Recurring concern

Unreliable access to specialist mental health treatment for serious mental illness

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First reported 30 Apr 2014•Latest report 6 Jul 2026

Definition

What this concern includes

Includes failures of arrangements dedicated to providing or securing specialist mental health assessment or treatment, including specialist hospital treatment, timely psychiatric input, diagnosis and treatment access, and provision for people whose mental health needs exceed available general or non-specialist care.

Not included

  • Excludes generic mental health service capacity, staffing or waiting-time concerns unless they directly impair access to specialist mental health assessment or treatment.
  • Excludes failures limited to a named crisis, referral, discharge, observation or care-coordination pathway where that pathway supplies the more specific supported concern.
  • Excludes failures in physical-health specialist input for mental health inpatients unless the asserted unsafe condition is access to specialist mental health treatment itself.
  • Excludes treatment-quality or clinical-decision failures occurring after appropriate specialist mental health treatment has been obtained.
Reports
14

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
21

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care5
NHS England5
Ministry of Justice4
HM Prison and Probation Service3
HM Inspectorate of Prisons2
Prisons and Probation Ombudsman2
Central and North West London NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Greater Manchester Mental Health NHS Foundation Trust1
Guys Marsh Prison1
Leeds Teaching Hospitals NHS Trust1
Ministry of Defence1
NHS South West London Integrated Care Board1
NHS Wirral Clinical Commissioning Group1
Nottinghamshire Healthcare NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Gateshead and South Tyneside

    AI-generated summary

    Scott Alan Taylor · 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

    Scott Alan Taylor, who had treatment-resistant obsessive compulsive disorder and was receiving community treatment, died by suicide on 12 May 2023. The report raises concerns about the limited number, geographical concentration, access criteria and capacity of tertiary services for patients with treatment-resistant OCD, including a reported waiting list of over 12–15 months.

    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

    Geographic concentration of tertiary specialist services for treatment-resistant OCD

    Wider context from the report

    “At the time of writing this report it appears that only a small number of tertiary centres able to care for patients with treatment resistant OCD exist in the United Kingdom. They appear to be located in London and the South East. The criteria to access these services and the limited capacity they have, it seems prevents clinicians treating patients being able to call upon specialist services that a tertiary centre/s can provide to they patients. Particularly, where a patient’s case is complex and resistant to all that primary and secondary care services can offer in terms of treatment. These centres are also not located across the whole of the United Kingdom for ease of access for those patients not residing in the immediate locality of the current centres. ”

    Source location

    Scott Alan Taylor · Prevention of Future Deaths report
    Page 3 · 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

    Restrictive criteria for access to tertiary specialist services for treatment-resistant OCD

    Wider context from the report

    “At the time of writing this report it appears that only a small number of tertiary centres able to care for patients with treatment resistant OCD exist in the United Kingdom. They appear to be located in London and the South East. The criteria to access these services and the limited capacity they have, it seems prevents clinicians treating patients being able to call upon specialist services that a tertiary centre/s can provide to they patients. Particularly, where a patient’s case is complex and resistant to all that primary and secondary care services can offer in terms of treatment. These centres are also not located across the whole of the United Kingdom for ease of access for those patients not residing in the immediate locality of the current centres. ”

    Source location

    Scott Alan Taylor · 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

    Commissioning specialist tertiary OCD care is assigned to ICBs, overseen by NHS England, which will provide the response.

    Verbatim wording from the response

    “Responsibility for the commissioning of specialist tertiary care for the treatment of OCD sits with Integrated Care Boards (ICBs) which are overseen by NHS England.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 2 September 2026

    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

    Highly specialised OCD/BDD care cannot feasibly be provided through specialist centres in every region or general healthcare settings.

    Verbatim wording from the response

    “It is correct to note that all five specialist centres are concentrated in the South East region, with four of them located in London. This distribution is not a deliberate policy choice but reflects the availability of providers with the necessary expertise to deliver this highly specialised care. While this concentration allows for the delivery of high quality, evidence-based treatment from recognised centres of excellence, it may pose challenges in terms of access for patients located in other regions of England. This geographic concentration underscores the importance of ongoing collaboration with local mental health services to manage care coordination and ensure equitable access.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 2 September 2026

    Open published response

  2. Milton Keynes

    AI-generated summary

    Ronald William MEIKLE · 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

    Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

    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

    Delays or insufficiency in psychiatric assessment and proactive mental health review

    Wider context from the report

    “Concern 8: Delay or insufficiency in mental health and psychiatric input The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review. Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and death. ”

    Source location

    Ronald William MEIKLE · 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

    Improve waiting-list management by setting escalation thresholds, increasing remote clinics and reviewing priority weekly by clinical risk and waiting time.

