Recurring concern

Unreliable shared terminology for mental-health emergency responses

First to latest report 19 May 2014 — 12 Jun 2023

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
4

What this concern includes

Includes failures of terminology, definitions or shared language used between mental-health services and police or other emergency-response organisations when the inconsistency can impair interpretation of risk, urgency, responsibility or required action.

What is not included
  • Excludes generic communication, information-sharing or policy failures where terminology or definitions are not themselves the unsafe condition.
  • Excludes terminology problems confined to a single organisation or internal process without a supported cross-organisational mental-health or emergency-response interface.
  • Excludes general language, accessibility or translation needs unrelated to shared professional terminology and definitions.
  • Excludes failures of clinical care, police attendance or emergency response where no terminology or definition problem is identified.

Reports and published responses 2 reports

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

  1. Inner North London

    AI-generated summary

    Heather FINDLAY · 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

    Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.

    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

    Inconsistent terminology and definitions between police and mental-health services

    Wider context from the report

    “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm. I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it. I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions. It seems that this would benefit from consideration. ”

    Source location

    Heather FINDLAY · 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

    Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.

    Verbatim wording from the response

    “The Commissioner of the Metropolitan Police, ████████, wrote to Health and Social Care Partners on 24th May 2023, to set out the Met Police’s intention to implement the national Right Care, Right Person approach. Under Assistant Commissioner ████████ a team is now working to put this in place, and an initial senior board has taken place with senior health and social care providers to work towards RCRP implementation. This is also in parallel with the work being done by health care providers on the London mental health concordat. A key aspect of this is working with all of the”

    Source location

    Response from Metropolitan Police
    Page 5 · response
    Published 22 June 2023

    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

    Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.

    Verbatim wording from the response

    “The concerns in your Report relate to organisational policy at East London Foundation Trust as well as policy within the Metropolitan Police Service. NHS England is not therefore the appropriate organisation to respond to many of the concerns raised.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 22 June 2023

    Open published response

  2. Mid Kent and Medway

    AI-generated summary

    Peter Franklin · 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

    Peter Franklin, who had longstanding mental health difficulties and increasingly frequent hospital attendances, died after jumping from a motorway bridge following an attempted jump earlier that day. The concerns included unclear communication about whether a referral, advice or assessment was required, relevant information not being passed on, and delays in sharing information with his GP.

    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

    Confusion and lack of clarity in terminology for out-of-hours CRISIS team calls

    Wider context from the report

    “(1) There was confusion in the terminology used between nursing staff or doctors and the CRISIS team when out of hours calls were made such that it was not clear between parties whether a referral, advice or assessment was sought. ”

    Source location

    Peter Franklin · 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

    Use and monitor a referral flow chart clarifying whether urgent referrals require advice or assessment.

    Verbatim wording from the response

    “We have developed a clear process outlining the pathway for urgent referrals through a referral flow chart which includes confirmation as to whether advice or assessment is being requested. This is being monitored by the Liaison Psychiatry Service Manager and at the monthly interface meeting between the two Trusts.”

    Source location

    2014-0230-Response-by-Kent-Medway-NHS-Trust
    Page 2 · response
    Published 19 May 2014

    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 update the Liaison Psychiatry out-of-hours roles and responsibilities protocol to improve staff guidance.

    Verbatim wording from the response

    “In addition we have reviewed and updated the Liaison Psychiatry roles and Responsibilities Out of Hours Protocol. This provides improved guidance to staff.”

    Source location

    2014-0230-Response-by-Kent-Medway-NHS-Trust
    Page 2 · response
    Published 19 May 2014

    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 the SMART Tool in the Emergency Department, finalise its design, incorporate it into the Junior Doctor Handbook, and use it with the Mental Health Trust.

    Verbatim wording from the response

    “Firstly I would like to address the issue of confusion in terminology 5(1). The use of a SMART Tool was discussed and agreed at the Emergency Directorate Clinical Governance meeting on 1st July 2014. It is being implemented from an Emergency Department perspective by Dr Bell, Consultant in A&E Medicine and Cliff Evans, Consultant Nurse. Once the design is finalised this will be incorporated into the Junior Doctor Handbook. A copy of the format is attached for your information. This will be used in conjunction with the Mental Health Trust.”

    Source location

    2014-0230-Response-by-Tunbridge-Wells-Hospital
    Page 1 · response
    Published 19 May 2014

    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