Recurring concern

Unreliable inter-agency information sharing for coordinated care

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First reported 29 May 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures of the inter-agency care information-sharing system, including inadequate arrangements, communication channels, shared records or contact mechanisms when these prevent timely access to relevant care, needs or risk information between agencies.

Not included

Excludes information-sharing failures unrelated to coordination between agencies supporting a person.
Excludes failures confined to a single organisation's records, assessment, documentation or communication process unless the report directly links them to inter-agency information sharing.
Excludes generic staffing, confidentiality, policy or technology deficiencies that are not specifically tied to the unsafe inter-agency information-sharing condition.
Excludes hazards involving public access to harmful information or physical communication and rescue equipment.

Reports: 212
Individual concerns: 235
Date range: 2013–2026
Stated actions: 492

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care57

NHS England39

Ministry of Justice14

Home Office11

Greater Manchester Health and Social Care Partnership9

HM Prison and Probation Service8

NHS Greater Manchester Integrated Care Board8

Care Quality Commission7

Greater Manchester Mental Health NHS Foundation Trust7

Birmingham and Solihull Mental Health NHS Foundation Trust6

Metropolitan Police Service6

College of Policing5

Greater Manchester Police5

Midlands Partnership University NHS Foundation Trust5

Pennine Care NHS Foundation Trust5

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.

12 Jul2022
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Failure of communication and information sharing between Primary Mental Health Services and Tier 2 therapy providers
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kieran Joseph Kevan CRIMMINS · 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

Kieran Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of communication and information sharing between Primary Mental Health Services and Tier 2 therapy providers
Wider context from the report
“(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies. My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy. ”
Source location
Kieran Joseph Kevan CRIMMINS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
27 Jun2022
East London
Concerns raised1
1. Failure to share dependence information with the mental health trust
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Commence more proactive referral of patients appearing dependent on Z-Drug hypnotics to specialist mental-health services for review and advice.
  Stated by High Street SurgeryStated in progress
AI-generated summary

Michael John Vince · 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

Michael John Vince, a patient of the community mental health team receiving treatment for schizo-affective disorder, was found deceased at home on 19 June 2021 after apparently taking an overdose. The concerns included prolonged prescribing of medication for insomnia, lack of meaningful prescription review, failure to share evidence of dependence, and failure to monitor the frequency of PRN administration.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share dependence information with the mental health trust
Wider context from the report
“3. Evidence of Mr Vince’s dependence upon ████████ was not shared by his GP with the mental health trust. ”
Source location
Michael John Vince · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Commence more proactive referral of patients appearing dependent on Z-Drug hypnotics to specialist mental-health services for review and advice.

Verbatim wording from the response
“For my part, I have commenced more proactive referral of patients who appear dependent upon Z-Drug hypnotics for review and advice by specialist NELFT Mental Health services. This has been assisted by the response of the NELFT to the Coronal recommendations and the discussion and collaboration that has resulted. My practice’s Z-Drug Protocol includes a requirement for structured medication review for patients on long term Z-Drugs with mental health issues, and a requirement to notify the Mental Health Team for those patients who request additional Z drugs.”

Source location
Response from High St Surgery
Page 3 · response
Published 23 September 2022
Open published response
27 Jun2022
East Riding and Hull
Concerns raised2
1. Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people
2. Unavailability of a shared database for agencies to input common concerns
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The Home Office and Department of Health and Social Care hold responsibility for the majority of concerns and lead related recommendations.
  Stated by Ministry of JusticeRedirects responsibility
AI-generated summary

Jessica Louise LAVERACK “Jessie” · 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

Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.

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 a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people
Wider context from the report
“(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse. a. There is no one database which is accessible for all agencies to input their common concerns. b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable. It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues. ”
Source location
Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of a shared database for agencies to input common concerns
Wider context from the report
“(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse. a. There is no one database which is accessible for all agencies to input their common concerns. b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable. It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues. ”
Source location
Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Home Office and Department of Health and Social Care hold responsibility for the majority of concerns and lead related recommendations.

Verbatim wording from the response
“Responsibility for the majority of the concerns raised in your report sits with the Home Office and Department of Health and Social Care and we have seen and support the response that the Home Office sent you on 23rd August. However, we have separately considered the third concern in your Report where you refer to a lack of information sharing between agencies, including no singular database for all agencies to input common concerns and a lack of robust policy of information sharing regarding both suicidal ideation, self-harm as well as identification of the vulnerable.”

