13 Nov 2023 Roger Adrian Stevenson · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Insufficient staffing capacity for mental health treatment 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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AI-generated summary
Roger Adrian Stevenson · 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
Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.
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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 Insufficient staffing capacity for mental health treatment
Wider context from the report “7. That staffing shortages continue to be a major issue in mental health treatment and that although efforts towards recruitment may alleviate this to some extent KMPT adding text to template letters giving a little more information to service users as to when they may expect to be seen is unlikely to be sufficient. Where such text is used though there would be an opportunity of referring to 3rd party agencies from whom additional support can be sought including charities like the Samaritans or emergency numbers (999 and 111).
” Source location Roger Adrian Stevenson · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Grow the NHS mental health workforce by an additional 27,000 staff between 2019/20 and 2023/24.
Verbatim wording from the response “With regard to your concerns around staffing shortages, the government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, we are making positive progress on our ambition to grow the mental health workforce by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this (around 20,800) by December 2023 with further growth expected to have been achieved once the full year figures for 2023/24 are available.” Source location Response from Department of Health and Social Care
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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 addressing the report’s concerns about local mental health service issues.
Verbatim wording from the response “I note that you have also addressed matters of concern to the Chief Executive of NHS England, and I would expect her response to address the concerns raised around local issues.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The relevant trust is responsible for local mental health service staffing levels and operations.
Verbatim wording from the response “With regard to your concerns around staffing shortages, the government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, we are making positive progress on our ambition to grow the mental health workforce by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this (around 20,800) by December 2023 with further growth expected to have been achieved once the full year figures for 2023/24 are available.” Source location Response from Department of Health and Social Care
Open published response
19 Sep 2023 Lauren Elizabeth Bridges · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Underfunding for local mental health beds View source Over-reliance by the NHS on independent providers for mental health beds 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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AI-generated summary
Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.
Read the report on judiciary.uk
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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 Underfunding for local mental health beds
Wider context from the report “This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Lauren was 20 years of age. The other inquest involved a 15 years old patient - 115 miles from home.
Both of these cases illustrate,
a) Underfunding for local mental health beds .
b) An over-reliance by the NHS on independent providers for mental health beds.
” Source location Lauren Elizabeth Bridges · Prevention of Future Deaths report
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 Over-reliance by the NHS on independent providers for mental health beds
Wider context from the report “This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Lauren was 20 years of age. The other inquest involved a 15 years old patient - 115 miles from home.
Both of these cases illustrate,
a) Underfunding for local mental health beds.
b) An over-reliance by the NHS on independent providers for mental health beds .
” Source location Lauren Elizabeth Bridges · 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 Support health and care systems to operationalise inpatient mental health care localisation plans through regional and national assistance.
Verbatim wording from the response “To implement this, all ICBs have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of the mental health, learning disability and autism inpatient quality transformation programme launched in 2022. Health and Care systems across England are currently being supported to operationalise the guidance via 3-year plans with direct support from regional and national teams. The transformation programme is underpinned by a £36 million investment.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrated care boards are responsible for developing three-year plans to localise and realign inpatient mental health care, including independent-sector provision.
Verbatim wording from the response “Turning to your concerns around an over-reliance by the NHS on independent providers for mental health beds, private companies have always played a role in the NHS and patients should expect a safe and good quality service regardless of whether their care is delivered by independent sector or public sector providers. As set out in NHS England’s response to your report, all integrated care boards have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of NHS England’s mental health, learning disability and autism inpatient quality transformation programme.” Source location Response from Department of Health and Social Care
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30 Aug 2023 Allison Vivian Jacome Aules · Prevention of Future Deaths report East London
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Concerns raised 1
Under-resourcing of CAMHS services View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England NHS North East London
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Department of Health and Social Care
Increase the mental health workforce by 27,000 staff, with three quarters of the target delivered by December 2023.
View source
Department of Health and Social Care
Attract, train, recruit, retain and reskill the current and future mental health workforce.
View source
Department of Health and Social Care
Continue increasing education and training commissions across mental health training programmes.
View source
Department of Health and Social Care
Develop new mental health workforce roles and use existing roles to transform service delivery and improve service user experiences.
View source
NHS England
Increase investment in the children and young people’s mental health workforce to expand service capacity.
