Recurring concern

Insufficient mental health service capacity for timely patient care

First to latest report 14 Aug 2013 — 24 Oct 2025

Reports that mention this concern
40
Times this concern has been raised
48
Stated actions linked to this concern
87

What this concern includes

Includes failures of funding, staffing, recruitment, retention, service capacity or resource resilience that are explicitly tied to the ability of mental health services to provide timely and safe patient care, including psychiatric units, CAMHS, older-age psychiatric teams and comparable mental health services.

What is not included
  • Excludes generic workforce, funding or resource deficiencies without an explicit mental health service safety impact.
  • Excludes delays or access failures in a specific mental health pathway when the wider service-capacity deficiency is not identified.
  • Excludes non-mental-health services, including police, ambulance, epilepsy, maternity, social-care and general hospital capacity concerns.
  • Excludes deficiencies in a separately named mental health system or pathway where that named concern provides the more specific supported boundary, unless the assertion also directly identifies inadequate overall mental health service capacity.

Reports and published responses 40 reports

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

  1. Birmingham and Solihull

    AI-generated summary

    Simon Anthony Graham · 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

    Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.

    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

    Under-funding of mental health services creating a risk of future deaths

    Wider context from the report

    “6. The strain on the systems of Mental Health Services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding. ”

    Source location

    Simon Anthony Graham · 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

    Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.

    Verbatim wording from the response

    “5.4.1 An independent system simulation modelling exercise, which was jointly commissioned with FTB and BSMHFT, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.”

    Source location

    Birmingham-and-Solihull-CCG-Response
    Page 4 · response
    Published 4 October 2018

    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 additional investment to expand commissioned mental-health service capacity and provision.

    Verbatim wording from the response

    “5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).”

    Source location

    Birmingham-and-Solihull-CCG-Response
    Page 5 · response
    Published 4 October 2018

    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

    Funding is not the sole cause of the identified failures, and the link between funding and the deaths cannot currently be validated.

    Verbatim wording from the response

    “5. Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase). In 2018/19 the CCG provided additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and FTB amounting to £2,881,000 (9.3% increase). Further funding discussions are ongoing but at present the CCG is unable to validate a link between funding and the deaths presented. However, the CCG continuously monitors this position and demand in order to ensure it is responsive to any increase in demand where funding would be either the sole, or contributory solution.”

    Source location

    NHS-England-Response.pdf
    Page 3 · response
    Published 4 October 2018

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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

    The Clinical Commissioning Group will lead the shared demand analysis needed to assess demand, capacity and funding constraints.

    Verbatim wording from the response

    “Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services, all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authority and schools) and a ‘Suicide prevention strategy’. The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health.”

    Source location

    NHS-England-Response.pdf
    Page 4 · response
    Published 4 October 2018

    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

    There is currently no evidence that insufficient funding contributed to the deaths.

    Verbatim wording from the response

    “7.8 It is noted from the Coroner’s letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths. The CCG is still awaiting detailed investigation reports into all of the deaths. However, at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018.”

    Source location

    Birmingham-and-Solihull-CCG-Response
    Page 8 · response
    Published 4 October 2018

    Open published response

  2. Blackpool and the Fylde

    AI-generated summary

    Sara Antonia MORAN, known as Sally · 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

    Sara Antonia MORAN, known as Sally, was found deceased at home on 22 April 2017 after being reported missing; the medical cause of death was morphine toxicity and the inquest conclusion was drug related. The report raised concern that excessive demands on mental health professionals and inadequate staffing could result in service users not receiving the attention they need, potentially with fatal consequences.

    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 ensure mental health professionals have manageable caseloads

    Wider context from the report

    “I am concerned that if mental health professionals are expected to provide care to an excessive number of service users – many of whom inevitably pose significant challenges – then there a genuine risk of future deaths arises as a result of this. Sara Moran had a history of drug and mental health problems. Although I did not find that the care afforded to Sara contributed to her fatal outcome this does not prevent me from writing this report. If mental health professionals are finding themselves struggling to provide the level of service that Service Users such as Sara require then such demands in my judgement inevitably pose a significant risk that one or more such Service Users may not receive the level of attention they need and with potentially fatal consequences. ”

    Source location

    Sara Antonia MORAN, known as Sally · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Individual NHS trusts are responsible for determining staffing numbers and types and ensuring sufficient trained and competent staff.