Source location
Response from Ministry of Justice
Page 1 · response
Published 3 November 2022
Open published response
17 Jun2022
Blackpool and the Fylde
Concerns raised1
1. Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Review the format of the overview document to improve how risk information is presented.
  Stated by Lancashire County CouncilStated in progress
2. Action
  Meet and continue working with the relevant NHS Trusts to improve discharge information and systems.
  Stated by Lancashire County CouncilStated in progress
3. Action
  Attend a cross-organisational meeting to consider alignment of communication and information-sharing expectations with LSCFT.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
1. Action
  Hold a further meeting with LSCFT and LCC to consider continuity and safety of communication and information sharing.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
2. Action
  Collaborate with LSCFT and LCC to examine the transfer policy and its interface with acute trusts and local authorities.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
3. Action
  Cascade respective organisational expectations to matrons, ward managers and consultant groups, including requirements for communicating suicide-risk information.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
Respondent positions 4
1. Position
  Existing assessment, risk management, information sharing and placement arrangements were considered adequate, requiring no specific corrective action.
  Stated by Lancashire County CouncilExisting arrangements considered sufficient
1. Position
  System or process changes for identifying suicide risk should originate with LSCFT and be cascaded to acute trusts and local authorities.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustRedirects responsibility
2. Position
  BTHFT proposes no change to its internal processes because existing inter-hospital transfer practice requires sharing key medical and mental health information.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficient
3. Position
  Local authorities and the Clinical Commissioning Group have primary responsibility for Mental Health Act section 117 aftercare arrangements.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustRedirects responsibility
AI-generated summary

Margaret Florence Joyce Stringer · 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

Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers
Wider context from the report
“3) (Addressed to Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited (the latter referred to collectively as ‘Nightingales’)) The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs Stringer’s risk of suicide. They included the following: i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review; ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge to Nightingales and for the family to have been invited, to ensure that everyone was aware of the plan, that the family was aware of Mrs Stringer’s legal status and to discuss next steps in terms of liaison with other services; iii. There should have been greater professional curiosity and better communication at the time of transfer; iv. The Harbour mental health hospital’s RNNA should have been reviewed to determine whether it needed to be updated and it should have been updated if there was any different clinical information. Further self harm or suicidal ideation, if seen to be significant, should have given rise to a further RNNA; v. There had, in fact, been further indications of self harm and suicidal ideation and, in any event, of a wish to die, on 30th June 2020, in August 2020 and on 3rd September 2020 which were significant and should have been addressed in the information provided to Nightingales and had not been; vi. Mrs Stringer was discharged from The Harbour mental health hospital without an up-to-date Care Act Assessment and, in any event, taking into account the need for Mrs Stringer to be transferred to the acute hospital (which had been necessary), an up-to-date Care Act Assessment had not been completed during the period of her admission to the latter hospital; vii. The risk assessment should have been completed and provided to Nightingales; viii. A positive behaviour support plan should have been completed and provided to Nightingales; ix. A care plan, compliant with CPA Policy and Procedures Key Standard 10, which should have identified a suitable environment in which to manage Mrs Stringer’s risk, her needs and mental health and crisis and contingency planning, to cater for the event of a significant relapse in her mental health, should have been completed and provided to Nightingales; x. Risk behaviour should have been identified to Nightingales and context given, whereas that had not been the case in respect of certain behaviour, including the incident on 30th June 2020; xi. The care coordinator should have been better informed at the points of transfer and discharge; xii. There should have been more robust follow up by the care coordinator whilst Mrs Stringer was at the acute hospital; xiii. There had been no mental health service involvement between the 7-day follow up and 28th September 2020 or, if there had, it had not been recorded; xiv. During the COVID-19 pandemic, it was not possible for a manager to carry out a face-to-face assessment in the mental health hospital but no equivalent measure had been implemented; xv) Whereas it would have been helpful for Nightingales to have received the Continuing Healthcare Checklist, it had not been provided; xvi) Nightingales would have wished to see the risk of suicide referred to in the “Risks to the Service User” section of the FACE Overview Assessment; xvii) The court appointed expert had concerns about the accessibility of key information in the FACE Overview Assessment given the format of that document. Whereas the court heard evidence concerning subsequent, significant, purposeful, developments in practice, the matters listed above can be condensed into a single concern that there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned. ”
Source location
Margaret Florence Joyce Stringer · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the format of the overview document to improve how risk information is presented.