View source
NHS North East London
Develop a business case for additional CAMHS funding, including proposals for extended working and face-to-face initial assessments.
View source
NHS North East London
Work with NELFT and other providers to support consultant psychiatrist recruitment and develop innovative recruitment approaches.
View source
NHS North East London
Review growing CAMHS demand through the Mental Health, Learning Disability and Autism Collaborative transformation work.
View source
NHS North East London
Develop a business case for additional NELFT CAMHS funding to address increasing demand.
View source See 6 more actions
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AI-generated summary
Allison Vivian Jacome Aules · 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
Allison Aules was referred to a child and adolescent mental health service in May 2021 following concerns including self-harm, low mood and anxiety, but her referral was delayed and the eventual assessment was incomplete. She was discharged without a documented risk management plan, and was found suspended in her bedroom on 18 July 2022; the investigation states that she died on 19 July 2022 as a result of suicide, contributed to by neglect. The principal concerns were failings in care and the under-resourcing of CAMHS services, including delays in assessment and concern that continuing under-resourcing amid rising demand could result in similar deaths.
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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 Under-resourcing of CAMHS services
Wider context from the report “The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced .
The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern.
The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country.
There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams.
The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor.
The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week.
There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase) , will result in future similar deaths.
” Source location Allison Vivian Jacome Aules · 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 Increase the mental health workforce by 27,000 staff, with three quarters of the target delivered by December 2023.
Verbatim wording from the response “We are also making positive progress on our ambition to grow the mental health workforce by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this (around 20,800) by December 2023 with further growth expected to have been achieved once the full year figures for 2023/24 are available. In December 2023, there were nearly 149,000 full time equivalents in the mental health workforce. This is over 10,300 more (7.5% increase) since December 2022.” Source location Response from Department of Health and Social Care
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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 Attract, train, recruit, retain and reskill the current and future mental health workforce.
Verbatim wording from the response “We are committed to attracting, training, and recruiting the mental health workforce of the future as well as retaining and re-skilling our current workforce. We are also continuing to increase our education and training commissions (across all mental health training programmes) alongside continuing to develop new roles and using existing roles to transform service delivery and enhance service user experiences. The NHS aims to meet this commitment through a range of different training programmes, including:” Source location Response from Department of Health and Social Care
Open published response
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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 Continue increasing education and training commissions across mental health training programmes.
Verbatim wording from the response “We are committed to attracting, training, and recruiting the mental health workforce of the future as well as retaining and re-skilling our current workforce. We are also continuing to increase our education and training commissions (across all mental health training programmes) alongside continuing to develop new roles and using existing roles to transform service delivery and enhance service user experiences. The NHS aims to meet this commitment through a range of different training programmes, including:” Source location Response from Department of Health and Social Care
Open published response
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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 new mental health workforce roles and use existing roles to transform service delivery and improve service user experiences.
Verbatim wording from the response “We are committed to attracting, training, and recruiting the mental health workforce of the future as well as retaining and re-skilling our current workforce. We are also continuing to increase our education and training commissions (across all mental health training programmes) alongside continuing to develop new roles and using existing roles to transform service delivery and enhance service user experiences. The NHS aims to meet this commitment through a range of different training programmes, including:” Source location Response from Department of Health and Social Care
Open published response
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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 Increase investment in the children and young people’s mental health workforce to expand service capacity.
Verbatim wording from the response “Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. This commitment came with significant additional funding, rising to over £900m in 2023/24. We have made significant progress towards this commitment with 702,000 children and young people receiving support from the NHS in the 12 months to June 2023. This has been achieved through investment in the children and young people’s mental health workforce, which has increased by 46% since the start of the LTP, and by 70% since 2016.” Source location Response from NHS England
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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 a business case for additional CAMHS funding, including proposals for extended working and face-to-face initial assessments.
Verbatim wording from the response “• We are developing a business case to secure additional funding to support improved resourcing of CAMHS services within NELFT.” Source location Response from North East London Integrated Care Board
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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 Work with NELFT and other providers to support consultant psychiatrist recruitment and develop innovative recruitment approaches.
