Recurring concern

Inadequate assessment of causes and risks of mental health relapse

First to latest report 26 Aug 2020 — 6 Feb 2026

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
11

What this concern includes

Includes failures in mental-health care to assess or discuss the causes, triggers, substance-use links, warning signs or recurrence risks associated with relapse, including discussion with the patient where needed to understand a rapid relapse.

What is not included
  • Excludes generic mental-health communication or clinical-assessment deficiencies where relapse or relapse risk is not materially involved.
  • Excludes failures limited to discharge-letter content, referral processing or follow-up arrangements when the underlying assessment of relapse causes and risks was adequate.
  • Excludes generic confirmation-bias, professional-curiosity or substance-misuse concerns that are not specifically connected to understanding or managing mental health relapse.
  • Excludes treatment, prescribing or service-capacity failures where no deficiency in assessing or discussing relapse causes or risks is identified.

Reports and published responses 4 reports

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

  1. Manchester West

    AI-generated summary

    Michaela FINCH · 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

    Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.

    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 evaluate alcohol misuse as a possible consequence of mental health deterioration

    Wider context from the report

    “5. The evidence established a potential lack of professional curiosity and confirmation bias as to the aetiology of the deceased’s relapse profile - her recourse to alcohol misuse not being evaluated to be a consequence of mental health deterioration. ”

    Source location

    Michaela FINCH · 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

    Roll out mandatory professional-curiosity training to Community Care Group clinical staff, with attendance and feedback monitored through the care-group training group.

    Verbatim wording from the response

    “A professional curiosity training package has been developed by the Trust and piloted across our Salford Community Services in 2025. Following the reconfiguration of the care groups in November 2025 a group was set up to review the existing package before rolling out across the community care group. The package has been slightly amended to ensure most up to date case examples are included and that it also covers older adults.”

    Source location

    2026-0064 - Response from Greater Manchester Mental Health
    Page 3 · response
    Published 11 February 2026

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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

    Develop and provide formulation training for clinical staff across the Community and Acute Care Groups.

    Verbatim wording from the response

    “In addition to this training the Trust has commissioned it’s Psychological Therapies Training Centre to develop and provide formulation training to clinical staff across the Community and Acute Care Groups. This training will support staff to work collaboratively with patients to understand the whole person, identify their difficulties, which are often multi-faceted, what makes them worse and what might help and how this can guide treatment and support decision making.”

    Source location

    2026-0064 - Response from Greater Manchester Mental Health
    Page 3 · response
    Published 11 February 2026

    Open published response

  2. Manchester North

    AI-generated summary

    Mr David Thompson · Prevention of Future Deaths report

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

    Report summary

    Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.

    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 discuss the reasons for rapid relapse with the patient

    Wider context from the report

    “1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly. ”

    Source location

    Mr David Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Cheshire

    AI-generated summary

    Olivia Amy RUSSELL · 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

    Olivia Russell had a history of anxiety, started citalopram in November 2020, stopped taking it without consulting a GP around June 2021, and restarted it in August 2021 after a relapse. She took her own life on 19 September 2021. Concerns included a lack of recorded evidence that risks associated with stopping medication or initially feeling worse had been discussed, uncertainty about consistent adherence to relevant guidance, and delay in carrying out a significant event review after her death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to routinely discuss medication relapse and worsening risks with patients

    Wider context from the report

    “During the inquiry, evidence was heard from ████████, one of your salaried GPs as to his interactions with Olivia, and based on the records, his colleagues’ interactions. There was no evidence within the notes that the risk of relapse if a medication is stopped was discussed in either November 2020 or August 2021, nor is there evidence that Olivia was told she may feel worse before she feels better. I did not find that this advice was not given, simply that I could not say either way. When asked, ████████ evidence was that you would discuss the risks when prescribing the drug, but was not entirely clear as to which risks he would discuss, and gave evidence that it is likely each GP has a different approach, bearing in mind the time limitations of the appointment. He could not say with confidence that every GP within the practice was discussing these key risks. A copy of the relevant NICE guidance was provided to me which states that these risks should be discussed with the patient, and I look specifically at sections 1.3.1 and 1.5.2 as a minimum. I am concerned that this guidance is not being followed as a matter of routine within the surgery and that this gives rise to a risk of future deaths. ”

    Source location

    Olivia Amy RUSSELL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Recirculate NICE antidepressant guidance and GMC prescribing guidance to clinicians, highlighting discussion of medication risks.

    Verbatim wording from the response

    “2. To ensure relevant information is shared with a patient when commencing an antidepressant, in accordance with relevant clinical guidelines. This includes a discussion about risks, in particular the risk of relapse when stopping a medication and the risk of increased self-harm ideation at the outset of treatment.”