Verbatim wording from the response
“xvii - the format of this document will be reviewed, but it has a clear heading “risk” with a subdivision re self-harm/injury described as “serious apparent risk” and details of risk setting out mental health deterioration and attempts to kill herself (A1253). The review is taking place in line with the adoption of a strength based approach framework which has started and is planned to be rolled out across all Adult Social Care teams within the next 18 months. The Local Authority would question the proportionality of using Reg 28 in respect of a detail such as the format of a particular document.”

Source location
Response from Adult Community Social Care
Page 3 · response
Published 21 September 2022
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
Meet and continue working with the relevant NHS Trusts to improve discharge information and systems.

Verbatim wording from the response
“Hospitals NHS Foundation Trust in ensuring that their provision of information and systems at discharge are as effective as possible, LCC have agreed to meet with and will continue to work with the Trusts in the future.”

Source location
Response from Adult Community Social Care
Page 4 · response
Published 21 September 2022
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
Attend a cross-organisational meeting to consider alignment of communication and information-sharing expectations with LSCFT.

Verbatim wording from the response
“I, as BTHFT’s Executive Medical Director, together with the Clinical Lead for Discharge Services and Interim Head of Legal Services, have attended a meeting with LSCFT, to consider whether expectations are aligned for the continuity and safety of communication and information sharing between our organisations. A further meeting is proposed in September, to include LCC.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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
Hold a further meeting with LSCFT and LCC to consider continuity and safety of communication and information sharing.

Verbatim wording from the response
“I, as BTHFT’s Executive Medical Director, together with the Clinical Lead for Discharge Services and Interim Head of Legal Services, have attended a meeting with LSCFT, to consider whether expectations are aligned for the continuity and safety of communication and information sharing between our organisations. A further meeting is proposed in September, to include LCC.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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
Collaborate with LSCFT and LCC to examine the transfer policy and its interface with acute trusts and local authorities.

Verbatim wording from the response
“BTHFT has also been provided with a copy of a policy prepared by LSCFT; the Admission, Discharge and Transfer of Care Policy and Procedure, which provides LSCFT clinical staff with guidance on the admission, discharge, transfer and hand over of patients between wards, teams and services whether they are within LSCFT or other service/private providers.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Cascade respective organisational expectations to matrons, ward managers and consultant groups, including requirements for communicating suicide-risk information.

Verbatim wording from the response
“BTHFT will collaborate with LSCFT and LCC to examine this LSCFT policy, and the interface with Acute Trusts and Local Authorities. We will cascade to the Matron, ward manager and consultant groups, what is expected of the respective organisations; to ensure that all relevant information, including suicide risk, is known, managed and communicated.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing assessment, risk management, information sharing and placement arrangements were considered adequate, requiring no specific corrective action.

Verbatim wording from the response
“vi - an Assessment was available at discharge and this was provided to Nightingale prior to them accepting Mrs Stringer. The social worker was not able to see Mrs Stringer in BVH due to Covid restrictions. The placement at Nightingale was “for assessment” (A1264);”

Source location
Response from Adult Community Social Care
Page 2 · response
Published 21 September 2022
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
System or process changes for identifying suicide risk should originate with LSCFT and be cascaded to acute trusts and local authorities.

Verbatim wording from the response
“BTHFT is one of many acute hospitals across this region which will interface with LSCFT for inter-hospital referrals and transfers. Similarly, it will interface with a number of local authorities who are making s.117 arrangements for patients previously admitted to LSCFT. LSCFT also provides a Mental Health Liaison Team service for BTHFT patients. The Trust respectfully submits that any system or process change for the sufficient identification of suicide risk should originate in LSCFT for their patients, to be cascaded and embedded with Acute Trusts and Local Authorities in the region.”

Source location
Response from Blackpool Teaching Hospitals
Page 1 · response
Published 21 September 2022
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
BTHFT proposes no change to its internal processes because existing inter-hospital transfer practice requires sharing key medical and mental health information.

