southern Health NHS Foundation Trust
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PFD Monitor interpretation Continue sharing national principles, guidance and positive practice on personality disorder services with health systems.
Verbatim wording from the response “As part of the NHS Long Term Plan, all systems in England have been receiving significant funding from 2021/22 to develop and roll out new models of integrated primary and community mental health care in line with the Community Mental Health Framework for the improved support of adults with severe mental illness in their community and to integrate mental, physical and social care. A key requirement of the new model of care is the provision of a dedicated community mental health offer for those with diagnosis of ‘personality disorder’ or complex emotional needs. This offer should be co-produced and person-centred, trauma-informed, and flexible care that is responsive to individuals changing needs. NHS England has shared key principles for the development of services for people with personality disorder and will continue to share guidance and positive practice with health systems.” Source location Response from NHS England
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PFD Monitor interpretation Explore opportunities to improve care quality for patients with higher-suicide-risk diagnoses and support compliance with NICE guidelines.
Verbatim wording from the response “As part of the strategy, NHS England and DHSC will explore opportunities to improve the quality of care for patients with specific diagnoses of conditions associated with higher rates of suicide and ensure compliance with the National Institute for Health and Care Excellence (NICE) guidelines. This includes patients with personality disorders. It is also intended that by 2024/25 all parts of the country will have introduced crisis text lines to enable easier access to crisis care for people who are neurodiverse.” Source location Response from NHS England
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PFD Monitor interpretation Review current and future personality-disorder provision using benchmarking, stakeholder views, projected need, and best practice.
Verbatim wording from the response “Issue - Evidence before this inquest indicated that SHFT has recognised that the mental health provision for those with personality disorders must move towards an individual, therapeutic and trauma-informed approached.” Source location Response from Hampshire and Isle of Wight
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PFD Monitor interpretation Develop improved personality-disorder provision for mobilisation in 2024/25.
Verbatim wording from the response “The review and development of evidence-based pathway and provision for people with personality disorders is one of five key Mental Health System Transformation priorities in 2023/24 for the Hampshire and the Isle of Wight system. The review is in process and will consider:” Source location Response from Hampshire and Isle of Wight
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PFD Monitor interpretation Deliver the Hampshire and Isle of Wight trauma-informed strategy, allocating resources and providing senior-level support.
Verbatim wording from the response “Mental Wellbeing is a priority set out in the Hampshire and Isle of Wight Forward Plan including working in partnership with the system in developing trauma informed approaches across services to reduce health inequalities and improve emotional wellbeing. The ICB, alongside Southern Health Foundation NHS Trust, is a signatory of the Trauma Informed concordat for Hampshire, the Isle of Wight, Portsmouth and Southampton, committing to the delivery of the Trauma Informed Strategy, allocating resources, and providing support and commitment at a senior level.” Source location Response from Hampshire and Isle of Wight
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PFD Monitor interpretation Delivery of the new Personality Disorder and Complex Trauma model must be phased to align with available commissioner funding.
Verbatim wording from the response “The delivery of this new model will be in a phased approach to align with available funding from commissioners with the first phase of work focussed on reducing waiting times for psychological therapy in secondary care.” Source location Response from Southern Health NHS Foundation Trust
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30 Apr 2021 Joanna Leven · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of a consistent therapeutic pathway and therapy availability for Personality Disorders View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Joanna Leven · 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
Joanna Leven was found dead at home on 26 March 2020 after self-induced asphyxia, following a deterioration in her mental health after her dog became seriously unwell and was euthanised. The report identified concerns about the absence of a comprehensive mental health assessment, variable access to therapeutic pathways and trauma-focused services, and the risk of information being lost between hospital and mental health liaison records systems.
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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 Lack of a consistent therapeutic pathway and therapy availability for Personality Disorders
Wider context from the report “1) The court heard evidence that there is no national therapeutic pathway for treatment of Personality Disorders . Whilst the court heard steps are in place to introduce a local pathway for residents of Greater Manchester, it is understood eligibility for and availability of various therapies which may be beneficial to patients diagnosed with a Personality Disorder varies from place to place ;
” Source location Joanna Leven · Prevention of Future Deaths report
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PFD Monitor interpretation Invest almost £1 billion in adult community mental health care by 2023/24.
Verbatim wording from the response “Under the NHS Long Term Plan, we are investing almost £1billion extra in community mental health care for adults by 2023/24. New and integrated models of primary and community mental health care will give 370,000 adults with serious mental illnesses, including personality disorders, greater choice and control over their care and support them to live well in their communities by 2023/24.” Source location 2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
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PFD Monitor interpretation Redesign community mental health provision through integrated, place-based multidisciplinary services aligned with primary care networks.