    Source location

    Response from Stretton Branch Surgery
    Page 2 · response
    Published 28 December 2023

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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

    Add a medication-label warning advising patients not to stop antidepressant or anti-anxiety medication without medical advice.

    Verbatim wording from the response

    “We have implemented a system whereby whenever an antidepressant or an anti-anxiety medication is prescribed a note will be added to patient and pharmacist to confirm “please do not stop these medications without medical advice”. This note will show up on the medication box label.”

    Source location

    Response from Stretton Branch Surgery
    Page 2 · response
    Published 28 December 2023

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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

    Remind GPs to discuss antidepressant risks and arrange follow-up, incorporating the requirement into new-starter and locum induction materials.

    Verbatim wording from the response

    “We have reminded all GPs that at the time of commencing an antidepressant, they should have a conversation with the patient mindful of the relevant clinical guidelines. The GP is then to book a follow up review with the patient. We have included this reminder in new starters and locum induction pack to ensure they act accordingly.”

    Source location

    Response from Stretton Branch Surgery
    Page 2 · response
    Published 28 December 2023

    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

    Provide 20-minute appointments for patients booking to discuss mental health concerns so medication risks can be discussed adequately.

    Verbatim wording from the response

    “To ensure risks are discussed with patients on anti-depressant medication, the Practice recognises that appointment times would need to be extended beyond the usual 10-minute slot. Hence patients booking to discuss a mental health concern will be given a 20-minute appointment. However, if a patient has not declared at the time of making the appointment that the appointment is to discuss a mental health concern, then the GP can send a message to reception to say that the consultation will take another 10 minutes and to keep any waiting patients informed of any delays. It is standard practice for our reception team to ask a patient the reason for their appointment at the time of booking an appointment to assist with planning the patient journey. There is no obligation on the patient to share information. While most patients declare their reasons for appointment some say it is “private”.”

    Source location

    Response from Stretton Branch Surgery
    Page 3 · response
    Published 28 December 2023

    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

    Cascade Significant Event Analysis outcomes to clinical, reception and administration staff to support appropriate appointment booking and patient communication.

    Verbatim wording from the response

    “We have cascaded the outcomes of the Significant Event Analysis to all clinical members of our Practice team, which includes the reception and administration teams to ensure that they book the appropriate duration for each appointment and to reassure patients awaiting a consultation that they will be seen.”

    Source location

    Response from Stretton Branch Surgery
    Page 3 · response
    Published 28 December 2023

    Open published response

  4. Lincolnshire

    AI-generated summary

    Toby Peter Edward Nieland · 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

    Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

    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

    Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures

    Wider context from the report

    “5. Inadequate evaluation of the deceased's previous history; his purported non-concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to a missed opportunities to appreciate a series of acceptable relapse signatures; ”

    Source location

    Toby Peter Edward Nieland · 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 a prompt system at every NSP visit to assess presentation, health, housing, harm reduction, substance use and treatment referrals.

    Verbatim wording from the response

    “• Our staff now use a ‘prompt system’ at each visit. These include discussions around the persons initial presentation, mental and physical health, housing needs, harm reduction, more in depth substance use and clarifying and discussing referrals into structured treatment should it be required and consented to.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement an enhanced NSP questionnaire to identify complex health issues and mental-health concerns, informing risk assessment and decisions.

    Verbatim wording from the response

    “• We have introduced better identification of those with complex health issues. We have implemented an enhanced standard questionnaire for our NSP service users. It incorporates questions to ascertain concerns individuals may have on their own mental health and current engagement with mental health (or any other relevant) services. The aim is to enable the key-worker to make better informed decisions of any immediate concerns / risks surrounding an individual’s mental health, based on presentation and information disclosed.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Roll out revised suicide-prevention training covering history, accommodation, relationships and substance and alcohol misuse risk factors.

    Verbatim wording from the response

    “Learning from the tragic death of Mr Nieland, the Trust has taken steps to enhance the training offered to staff about assessing risk of suicide to reinforce the complex interplay of factors mentioned above including previous history, accommodation and employment needs, substance and alcohol misuse patterns and relationships. This revised suicide prevention training will be rolled out to all staff commensurate with their role and clinical responsibility, within the next 6-12 months.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 5 · response
    Published 26 October 2020

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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 training and competencies to cover dual-diagnosis presentations, risk assessment and information sharing.

    Verbatim wording from the response

    “The Trust is committed to a review of the training provided to staff to ensure they are appropriately equipped with the knowledge and ability to care for patients with dual diagnosis. The Learning and Development Lead is working with Divisional staff to develop the appropriate training package, over the next 6-12 months.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 7 · response
    Published 26 October 2020

    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