Verbatim wording from the response
“In relation to BTHFT’s internal process and protocol for the management of patients admitted from a mental health facility, and/or in relation to the Trust’s contribution to the Mental Health Act (MHA) s.117 aftercare arrangements (which are the primary responsibility of the local authority and Clinical Commissioning Group, there is nothing BTH would propose to change at this point. The expectation and standard practice is that in inter-hospital transfers, the transferring hospital should always provide the receiving hospital with key medical and mental health information, together with contact details for the referring clinician, for ongoing communication. The provided mental health information can then be included in the Registered Nursing Needs Assessment, in addition to the medical aspects, to feed into the MHA s.117 aftercare arrangements.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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
Local authorities and the Clinical Commissioning Group have primary responsibility for Mental Health Act section 117 aftercare arrangements.

Verbatim wording from the response
“In relation to BTHFT’s internal process and protocol for the management of patients admitted from a mental health facility, and/or in relation to the Trust’s contribution to the Mental Health Act (MHA) s.117 aftercare arrangements (which are the primary responsibility of the local authority and Clinical Commissioning Group, there is nothing BTH would propose to change at this point. The expectation and standard practice is that in inter-hospital transfers, the transferring hospital should always provide the receiving hospital with key medical and mental health information, together with contact details for the referring clinician, for ongoing communication. The provided mental health information can then be included in the Registered Nursing Needs Assessment, in addition to the medical aspects, to feed into the MHA s.117 aftercare arrangements.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
Open published response
16 Jun2022
West Sussex
Concerns raised1
1. Failure to communicate specialist referral priorities to local hospitals
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

James Joseph MANNING · 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

James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate specialist referral priorities to local hospitals
Wider context from the report
“d) I also heard evidence to suggest that locally devised priorities agreed in specialist or tertiary centres (in this case the Royal Sussex County Hospital, Brighton) had not been communicated to local hospitals and shared so that doctors making a referral can consider the best place to refer a case taking into consideration relative waiting times. ”
Source location
James Joseph MANNING · Prevention of Future Deaths report
Page 3 · concerns
Open source report
1 Jun2022
West London
Concerns raised1
1. Lack of a shared regional system for cross-site sharing of radiology images
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Support Imaging Networks to mature shared access to imaging histories, reports and images across organisations.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  Individual Imaging Networks are responsible for assessing their maturity and implementing network-level imaging-sharing plans.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Angela Maguire · 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

Angela Maguire deteriorated after being referred for investigation of suspected malignancy and died in Kingston Hospital on 8 April 2021 following an upper gastrointestinal bleed. The report identified the lack of a shared regional system for accessing radiology images, which meant Kingston Hospital could not access previous images from Queen Mary's Hospital; this resulted in missed opportunities for diagnosis and palliative care, although it did not affect the outcome in this case.

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 a shared regional system for cross-site sharing of radiology images
Wider context from the report
“The clinicians assisting with the inquest advised the court that there was no system to share radiology across the Region. In West London, patients are frequently transferred from hospitals to access particular specialisms of care, such as cancer care. In this case, the previous images taken at Queen Mary's Hospital, London, could not be accessed across a common link by Kingston Hospital, Surrey and therefore the opportunity was missed to see and compare previous images. While this did not have an impact on the outcome in this case, it could have very significant consequences and lead to missed diagnoses and potentially fatal outcomes of untreated disease processes. In this case the opportunity to offer palliative care and ease the relatives of end of life treatment was lost. The lack of a shared portal also creates further work for clinicians who have to contact the previous hospitals to access this information. There are many shared systems in place in the NHS for cross-site sharing of images and reports, and it was not clear from those assisting the court at this inquest why similar systems are not currently in place for this Region and not anticipated for “several more years”. ”
Source location
Angela Maguire · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Support Imaging Networks to mature shared access to imaging histories, reports and images across organisations.

Verbatim wording from the response
“The NHS Long Term Plan committed to establishing Imaging Networks across England by 2023. Currently, the 22 Imaging Networks across England are being supported to increase their maturity, with a specific focus on the sharing of imaging history, reports and the images themselves.”

Source location
Response from NHS England
Page 1 · response
Published 16 September 2022
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
Individual Imaging Networks are responsible for assessing their maturity and implementing network-level imaging-sharing plans.