Verbatim wording from the response “Under the NHS Long Term Plan, we are investing almost £1billion extra in community mental health care for adults by 2023/24. New and integrated models of primary and community mental health care will give 370,000 adults with serious mental illnesses, including personality disorders, greater choice and control over their care and support them to live well in their communities by 2023/24.” Source location 2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
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25 Apr 2017 Linsay Bushell · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to provide psychologically driven care and consistently available psychology interventions View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Linsay Bushell · 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
Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.
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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 provide psychologically driven care and consistently available psychology interventions
Wider context from the report “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area.
The Jury found:
Para 3
1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital.
2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014.
3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation.
4. Linsay put herself in the position in which she was found however her intention was unclear.
5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder.
6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death.
7. The risk was managed adequately and effectively during Linsay's period as an in-patient.
8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made.
a. In the Trust Position Statement
Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them.
2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015.
3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material.
4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest.
5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity.
6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care . The Trust accepts this criticism.
It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment.
a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour.
b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism.
c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism.
7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust.
8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows:
a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub.
b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour.
c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient.
d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases.
e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package.
9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation.
10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided.
11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels.
12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better.
b. In the implementation of Lessons learnt the Trust further accepts
1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay".
a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:-
b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan.
c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay.
d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all.
e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear.
f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan.
g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time.
h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together.
i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs.
j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for.
k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission.
l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation.
m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective.
2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation.
Discontinuity of Care/Management of Care
3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B.
4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units.
5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach.
6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager.
7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse.
8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway.
9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible.
Risk Assessment/Care Planning
10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk.
11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required.
” Source location Linsay Bushell · Prevention of Future Deaths report
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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 NHS England is responsible for overseeing commissioning and delivering related improvements to mental health services.
Verbatim wording from the response “You issued your Report to NHS England, alongside the Secretary of State for Health, and I understand Professor Sir Bruce Keogh replied to you on 21 July.” Source location 2017-0137-Response-by-Department-of-Health
Open published response
9 Mar 2016 William Stanley Higgleton · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of psychotherapy service provision for persons with anti-social personality disorder View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William Stanley Higgleton · 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
William Stanley Higgleton, who had anti-social personality disorder and mixed anxiety and depressive disorder and was considered at high risk of harm to himself, was found deceased at home on 22 July 2015. The cause of death was recorded as a multiple drug overdose. The principal concerns were the lack of psychotherapy provision for people with anti-social personality disorder and the absence of limits on his access to medication or community mental health support to assist with medication compliance and more frequent assessment.
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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 Lack of psychotherapy service provision for persons with anti-social personality disorder
Wider context from the report “████████ considered that Mr Higgleton's primary diagnosis was anti-social personality disorder. She confirmed that the primary treatment for this condition would be psychotherapy services. ████████ confirmed however that there is a lack of service provision for psychotherapy care to be provided to persons suffering from anti-social personality disorder . The lack of service provision in this regard was confirmed by ████████ (Assistant Director Adult Mental Health and Learning Disabilities).
I consider that the lack of provision of psychotherapy services to this group of patients presents a risk of future deaths occurring.
” Source location William Stanley Higgleton · Prevention of Future Deaths report
Open source report
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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 care pathways for patients with antisocial personality disorder against NICE guidance, identify service gaps, and determine appropriate action.
Verbatim wording from the response “At the meeting, an agreement was reached to review the care pathways for the patients suffering with anti-social personality disorder, to ensure that they are supported to access the existing services in conjunction with National Institute for Health and Social Care Excellence (NICE) guidelines.” Source location William-Higgleton-Response
Open published response
9 Mar 2015 Craig Douglas Bell · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Craig Douglas Bell · 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
Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.
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 psychological therapy identification and treatment for prisoners with personality disorders or related traits
Wider context from the report “1. The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm ( which may ultimately result in death ) or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering from these conditions will end up deliberately or accidentally killing themselves.
” Source location Craig Douglas Bell · Prevention of Future Deaths report
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Includes only assertions that directly instantiate the manually reviewed condition ‘Insufficient therapeutic pathways for people with personality disorders’ and satisfy this evidence boundary: Multiple distinct reports directly support absent, incomplete or geographically inconsistent therapy pathways for people with personality disorders. The generic ten-month psychotherapy-wait assertion does not identify a personality disorder and must be excluded; retain only personality-disorder-specific pathway, therapy-availability and service-provision assertions.