    Verbatim wording from the response

    “I should firstly point out that individual NHS Trusts are responsible for the number and type of staff they employ and for ensuring there is a sufficiency of staff trained and competent to carry out their duties.”

    Source location

    2018-0133-Response-by-Department-of-Health
    Page 1 · response
    Published 1 July 2018

    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

    Existing CQC registration requirements already require providers to deploy sufficient suitably qualified, competent, skilled and experienced staff.

    Verbatim wording from the response

    “Appropriate staffing levels are already a core element of the Care Quality Commission’s (CQC’s) registration regime underpinned by legislation. All providers of regulated activities must be registered with the CQC and meet the registration requirements. The 16 safety and quality requirements set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 include a requirement for the deployment of sufficient numbers of suitably qualified, competent, skilled and experienced persons.”

    Source location

    2018-0133-Response-by-Department-of-Health
    Page 1 · response
    Published 1 July 2018

    Open published response

  3. Cumbria

    AI-generated summary

    Karen Jane Edgar · 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

    Karen Jane Edgar had emotional and behavioural difficulties and was referred to CAMHS in October 2015, aged 15. She received delayed and limited mental health support, including gaps in family therapy, individual therapy, risk reassessment and care planning, before she died after hanging herself on 8 April 2017. The report raised concerns about underfunded child and adolescent mental health services, delays in treatment and inadequate resources and 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

    Underfunding of mental health services for children and young people in Cumbria

    Wider context from the report

    “(1) The provision of mental health services for children and young people in Cumbria is underfunded. (2) There are long delays in getting treatment. ”

    Source location

    Karen Jane Edgar · 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

    Make an additional £1.4 billion available to improve mental health services for children and young people, including £150 million for eating disorders.

    Verbatim wording from the response

    “The Government is already making an additional £1.4 billion available, which includes £150 million for eating disorders, to improve mental health services for children and young people with mental health problems.”

    Source location

    2018-0106-Response-by-Department-of-Health-Social-Care
    Page 2 · response
    Published 17 June 2018

    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

    Make over £300 million in additional funding available after the consultation.

    Verbatim wording from the response

    “Additional funding of over £300 million will be made available post consultation. The consultation closed on 2 March 2018 and we are currently finalising the response to the consultation, which will be published in due course.”

    Source location

    2018-0106-Response-by-Department-of-Health-Social-Care
    Page 3 · response
    Published 17 June 2018

    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

    Commissioning mental health services in Cumbria is the responsibility of local NHS commissioners.

    Verbatim wording from the response

    “I would first like to explain that the commissioning of mental health services in Cumbria is a matter for the local NHS. I note that you have issued your report to local commissioners, the North Cumbria and the Morecambe Bay Clinical Commissioning Groups (CCGs), as well as the Cumbria Partnership NHS Foundation Trust, and I hope their response will be helpful.”

    Source location

    2018-0106-Response-by-Department-of-Health-Social-Care
    Page 1 · response
    Published 17 June 2018

    Open published response

  4. Essex

    AI-generated summary

    Dean Gary Saunders · 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

    Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.

    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

    Insufficient resilience of psychiatric cover at Chelmsford prison

    Wider context from the report

    “5. FOR NHS ENGLAND:- The resilience of psychiatric cover at Chelmsford prison, which would need to be raised with NHS England who commission such services and decide on the budget. ”

    Source location

    Dean Gary Saunders · 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

    Assess the resilience of psychiatric care at HMP Chelmsford.

    Verbatim wording from the response

    “NHS England (Midlands and East region) has considered the resilience of the psychiatric care service at HMP Chelmsford, a category B local prison. Care UK are the current providers of mental health services at HMP Chelmsford and deliver a total of 5 sessions of psychiatry per week for a population of 710 men. A health needs assessment was conducted in 2016 by an independent author who concluded that the overall provision of psychiatry cover at HMP Chelmsford meets the needs of the population. The Health Needs Assessment is provided at Appendix B”

    Source location

    2017-0056-Response-by-NHS-England
    Page 2 · response
    Published 5 March 2017

    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

    Psychiatric provision at HMP Chelmsford was considered sufficient because an independent health needs assessment found it met the population’s needs.