Verbatim wording from the response
“Each Imaging Network is responsible for assessing their own maturity against a maturity matrix, with the aim of having 70% at a “Maturing” level by the end of the financial year 2024/5. By reaching a “Maturing” level, this means that the Networks will be “jointly working across the Network with the implementation of a network level plan underway”.”

Source location
Response from NHS England
Page 2 · response
Published 16 September 2022
Open published response
30 May2022
Derby and Derbyshire
Concerns raised1
1. Failure to make systematic enquiries for care plans and other relevant documentation between agencies
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Develop, approve and disseminate urgent communications asking care homes to use red bags and revising transfer guidance where bags are unavailable.
  Stated by Derbyshire County CouncilStated completed
2. Action
  Agree acute-trust actions for robust handover communications and investigation of red-bag contents when care homes use them.
  Stated by Derbyshire County CouncilStated completed
3. Action
  Implement an interim transfer document for transfers between care homes and hospitals pending the digital solution.
  Stated by Derbyshire County CouncilStated planned
1. Action
  Review the urgent-transfer information standard and liaise with digital-transformation leads to expedite an integrated care system digital-standards initiative.
  Stated by Derbyshire County CouncilStated planned
2. Action
  Meet hospital nursing directors to agree internal actions for robust handover communications in emergency departments and wards.
  Stated by NHS Derby and Derbyshire Integrated Care Board / Joined Up Care DerbyshireStated completed
3. Action
  Implement an interim care-home-to-hospital and hospital-to-care-home transfer document and complete its full rollout by September 2022.
  Stated by NHS Derby and Derbyshire Integrated Care Board / Joined Up Care DerbyshireStated in progress
4. Action
  Incorporate monitoring of care-home transfer documentation into routine Local Authority and ICB Care Home Quality Team monitoring.
  Stated by NHS Derby and Derbyshire Integrated Care Board / Joined Up Care DerbyshireStated planned
5. Action
  Review the urgent care-home-to-hospital transfer information standard.
  Stated by NHS Derby and Derbyshire Integrated Care Board / Joined Up Care DerbyshireStatus unclear
6. Action
  Establish links with local NHS and Local Authority digital transformation leads through the Digital Social Care Records workstream.
  Stated by NHS Derby and Derbyshire Integrated Care Board / Joined Up Care DerbyshireStated completed
AI-generated summary

Mark SUMNALL · 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

Mark Sumnall died in hospital on the morning of 21 December 2020 after choking and aspirating on a sandwich given by hospital staff. He had a recognised choking risk, but hospital staff were not aware of it despite his care plan being sent with him in a Red Bag. The report raised concerns about failures to identify and use the Red Bag and to transfer relevant care and risk information between the care home, ambulance service and hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to make systematic enquiries for care plans and other relevant documentation between agencies
Wider context from the report
“The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall's inquest: - 1. The scheme does not appear to be widely used in Derbyshire, although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises, and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags. 2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information. This being the case it appears to me that there is lack of awareness of how the bag should be used, but also, as no enquiries were separately made for care plan and other relevant documentation, that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies. ”
Source location
Mark SUMNALL · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop, approve and disseminate urgent communications asking care homes to use red bags and revising transfer guidance where bags are unavailable.

Verbatim wording from the response
“1. Develop, approve and disseminate urgent communications to care homes asking them to utilise red bags where they have them. Review previous guidance on the scheme and revise and develop guidance on formal communication and handover requirements when transferring a resident to hospital where they do not have a red bag. The timescale for completion of this was by the end of July 2022 and it has been completed.”

Source location
Response from Derbyshire County Council
Page 2 · response
Published 16 September 2022
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
Agree acute-trust actions for robust handover communications and investigation of red-bag contents when care homes use them.

Verbatim wording from the response
“3. For the CCG lead to meet with the Deputy Directors of Nursing from both Acute Trusts to agree the internal actions each will take to ensure effective and robust handover communications when receiving patients into the hospital in both the emergency department and on assessment and treatment wards. This will include investigation of the contents of red bags when they are used by care homes. The timescale for completion of this was by the end of July 2022 and this has been completed.”

Source location
Response from Derbyshire County Council
Page 2 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement an interim transfer document for transfers between care homes and hospitals pending the digital solution.