Verbatim wording from the response “• Recruitment of consultant psychiatrists is a national issue which we recognise locally. NHS North East London is working with NELFT and other providers to support recruitment and looking at innovative ways of recruiting. This work is being led by our Chief People and ████████
The growing demand in CAMHS referrals and the lack of capacity to deal with this.” Source location Response from North East London Integrated Care Board
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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 growing CAMHS demand through the Mental Health, Learning Disability and Autism Collaborative transformation work.
Verbatim wording from the response “• We recognise the growing demand in CAMHS services and this demand is being reviewed as part of the wider transformation work via our Mental Health, Learning Disability and Autism Collaborative” Source location Response from North East London Integrated Care Board
Open published response
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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 a business case for additional NELFT CAMHS funding to address increasing demand.
Verbatim wording from the response “• In the short term for CAMHS for NELFT we have developed a business case for more funding to support this demand.” Source location Response from North East London Integrated Care Board
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local support provision and related actions must be addressed by the relevant local commissioners and providers.
Verbatim wording from the response “This response focuses on the national NHS England policy and programmes relevant to the matters of concern you have identified in your Report. The concerns you have raised relating to the provision of local support and the actions taken in providing that support to Allison would need to be addressed by the relevant local commissioners and providers.” Source location Response from NHS England
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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 Delivery of expanded children’s mental health access and workforce ambitions is subject to future funding settlements.
Verbatim wording from the response “The NHS Long Term Workforce Plan (June 2023) sets out the importance of continued investment in the mental health workforce and in 2022, NHS England consulted on potential new access and waiting time standards including for children and young people’s mental health. Delivering these ambitions will be subject to future funding settlements and we will clarify plans in due course.” Source location Response from NHS England
Open published response
23 Jun 2023 Stephen Kurt Beadman · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Insufficient specialist psychiatric care for prisoners View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring 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
Stephen Kurt Beadman · 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
Stephen Kurt Beadman was a 34-year-old serving prisoner at HMP Wakefield who was found unresponsive after applying a ligature to his neck and died in hospital the following day. The Inquest found that he committed suicide having been bullied by other prisoners. The principal concern was that the prison’s limited consultant psychiatrist resource was insufficient for the complex mental health needs of its prisoner population, creating concern that other deaths may occur.
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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 Insufficient specialist psychiatric care for prisoners
Wider context from the report “2) Despite this complex cohort of prisoners, the prison only has one day per week of consultant psychiatrist resource . As the professed principle is equivalence of care with the community, this seems not to be achieved , particularly having regard to the psychological make up of the prisoner population.
3) Evidence taken at the Inquest indicated that further senior psychiatric doctor resource would enable the prison to provide better for the needs of the prisoners .
4) For the avoidance of doubt, it is accepted that Mr Beadman himself was able to see the consultant psychiatrist on 19th October 2021 for 1 hour and again on 25th January 2021 (at which time he was discharged). Notwithstanding that his death on 8th April 2021 cannot be attributed to a lack of psychiatric attention, there is a concern that other long-term inmates in the prison are not receiving the specialist care they probably need . This in turn gives rise to a concern that other deaths may occur.
” Source location Stephen Kurt Beadman · Prevention of Future Deaths report
Open source report
22 Jun 2023 Lucy Anne Walles · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Inadequate or unsafe resourcing of mental health services View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Berkshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Berkshire Healthcare NHS Foundation Trust
Complete the community mental health service reconfiguration bringing East and West services together to improve resilience and deploy resources safely.
View source
Berkshire Healthcare NHS Foundation Trust
Review community mental health service leadership to determine the appropriate operational support and workforce deployment across Berkshire.
View source
Berkshire Healthcare NHS Foundation Trust
Conduct caseload reviews to ensure patients are on appropriate pathways and receive evidence-based treatment and support.
View source
Berkshire Healthcare NHS Foundation Trust
Maintain the Nurse Consultant network to provide specialist support, education, research, development, complexity intervention, and workforce-capacity monitoring.
View source
Berkshire Healthcare NHS Foundation Trust
Provide monthly restorative supervision through trained professional nurse advocates to reduce burnout-related staff turnover.
View source
Berkshire Healthcare NHS Foundation Trust
Implement targeted recruitment, apprenticeships, university links, social media, and recruitment campaigns to strengthen the mental health workforce.
View source See 3 more actions
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AI-generated summary
Lucy Anne Walles · 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
Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.