    Verbatim wording from the response

    “NHS England commissions healthcare in prisons using an outcomes-based service specification. NHS England (Midlands and East) is responsible for the performance management of the healthcare contract. The provider, Care UK, is required to submit quarterly data on a range of qualitative and activity-based key performance indicators.”

    Source location

    2017-0056-Response-by-NHS-England
    Page 2 · response
    Published 5 March 2017

    Open published response

  5. Cheshire

    AI-generated summary

    Kevin Dermott · Prevention of Future Deaths report

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

    Report summary

    Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his 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

    Inadequate mental health staffing and psychiatric referral provision

    Wider context from the report

    “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

    Source location

    Kevin Dermott · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of suitable psychiatric care facilities

    Wider context from the report

    “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

    Source location

    Kevin Dermott · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain nationally specified integrated stepped mental-health care, including consultant psychiatry, long-term care planning and continuity of care.

    Verbatim wording from the response

    “Better integration of health care services within prisons has also been supported by the development of a national set of service specifications for primary care services (including GP and nursing services), mental health services and substance misuse services. The mental health service specification outlines the requirement for mental health services to provide an integrated stepped care model for mental health which enables patients to flow seamlessly between mild to moderate and severe and enduring stages based on clinical need and include the provision of a consultant psychiatrist. These service specifications were developed in December 2013 and set the outcomes and standards required from the services including long-term care planning and continuity of care.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    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

    Work with specialised commissioning teams and partner organisations to address the shortage of secure psychiatric beds and delays transferring acutely unwell prisoners.

    Verbatim wording from the response

    “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    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

    Specialised Commissioning teams are responsible for secure mental health provision, including addressing shortages affecting transfers of acutely unwell prisoners.

    Verbatim wording from the response

    “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    Open published response

  6. Leicester City and South Leicestershire

    AI-generated summary

    Barry Thraves · 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 Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and 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

    Insufficient resourcing of the psychiatric unit

    Wider context from the report

    “3. The expectation of the Local Authority is that appointments should take place within 28 days, but the unit is significantly under-resourced and delays are common and appear to be tolerated, and have been for some time. Earlier, timely appointments could assist in identifying and intervening with relapsing patients. This opportunity was lost. ”

    Source location

    Barry Thraves · 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

    Fill vacancies and improve staffing capacity to reduce assessment waiting times.

    Verbatim wording from the response

    “Unfortunately at this time the team was under particular pressure due to long term sickness and vacancies, subsequently resulting in individuals waiting a long period of time for assessments. It is most unfortunate that this consequently impacted upon Mr Thraves and also other people awaiting assessment at that time. Fortunately, the staffing situation has now improved, vacancies are filled, and waiting times for assessment have reduced.”

    Source location

    2015-0443-Response
    Page 2 · response
    Published 26 October 2015

    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

    Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.

    Verbatim wording from the response

    “In the period between completion of the investigation and leading up to the Coroner’s inquest LPT has been undertaking a programme of specific work to ensure that the maximum use of clinical appointment slots are available in the Adult Mental Health Outpatients department thereby increasing the availability of appointments to our patients. This will reduce the numbers of people who are not attending appointments.”

    Source location

    2015-0443-Response2
    Page 2 · response
    Published 26 October 2015

    Open published response

  7. Manchester (North)

    AI-generated summary

    Lucasz Lewandowski · 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

    Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

    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 resources for mental health response

    Wider context from the report

    “3. The use of S.136 of the Mental Health Act due to lack of resources – albeit on logical, pragmatic grounds. ”

    Source location

    Lucasz Lewandowski · 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

    Complete the review of the Escalation Policy to improve risk identification, patrol allocation and supervisory escalation when resources are unavailable.

    Verbatim wording from the response

    “The Operational Communications Branch (OCB) has undertaken a review of its Escalation Policy. The intention of this review, which is in its final stages, is to ensure the OCB works effectively with Divisions to enhance its ability to effectively identify areas of risk and then effectively manage the allocation of patrols to address that risk. In cases when it becomes apparent that resources are unavailable for allocation, the Escalation Policy will ensure the incident is brought to the attention of the appropriate Divisional supervisor.”

    Source location

    2014-0445-Response-by-Greater-Manchester-Police
    Page 1 · response
    Published 15 October 2014

    Open published response

  8. South and East Cumbria

    AI-generated summary

    Helena Kathleen Farrell · 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

    Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.