Verbatim wording from the response
“4. Review the sustainability of the red bag pathway including consideration of the risks associated with it and opportunities to implement a sustainable approach across the whole of the County footprint. Implement an interim transfer document for use when transferring individuals from care homes to hospital and hospital to care homes pending the digital solution being implemented. The timescale for full roll-out of this across Derbyshire is by the end of September 2022.”

Source location
Response from Derbyshire County Council
Page 2 · response
Published 16 September 2022
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 urgent-transfer information standard and liaise with digital-transformation leads to expedite an integrated care system digital-standards initiative.

Verbatim wording from the response
“5. Review the Urgent transfer from care home to hospital information standard and link with the local NHS and Local Authority digital transformation leads to expedite an Integrated Care System-wide initiative to implement the new digital standards. This would enable care homes to digitise and transfer individuals’ records electronically to hospital containing all relevant information. The timeframe for the discussion with local NHS and Local Authority digital transformation leads is the end of August 2022. By March 2024, 80% of adult social care providers registered with the Care Quality Commission will have digital social care records, with progress well underway for the remaining 20% by that date.”

Source location
Response from Derbyshire County Council
Page 3 · response
Published 16 September 2022
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
Meet hospital nursing directors to agree internal actions for robust handover communications in emergency departments and wards.

Verbatim wording from the response
“➢ Meet with the Deputy Directors of Nursing from both Hospital Trusts to agree internal action each will take to ensure effective and robust handover communications when receiving patients into the hospital both in the emergency department and wards. These meetings have taken place.”

Source location
Response from NHS Derby and Derbyshire
Page 2 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement an interim care-home-to-hospital and hospital-to-care-home transfer document and complete its full rollout by September 2022.

Verbatim wording from the response
“➢ Implement an interim care home to hospital and hospital to care home transfer document. Full roll out will be by the end of September 2022.”

Source location
Response from NHS Derby and Derbyshire
Page 2 · response
Published 16 September 2022
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
Incorporate monitoring of care-home transfer documentation into routine Local Authority and ICB Care Home Quality Team monitoring.

Verbatim wording from the response
“➢ Monitor of the use of the care home to hospital transfer documentation, this will be incorporated into the routine quality monitoring undertaken by the Local Authority and the ICB Care Home Quality Team. This will be put in place once the interim arrangements are rolled out.”

Source location
Response from NHS Derby and Derbyshire
Page 2 · response
Published 16 September 2022
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 urgent care-home-to-hospital transfer information standard.

Verbatim wording from the response
“➢ Review the urgent transfer from care home to hospital information standard and link with the local NHS and LA digital transformation leads to expedite ICS wide initiatives to implement the new digital standards. The link with Digital workstream 'Digital Social Care Records' has been established.”

Source location
Response from NHS Derby and Derbyshire
Page 2 · response
Published 16 September 2022
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
Establish links with local NHS and Local Authority digital transformation leads through the Digital Social Care Records workstream.

Verbatim wording from the response
“➢ Review the urgent transfer from care home to hospital information standard and link with the local NHS and LA digital transformation leads to expedite ICS wide initiatives to implement the new digital standards. The link with Digital workstream 'Digital Social Care Records' has been established.”

Source location
Response from NHS Derby and Derbyshire
Page 2 · response
Published 16 September 2022
Open published response
19 May2022
Birmingham and Solihull
Concerns raised2
1. Lack of central points of contact for inter-agency referrals and information sharing
2. Failure to share relevant information adequately between agencies
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Establish and operate a central Probation point-of-contact email for inter-agency information sharing.
  Stated by Probation Young Adults Central Team BirminghamStated completed
2. Action
  Raise partner-agency awareness of the central point of contact to facilitate ongoing information sharing.
  Stated by Probation Young Adults Central Team BirminghamStated in progress
3. Action
  Grant CGL licences to access important clinical patient details.
  Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveStated planned
1. Action
  Include alternative contact details in out-of-office messages when named professionals are unavailable.
  Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveStated planned
2. Action
  Maintain relevant, up-to-date information-sharing agreements covering Probation’s work with partner agencies.
  Stated by Probation Young Adults Central Team BirminghamStated planned
3. Action
  Review information-sharing arrangements with partner organisations to remove barriers to effective inter-agency cooperation.
  Stated by Probation Young Adults Central Team BirminghamStated in progress
Respondent positions 2
1. Position
  Existing named workers, duty workers and out-of-office arrangements provide central points of contact for information sharing and crisis queries.
  Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveExisting arrangements considered sufficient
1. Position
  CGL disputes that it lacks a central contact or accepts only GP referrals, citing established contacts and referrals from multiple agencies.
  Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveDisputes the concern
AI-generated summary