Read the report on judiciary.uk
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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 Inadequate or unsafe resourcing of mental health services
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” Source location Lucy Anne Walles · Prevention of Future Deaths 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 Complete the community mental health service reconfiguration bringing East and West services together to improve resilience and deploy resources safely.
Verbatim wording from the response “• The reconfiguration of community mental health services as part of the One Team project seeks to ensure the resources we have are being utilised in the right place. Significant changes have already been made to bring the East and West services together to improve resilience and make best use of staff resources and expertise. The leadership of these services is currently under review with the aim of ensuring the right level of operational support is in place, and that staff can be mobilised across the whole of Berkshire, reducing unwanted variation and moving resource around as required making services safer.” Source location Response from Berkshire Healthcare NHS Foundation Trust
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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 community mental health service leadership to determine the appropriate operational support and workforce deployment across Berkshire.
Verbatim wording from the response “• The reconfiguration of community mental health services as part of the One Team project seeks to ensure the resources we have are being utilised in the right place. Significant changes have already been made to bring the East and West services together to improve resilience and make best use of staff resources and expertise. The leadership of these services is currently under review with the aim of ensuring the right level of operational support is in place, and that staff can be mobilised across the whole of Berkshire, reducing unwanted variation and moving resource around as required making services safer.” Source location Response from Berkshire Healthcare NHS Foundation Trust
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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 Conduct caseload reviews to ensure patients are on appropriate pathways and receive evidence-based treatment and support.
Verbatim wording from the response “• Case load reviews - Historically in all mental health services, patients would remain on CMHT caseloads for many years, which can impact significantly on safety as thresholds for acceptance and waits for CMHT due to capacity are directly linked to this. The review will increase resources available by ensuring people are on the correct pathway and receiving the correct evidence based treatment and support.” Source location Response from Berkshire Healthcare NHS Foundation Trust
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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 Maintain the Nurse Consultant network to provide specialist support, education, research, development, complexity intervention, and workforce-capacity monitoring.
Verbatim wording from the response “• A Nurse consultant network is also now in place; these are senior specialist roles that attract mental health nurses by providing an opportunity to practice in a senior clinical role, as well as having protected time to focus on education and research and a clear development pathway. The Nurse Consultants can also intervene when there is complexity, which helps with resourcing as staff are supported with caseload capacity and complexity. Nurse Consultants also have a role to play in monitoring workforce capacity to ensure safety.” Source location Response from Berkshire Healthcare NHS Foundation Trust
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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 Provide monthly restorative supervision through trained professional nurse advocates to reduce burnout-related staff turnover.
Verbatim wording from the response “• Utilising professional nurse advocates to provide staff with restorative supervision through dedicated staff trained as professional nurse advocates on a monthly basis, to reduce staff turnover as a result of burnout.” Source location Response from Berkshire Healthcare NHS Foundation Trust
Open published response
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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 Implement targeted recruitment, apprenticeships, university links, social media, and recruitment campaigns to strengthen the mental health workforce.
Verbatim wording from the response “• Human Resource initiatives to focus on recruitment include targeted recruitment, apprenticeship schemes, linking with universities, using social media and recruitment campaigns.” Source location Response from Berkshire Healthcare NHS Foundation Trust
Open published response
17 Feb 2023 Mr Twm Bryn · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 1
Insufficient Primary Mental Health Services staffing causing assessment and counselling support delays View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Betsi Cadwaladr University LHB
Run additional assessment clinics using overtime staffing to address sickness and vacancy-related shortfalls.
View source
Betsi Cadwaladr University LHB
Explore block-booking agency staff as a short-term measure to reduce assessment backlogs and restore performance-standard alignment.
View source
Betsi Cadwaladr University LHB
Review assessment appointment scheduling and consider administrative or non-registered staff for scheduling tasks.
View source
Betsi Cadwaladr University LHB
Discuss expanding counselling options in the West to increase capacity and reduce waiting times.
View source
Betsi Cadwaladr University LHB
Offer additional shifts to mental health staff in West and Central services to complete assessments.
View source
Betsi Cadwaladr University LHB
Run a divisional recruitment drive using an external specialist recruitment firm.
View source
Betsi Cadwaladr University LHB
Review LPMHSS job descriptions to assess amendments enabling recruitment of non-nursing care professionals.