    Verbatim wording from the response

    “Concern 8: Delay or insufficiency of mental health and psychiatric input We have worked on our waiting list management, setting clearer escalation thresholds, and increasing the use of remote clinics. The mental health and clinical leads review waiting lists every week and prioritise patients based on clinical risk and time waiting to ensure timely assessment and follow-up. We have also expanded clinical capacity by introducing advanced clinical practitioner roles to support routine reviews, while escalating more complex cases directly to consultant psychiatrists. Recruiting to substantive consultant posts remains a key priority for the service.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Expand clinical capacity through advanced clinical practitioner roles for routine reviews and direct escalation of complex cases to consultant psychiatrists.

    Verbatim wording from the response

    “Concern 8: Delay or insufficiency of mental health and psychiatric input We have worked on our waiting list management, setting clearer escalation thresholds, and increasing the use of remote clinics. The mental health and clinical leads review waiting lists every week and prioritise patients based on clinical risk and time waiting to ensure timely assessment and follow-up. We have also expanded clinical capacity by introducing advanced clinical practitioner roles to support routine reviews, while escalating more complex cases directly to consultant psychiatrists. Recruiting to substantive consultant posts remains a key priority for the service.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

    Open published response

  3. Cheshire

    AI-generated summary

    Sarah Frances BOYLE · 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

    Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.

    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

    Delays in transferring women requiring mental health inpatient treatment

    Wider context from the report

    “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths. My concerns are based on the following points which I heard in evidence: • HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in; • I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting; • It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025); • I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents; • The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed; • The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed; • Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training. The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”. In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest. ”

    Source location

    Sarah Frances BOYLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Surrey

    AI-generated summary

    Locket Ure Williams · 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

    Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.

    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

    Inability of in-county psychiatric in-patient provision to treat children with eating disorders or needing psychiatric intensive care

    Wider context from the report

    “Concern 1 The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all. At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care. ”

    Source location

    Locket Ure Williams · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. South Wales Central

    AI-generated summary

    Isobel Lilian Stapleton · 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

    Isobel Lilian Stapleton, aged 32, was admitted to hospital for assessment and discharged to her father’s home with home treatment support. On 9 July 2022, she sustained likely self-inflicted injuries at home and died despite paramedic attendance; the inquest concluded that she died from suicide. Concerns included limited access to complete clinical records and a lack of clinical psychologist access for inpatient and home treatment teams, with psychotherapy waiting lists lasting months.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unavailability of clinical psychologist access for direct inpatient assessment and treatment at Royal Glamorgan Hospital

    Wider context from the report

    “(4) The inpatient hospital team at the Royal Glamorgan Hospital did and does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. ”

    Source location

    Isobel Lilian Stapleton · 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

    Provide psychological-professional sessions to the Royal Glamorgan Hospital mental-health unit.

    Verbatim wording from the response

    “There is no designated clinical psychology provision for the Royal Glamorgan Hospital Mental health Unit (RGH MHU). In an attempt to mitigate this, the following has been put in place:”

    Source location

    Response from Cwm Taf Morgannwg University Health Board
    Page 4 · response
    Published 27 June 2024

    Open published response

  6. Dorset

    AI-generated summary

    Frazer Charlie Williams · 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

    Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior 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

    Delays in transferring prisoners requiring mental health hospital admission

    Wider context from the report

    “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital. ”

    Source location

    Frazer Charlie Williams · Prevention of Future Deaths report
    Page 6 · 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

    Work with NHS England and His Majesty’s Prison and Probation Service to respond to concerns about delays transferring mentally unwell prisoners to hospital.

    Verbatim wording from the response

    “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the response to the thematic review and monitor progress in addressing delays transferring mentally unwell prisoners to hospital.

    Verbatim wording from the response

    “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 June 2024

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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

    Introduce the Mental Health Bill during the current Parliamentary session.

    Verbatim wording from the response

    “In addition to this, the Mental Health Bill will be introduced in this Parliamentary session. The Bill sets out vital reforms to support people with severe mental illness in the criminal justice”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 June 2024

    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

    Respond directly to concerns identified in the thematic review of delays transferring mentally unwell prisoners.

    Verbatim wording from the response

    “I would like to reassure you that NHS England consistently strives for equality in mental health healthcare provision. To address the specific concerns about Frazer’s care, there are several cross party workstreams underway.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 June 2024

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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

    Use a clinical template to record and monitor referrals, assessments and transfers under sections 47 and 48 of the Mental Health Act.

    Verbatim wording from the response

    “A new clinical template for improving data collection and monitoring has been developed and is now in place, to record the referral, assessment and transfer process for prisoners and detainees, under sections 47 and 48 of the Mental Health Act (MHA)”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 June 2024

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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

    Gather transfer-timeliness data and work with commissioners to improve the quality and completeness of existing data collection.