    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 CAMHS staffing numbers

    Wider context from the report

    “(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers. ”

    Source location

    Helena Kathleen Farrell · 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

    Increase CAMHS staffing from 45 to 63 and improve skill mix through development plans.

    Verbatim wording from the response

    “The Trust, with commissioners, has fully implemented the recommendations of the independent, external review of CAMHS in 2012 which has resulted in the staffing levels across the service increasing from 45 to 63, with improved skill mixes and clear development plans. Significant training has been identified, planned and delivery has commenced. Suicide prevention training was prioritised and delivered as shown in the action plan, point 10.”

    Source location

    2014-0309-Response-by-Cumbria-NHS-Foundation-Trust
    Page 2 · response
    Published 3 July 2014

    Open published response

  9. Inner West London

    AI-generated summary

    Mr Philip Anthony Dean · 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 Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident investigation.

    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

    Under-resourcing of HTT and liaison psychiatry services with medically qualified personnel

    Wider context from the report

    “(5) That secondary care services both the HTT and Liaison Psychiatry appear under to be under-resourced especially in terms of medically qualified personnel, and that this apparent under-resource impacts on the ability of these services to make accurate assessments of patients. ”

    Source location

    Mr Philip Anthony Dean · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Liaison Psychiatry under-resourcing is primarily a matter for the Trust’s commissioners, not internal Trust resource allocation.

    Verbatim wording from the response

    “The Liaison Psychiatry service is under-resourced compared to national guidance on staffing levels. In this regard, so are the majority of Liaison Psychiatry departments, and the under-resourcing is a matter primarily for the Trust’s commissioners, rather than a problem of resource allocation within the Trust. The Trust do have fewer Consultants than most London teaching hospital Liaison Psychiatry departments however the implication that only medically qualified staff can make accurate assessments is not accepted. An experienced and competent Band 7 nurse will do a much more robust assessment than a doctor who has been training in psychiatry for a few years and their assessments will be on a par with a senior doctor’s. An example of this was demonstrated last year when a Trust Consultant Psychiatrist provided a Coroner with data which showed a low”

    Source location

    2014-0172-Response
    Page 3 · response
    Published 15 April 2014

    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

    The implication that only medically qualified staff can make accurate Liaison Psychiatry assessments is not accepted.

    Verbatim wording from the response

    “The Liaison Psychiatry service is under-resourced compared to national guidance on staffing levels. In this regard, so are the majority of Liaison Psychiatry departments, and the under-resourcing is a matter primarily for the Trust’s commissioners, rather than a problem of resource allocation within the Trust. The Trust do have fewer Consultants than most London teaching hospital Liaison Psychiatry departments however the implication that only medically qualified staff can make accurate assessments is not accepted. An experienced and competent Band 7 nurse will do a much more robust assessment than a doctor who has been training in psychiatry for a few years and their assessments will be on a par with a senior doctor’s. An example of this was demonstrated last year when a Trust Consultant Psychiatrist provided a Coroner with data which showed a low”

    Source location

    2014-0172-Response
    Page 3 · response
    Published 15 April 2014

    Open published response

  10. Dorset

    AI-generated summary

    JORDAN ANTHONY BUCKTON · 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

    JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.

    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

    Insufficient mental health practitioner staffing capacity

    Wider context from the report

    “(3) The failure to continue the “Emotional Wellbeing” Course in January 2012 Mr Buckton had 4 sessions with HCA Board on this course which she regarded as successful in improving his outlook on life. However she was injured on the 1st January 2012 and off work but no other mental health staff were available to continue the course. Only 2 full time members of staff were in place to carry out the work of 5 full time mental health practitioners with 1 or occasionally 2 locum nurses employed to make up the deficiency. Whilst the jury did not regard the failure to continue the course as causative or contributory to Mr Buckton’s death they clearly felt it was important to record that the failure to continue possibly had a detrimental affect upon Mr Buckton’s wellbeing. He had been diagnosed with a personality disorder. Evidence was given that the only effective treatment for such a disorder is by talking therapy and management strategies. Greater regard should have been given to the cessation of this course and the effect upon all prisoners involved. ”

    Source location

    JORDAN ANTHONY BUCKTON · Prevention of Future Deaths report
    Page 2 · 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