View source See 4 more actions
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AI-generated summary
Mr Twm Bryn · 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 Twm Bryn died on 4 October 2021 in a shipping container near his home after suspending himself by the neck with a ligature. He had experienced mental health difficulties and was awaiting counselling after an assessment that identified a mild risk of suicide. The report raises concerns about delays and lengthy waiting lists for primary mental health support, and the lack of interim contact, monitoring or support for low-risk patients who are waiting for counselling.
Read the report on judiciary.uk
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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 Insufficient Primary Mental Health Services staffing causing assessment and counselling support delays
Wider context from the report “(1) Continued staffing pressures within Primary Mental Health Services resulting in assessment delays and waiting lists for support e.g the waiting list for LPMHSS counselling remains at 4 – 6 months . There was no evidence that the waiting list would improve moving forward .
” Source location Mr Twm Bryn · Prevention of Future Deaths 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 Run additional assessment clinics using overtime staffing to address sickness and vacancy-related shortfalls.
Verbatim wording from the response “Assessment clinics are planned utilising overtime staff to take into account any shortfall in staffing due to sickness absence and vacancies. There is a backlog of assessments despite this with the additional work only providing a short term maintenance position that is not sustainable in the longer term. We are exploring block booking of agency staff as a short term staffing solution to bring the service back into alignment with the Mental Health Measure performance standards.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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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 Explore block-booking agency staff as a short-term measure to reduce assessment backlogs and restore performance-standard alignment.
Verbatim wording from the response “Assessment clinics are planned utilising overtime staff to take into account any shortfall in staffing due to sickness absence and vacancies. There is a backlog of assessments despite this with the additional work only providing a short term maintenance position that is not sustainable in the longer term. We are exploring block booking of agency staff as a short term staffing solution to bring the service back into alignment with the Mental Health Measure performance standards.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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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 assessment appointment scheduling and consider administrative or non-registered staff for scheduling tasks.
Verbatim wording from the response “A scoping review is underway regarding scheduling of appointments for assessment, which has been found to take up a portion of time for clinical staff. Consideration is being given to administrative or non-registered staff performing this task, which would release more clinical time for assessments and interventions.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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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 Discuss expanding counselling options in the West to increase capacity and reduce waiting times.
Verbatim wording from the response “Discussions are in progress regarding expanding additional counselling options made available in the West. This will create more capacity for counselling and reduce waiting times.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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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 Offer additional shifts to mental health staff in West and Central services to complete assessments.
Verbatim wording from the response “The Service Managers for Community Mental Health Services have been directed to offer additional shifts to staff working in other mental health services in West and Central to complete assessments.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a divisional recruitment drive using an external specialist recruitment firm.
Verbatim wording from the response “Recognising the difficulty in recruiting to vacancies, as outlined earlier, a recruitment drive has been launched Divisionally using an external specialist firm, Just R Recruitment, to attract staff to the area. A review of job descriptions for LPMHSS is under way to consider what amendments would be required in order to recruit non-nursing care professionals such as Social Workers and Occupational Therapists, which would provide a wider scope of recruitment.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review LPMHSS job descriptions to assess amendments enabling recruitment of non-nursing care professionals.
Verbatim wording from the response “Recognising the difficulty in recruiting to vacancies, as outlined earlier, a recruitment drive has been launched Divisionally using an external specialist firm, Just R Recruitment, to attract staff to the area. A review of job descriptions for LPMHSS is under way to consider what amendments would be required in order to recruit non-nursing care professionals such as Social Workers and Occupational Therapists, which would provide a wider scope of recruitment.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Unfilled vacancies and recruitment difficulties limit the ability to reduce waiting lists, caseloads and delays in access to care.
Verbatim wording from the response “Any patients currently on waiting lists are supported by the duty teams whilst awaiting allocation. The waiting lists are due to currently unfilled vacancies that have been placed into recruitment but unfortunately not all have attracted candidates and have remained unfilled despite being advertised a number of times.” Source location Response from Betsi Cadwaladr University Health Board
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11 Jan 2023 Leroy Patrick HAMILTON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Lack of Psychiatric decisions unit spaces View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust Department of Health and Social Care NHS Birmingham and Solihull Integrated Care Board University Hospitals Birmingham NHS Foundation Trust West Midlands Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Support faster hospital discharge to reduce bed occupancy and A&E waiting times.