    Verbatim wording from the response

    “1983. This template is for use within the health and justice information system (HJIS) in prisons (current SystemOne). NHS England is working to use the information generated to gather data on the timeliness of transfers, whilst also proactively working with Health and Justice commissioners to improve data quality and completeness of existing manual collection.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 June 2024

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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 mental health pathway processes, communication and information sharing, then develop a proposed pathway and programme plan addressing identified gaps and priorities.

    Verbatim wording from the response

    “A review of processes, communication and information sharing around mental health concerns is also underway and will be completed by February 2025. This review is calling “Health and Justice Mental Health Pathway”. Work on the development of a Mental Health Pathway aims to:”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 June 2024

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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 leads the response to delays transferring mentally unwell prisoners to hospital, with the Department reviewing progress.

    Verbatim wording from the response

    “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 June 2024

    Open published response

  7. West Yorkshire Eastern

    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.

    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 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
    Page 1 · concerns

    Open source report

  8. Derby and Derbyshire

    AI-generated summary

    Jonathan “Jonny” Philip Cole [JC] · 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

    Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s 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

    Insufficient availability of psychiatrists and psychologists accessible to serving personnel

    Wider context from the report

    “1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel. This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis. ”

    Source location

    Jonathan “Jonny” Philip Cole [JC] · 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

    Expand mental-health recruitment advertising beyond NHS Jobs through targeted adverts and strengthened communication of the employment offer.

    Verbatim wording from the response

    “This picture presents a challenge to Defence. In response, the DMS has instituted a number of projects under its transformation portfolio that aim to improve the employment offer, maximise retention and ensure the workforce is efficiently used.”

    Source location

    Response from Ministry of Defence
    Page 4 · response
    Published 12 June 2023

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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

    Establish and develop the Defence Health Care Recovery Group to integrate and oversee mental-health, occupational-health and rehabilitation delivery.

    Verbatim wording from the response

    “The Defence Health Care Recovery Group (DHRG) is a new organisation, working to HQ Defence Primary Healthcare (DPHC)⁹, which will provide direct oversight and integration of Mental Healthcare (MH), Occupational Health (OH) and Rehabilitation delivery. The HQ element of DHRG reached Initial Operating Capability in Oct 2022, with a projected Full Operating Capability in Mar 2024. DHRG’s role is to transform extant Mental Health Delivery Services to ensure:”

    Source location

    Response from Ministry of Defence
    Page 4 · response
    Published 12 June 2023

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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

    Deliver the Mental Health Service Improvement Project, including piloting a new care pathway and developing workforce-management and integrated-data processes.

    Verbatim wording from the response

    “In conjunction with the activity above, a DMS Mental Health Service Improvement Project (MHIP) commenced in May 23 and is projected to be completed by Dec 24. It will be led by Commander DHRG and is designed to achieve the following:”

    Source location

    Response from Ministry of Defence
    Page 4 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement Unified Career Management (Medical) for all Defence mental-health personnel to improve workforce planning and prioritisation.

    Verbatim wording from the response

    “The final body of work of relevance to this concern is the Unified Career Management (Medical) (UCM (Med)) which has been introduced within Defence. All DMS mental health personnel were moved to this model on 01 Jul 23. This system enables DMS, through Strategic Command, to manage the workforce across the three services, resulting in a more agile and informed approach to workforce planning which will lead to a greater ability to mutually support and proactively prioritise workforce gapping where it exists.”

    Source location

    Response from Ministry of Defence
    Page 5 · response
    Published 12 June 2023

    Open published response

  9. Inner West London

    AI-generated summary

    Mrs Elsie Leaver · 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

    Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.

    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 formal psychiatric liaison cover at QMH

    Wider context from the report

    “4. That NHS South West London Integrated Care Board has made no formal provision for psychiatric liaison cover at QMH, despite there being such a clear clinical need for this that the team from psychiatric liaison have felt compelled to provide informal telephone advice for the last 10 years. ”

    Source location

    Mrs Elsie Leaver · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  10. Manchester (North)

    AI-generated summary

    Dominic Adam Travis · 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 Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.

    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 specialist inpatient provision for young adults with mental health problems

    Wider context from the report

    “1. Department of Health: Dominic was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-65. Given: i) the very stark differences between the mental health needs of younger adults and older adults, ii) an overall increase in the levels of vulnerability in such young people (by virtue of their age, condition, varying levels of maturity etc.), iii) that acute psychiatric ward environments often care for older adult patients with profound and enduring mental health problems (that are extremely frightening to the younger adult inpatient) & iv) the very different mental health requirements of young people, I am concerned that the needs of the latter are not being appropriately or adequately met, in the absence of specialist/specialist inpatient provision. The vulnerability of young adults is clearly recognised and acknowledged in other areas such as young offenders under the age of 21 who are sentenced to YOI establishments rather than being sent to an adult prison, however no such recognition appears to exist in relation to young adults with mental health problems. ”

    Source location

    Dominic Adam Travis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026