View source
Department of Health and Social Care
Provide funding to support adult social care and NHS discharges, including from mental health inpatient settings.
View source
Department of Health and Social Care
Develop and publish statutory guidance for discharge from mental health inpatient settings.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust and NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Use implemented processes to divert suitable patients from emergency departments to Psychiatric Decision Unit capacity.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust and NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Review the Psychiatric Decision Unit service, including higher-acuity capacity, access and onward-care pathways, and clinical support.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust and NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Explore alternative Psychiatric Decision Unit models to meet system need.
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Leroy Patrick HAMILTON · 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
Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.
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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 Psychiatric decisions unit spaces
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces : The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU . Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” Source location Leroy Patrick HAMILTON · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support faster hospital discharge to reduce bed occupancy and A&E waiting times.
Verbatim wording from the response “Regarding the lack of inpatient mental health beds and psychiatric decisions unit (PDU) spaces and the availability of ‘safe space’, we are supporting the NHS to take action to reduce waiting times in A&E, including through adding 5,000 more permanent general and acute beds, speeding up hospital discharge and increasing transparency and the available information on waiting times and the NHS’s progress in reducing them.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide funding to support adult social care and NHS discharges, including from mental health inpatient settings.
Verbatim wording from the response “To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, with the aim of reducing bed occupancy.” Source location Response from Department of Health and Social Care
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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 publish statutory guidance for discharge from mental health inpatient settings.
Verbatim wording from the response “The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use implemented processes to divert suitable patients from emergency departments to Psychiatric Decision Unit capacity.
Verbatim wording from the response “The Psychiatric Decision Unit (PDU) based at Oleaster Unit in BSMHFT, has been commissioned for patients who have capacity, are able to consent to attend the PDU and who are assessed as “low risk”. It is an ambulant assessment area which provides a calming environment for the assessment and development of treatment and pathway plans. As such it is not an admission area; it does not have beds within it. Like ED, there are no powers of detention for individuals accessing the PDU. There are six spaces (three male, three female) in the PDU. Processes implemented by the ICS help to divert suitable people to the PDU capacity rather than attendance at ED and the capacity is used regularly to take people from ED who meet the relevant criteria.” Source location Response from Birmingham and Solihull Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Psychiatric Decision Unit service, including higher-acuity capacity, access and onward-care pathways, and clinical support.
Verbatim wording from the response “However, it is recognised that review of the current PDU service is required; we need capacity that provides care for people with higher acuity of MH need, with clear pathways for access and onward care. As part of the review we will also be looking at the clinical support for PDU. As a system we recognise accessing help prior to coming to ED or PDU will be best for many patients.” Source location Response from Birmingham and Solihull Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore alternative Psychiatric Decision Unit models to meet system need.
Verbatim wording from the response “We recognise as an ICS that even with the introduction of the significant focus on pathways for individuals described above, the care for this group of people must remain a priority for us all. We have therefore established a system wide clinical oversight group to lead together this piece of work. This emphasizes joint ownership of care and pathways and will be a single liaison point with external agencies. Through the Mental Health Collaborative we are also ensuring that all work in this area is being streamlined and joined up under one programme linking clinical and operational elements along the whole pathway across all provider organisations. The clinical work programme includes an immediate adoption of jointly owned care standards across the pathway, with audit and learning against provided care, and exploration of different PDU models to meet ICS need.” Source location Response from Birmingham and Solihull Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning and operating psychiatric decisions units falls outside the police force’s functions and authority.
Verbatim wording from the response “Whereas the third, fourth and fifth of the Coroner’s concerns are pertinent to West Midlands Police (WMP), the first and second concerns relating to the Psychiatric Decisions Unit (PDU) are, in my view, pertinent to other addressees of the report, namely: (i) the Birmingham and Solihull Mental health NHS Foundation Trust; (ii) the Birmingham and Solihull Integrated Care Board; (iii) University Hospital Birmingham NHS Foundation Trust; and (iv) the Secretary of State for Health. WMP has no involvement in the commissioning and operation of the PDU. For these reasons, this response focuses on the third, fourth and fifth concerns identified by the Coroner.” Source location Response from West Midlands Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for psychiatric decisions unit beds and spaces rests with the named health bodies and Secretary of State for Health.
Verbatim wording from the response “Whereas the third, fourth and fifth of the Coroner’s concerns are pertinent to West Midlands Police (WMP), the first and second concerns relating to the Psychiatric Decisions Unit (PDU) are, in my view, pertinent to other addressees of the report, namely: (i) the Birmingham and Solihull Mental health NHS Foundation Trust; (ii) the Birmingham and Solihull Integrated Care Board; (iii) University Hospital Birmingham NHS Foundation Trust; and (iv) the Secretary of State for Health. WMP has no involvement in the commissioning and operation of the PDU. For these reasons, this response focuses on the third, fourth and fifth concerns identified by the Coroner.” Source location Response from West Midlands Police
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7 Aug 2022 Robyn Lily Audrey SKILTON · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Lack of resourcing and provision for young people’s mental health services 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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AI-generated summary
Robyn Lily Audrey SKILTON · 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
On 7 May 2021, 14-year-old Robyn Lily Audrey Skilton was found in Southwater Park with a ligature around her neck, and her death was confirmed by emergency services. The inquest concluded that Robyn took her own life while struggling with her mental health, and that mental health services failed to recognise the deterioration in her mental health or provide the care and treatment she required. The report raised concerns about delayed assessment and treatment, including a lack of timely access to Child Psychiatrist and CAMHS services and insufficient resourcing.
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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 resourcing and provision for young people’s mental health services
Wider context from the report “Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health . Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner.
I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn.
It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS).
By way of an example:-
Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761)
West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147)
West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494)
Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021).
Additionally, across Sussex CAMHS, as a whole, the referrals data shows:-
• May 2022 was the highest number of referrals the service has ever received (1350).
• Of those 1350 referrals, 80% (1,081) were accepted into the service.
• In comparison, in May 2019, 579 were accepted (65% accepted)
• So, an additional 502 young people have been accepted in May 2022 compared to May 2019
Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk.
” Source location Robyn Lily Audrey SKILTON · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand and strengthen the NHS mental health workforce, including adding 27,000 mental health professionals by 2023/24.
Verbatim wording from the response “Growth of the mental health workforce, as well as retaining and re-skilling our current workforce, is the key strategic priority to ensure we can deliver our commitments to expand services and increase access. This is why, through the Plan we are committed to expanding the NHS workforce, with an aim of having and additional 27,000 mental health professionals by 2023/24, to deliver the expansion and transformation of mental health services, including those for children and young people.” Source location Response from department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest additional funding to expand children’s mental health services and increase access to community and eating disorder services.
Verbatim wording from the response “This is why, in 2021/22 we provided an additional £79million to expand children’s mental health services, allowing around 22,500 more children and young people to access community health services, 2,000 more to access eating disorder services, as well as a faster increase in the coverage of mental health support teams in schools and colleges. There are currently 287 mental health support teams supporting schools and colleges, covering 20-25% of the country, with 13 planned or in operation across the Sussex integrated care system.” Source location Response from department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local commissioners are responsible for commissioning healthcare services that meet local population needs and expanding mental health services.
Verbatim wording from the response “A significant portion of this funding is provided through baseline funding to local commissioners (formerly clinical commissioning groups and now through the integrated care boards that replaced them). This is supporting them to deliver on their responsibilities to commission healthcare services that meet the needs of their local populations and to expand mental health services in line with the aims of the Long Term Plan and the NHS Mental Health Implementation Plan 2019/20 – 2023/24², which provides the framework for local delivery.” Source location Response from department of Health and Social Care
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1 Jul 2022 Dominic Robert Noble · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Insufficient availability of psychiatric doctor provision for the mentally unwell prison population 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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AI-generated summary
Dominic Robert Noble · 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
Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged referrals.
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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 Insufficient availability of psychiatric doctor provision for the mentally unwell prison population
Wider context from the report “(1) Evidence was taken at the inquest that:
(i) HMP Leeds has only 3 days per week of a psychiatrist's time available
(ii) HMP Leeds has some 5000 prisoners arriving each year.
(iii) A large proportion of the prisoners arriving have mental health issues
(iv) The mental health team is mainly a nurse-led service
(v) The division of labour between mental health nurses and psychiatrists is that a doctor is responsible for the diagnosis of mental illness, prescribing medication such as anti-psychic drugs and seeing prisoners/patients with severe or complex conditions. Mental health nurses make initial assessments and provide ongoing care.
(vi) Concern was expressed about the adequacy of the psychiatric doctor provision to provide psychiatric treatment for a large population which includes men with significant mental health issues.
(vii) Mr Noble was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given.
(viii) A mental health nurse working on behalf of PPG on 10 July 2020 identified the “possibility of emerging psychotic features” and noted the sentiment that engaging in treatment as soon as possible mitigated in favour of a better outcome. Where such a suspicion was raised it would have been advantageous to obtain a second opinion from a psychiatrist swiftly (particularly after his mother contacted the prison to report his paranoid and bizarre conversation regarding a gun, a secret room in the prison and some unknown person trying to kill him.)
” Source location Dominic Robert Noble · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Approach NHS England and discuss seeking additional psychology and psychiatry resource for HMP Leeds.
Verbatim wording from the response “Intended Changes
Following the Learned Coroner’s comments during the inquest into the death of Mr Afzal, ████████, Practice Plus Group’s Regional Director North – Health in Justice, began discussions with Commissioners at NHS England. Whilst Practice Plus Group maintains that the level of psychiatry provision is at least equivalent to that offered in the community, we also recognise that there are significant levels of mental health morbidity in prisons, particularly in a local remand setting such as HMP Leeds. The Learned Coroner’s comments and subsequent report have highlighted a potential need and we have therefore approached our Commissioners for additional resource.” Source location 2022-0204 - Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit a business case to Commissioners for increased psychology and psychiatry provision at HMP Leeds.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing stepped-care provision and multidisciplinary referral arrangements are considered sufficient to meet patients’ psychiatric needs at current levels.
Verbatim wording from the response “As in the community, Practice Plus Group delivers a stepped care model, which focuses on providing the most appropriate care for the concerns a patient may have. By adopting this model most people with mental health problems do not need to see a consultant psychiatrist. The stepped care model of mental health focuses on providing people with the right level of support from the right clinician at the right time. For example, people experiencing mild to moderate depression and anxiety would see a primary care mental health clinician in the community, alongside the GP, which is step 2/3.” Source location 2022-0204 - Response from Practice Plus Group
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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, as commissioner, is responsible for deciding whether additional psychology and psychiatry resources will be funded.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Even if additional funding is approved, recruitment difficulties may prevent immediate increases in psychiatric provision.
Verbatim wording from the response “HMP Leeds is a high demand remand site and we are seeking additional resource with the aim to improve the number of clinical sessions from 6 to 8 per week. In effect this means that HMP Leeds will need the equivalent of a half-time psychiatrist in addition to what is currently in place in order to achieve the additional clinical sessions. This is due to the non-patient facing time that all directly employed consultant psychiatrists working for Mental Health Trusts have in their contract. These activities include clinical administration tasks (e.g. letters and referrals), service development and training/development.” Source location 2022-0204 - Response from Practice Plus Group
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9 Jun 2022 Shirley Alice Moloney · Prevention of Future Deaths report East London
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Concerns raised 2
Insufficient resourcing of older age psychiatric teams View source Lack of older adult psychiatry resource for elderly patients View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Shirley Alice Moloney · 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
Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.
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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 Insufficient resourcing of older age psychiatric teams
Wider context from the report “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally . This is compounded by an absence of adequately trained staff, to address mental health in residential home settings. The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs.
” Source location Shirley Alice Moloney · Prevention of Future Deaths report
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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 older adult psychiatry resource for elderly patients
Wider context from the report “(v) As mental health and physical health are so closely inter-linked, the lack of older adult psychiatry resource for elderly patients , gives rise to a risk of future deaths.
” Source location Shirley Alice Moloney · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the mental-health workforce, including staffing capacity for community mental-health services for older adults.
Verbatim wording from the response “You have raised concerns around the resourcing of older age psychiatric teams. We recognise the need to increase capacity in NHS mental health services, including community mental health services for older adults, due to the increasing demand for services. The mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared with December 2020, and by over 11,800 compared to December 2010. However, we know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services for all ages. We therefore aim to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20).” Source location Response from Department of Health and Social Care
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.