Spencer George BARR · 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

Spencer George BARR was found unresponsive at home on 9 December 2021 and was declared deceased by paramedics after an overdose involving opioids, cocaine and pregabalin. He had a long history of substance misuse and labile mental health and was under the care of probation, addiction and mental health services. The principal concerns were inadequate sharing of information and cooperation between agencies, the lack of central points of contact, and limitations on inter-agency referrals.

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 central points of contact for inter-agency referrals and information sharing
Wider context from the report
“4. Additionally, I am concerned that there appear to be no central points of contact for agencies to facilitate that co-operation. I heard evidence that CGL has no central point of contact for referrals being made/to allow sharing of information - instead relying on information being conveyed via specific individuals. I am therefore concerned that where there is no central point of contact, there is a risk of information not being passed on in a timely manner when a specified person is absent from work for whatever reason. Consideration should be given to central points of contact being created within each agency, and ensuring that those points of contact are shared between agencies to ensure information can flow freely between them. ”
Source location
Spencer George BARR · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share relevant information adequately between agencies
Wider context from the report
“2. I heard evidence that full circumstances surrounding Spencer's deterioration and drug relapse in November 2021 - namely that he had received a significant back payment of benefits totalling over £5,000 from the DWP resulting in him purchasing drugs and overdosing - were not adequately conveyed between agencies, and as such agencies were unaware of the heightened risk of potential self harm and death that was posed by these circumstances. Inter-agency co-operation therefore appears to be inadequate, and consideration should be given to ensuring clinicians receive better training when it comes to the sharing of relevant information between agencies. ”
Source location
Spencer George BARR · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish and operate a central Probation point-of-contact email for inter-agency information sharing.

Verbatim wording from the response
“Response – Probation now has a central point of contact e-mail wmps.birminghamcstransfers@justice.gov.uk. Probation is taking steps to raise awareness of this SPOC with partner agencies to ensure this central point of contact facilitates information to be shared at all times.”

Source location
Response from Probation Service
Page 2 · response
Published 17 May 2022
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
Raise partner-agency awareness of the central point of contact to facilitate ongoing information sharing.

Verbatim wording from the response
“Response – Probation now has a central point of contact e-mail wmps.birminghamcstransfers@justice.gov.uk. Probation is taking steps to raise awareness of this SPOC with partner agencies to ensure this central point of contact facilitates information to be shared at all times.”

Source location
Response from Probation Service
Page 2 · response
Published 17 May 2022
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
Grant CGL licences to access important clinical patient details.

Verbatim wording from the response
“Response to matters of concern 4 & 5 In FTB both the service user’s named Core Worker and Lead Professional act as central point of contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts as a point of contact if the service user’s named Core Worker or lead professional is not available this ensures that there is always a specific allocated point of contact in the working day to share essential information. FTB is committed to ensuring information is shared across agencies to support patient safety and we have agreed to grant licences to CGL that will enable them to access important clinical patient details.”

Source location
Response from Birmingham Women's and Children's NHS Foundation Trust
Page 4 · response
Published 17 May 2022
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
Include alternative contact details in out-of-office messages when named professionals are unavailable.

Verbatim wording from the response
“When the Core Worker or lead professional is not available the out of office message will include the telephone number for colleagues who can redirect queries and make arrangements to make contact with patients in a crisis.”

Source location
Response from Birmingham Women's and Children's NHS Foundation Trust
Page 4 · response
Published 17 May 2022
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
Maintain relevant, up-to-date information-sharing agreements covering Probation’s work with partner agencies.

Verbatim wording from the response
“Response – Probation is committed to having in place relevant and up to date Information Sharing Agreements to cover all areas of its work which provide a legal framework within which information can be passed to and from partner agencies. Probation is reviewing the position in this regard with the other IP organisations to ensure there are no barriers to sound and effective inter agency co-operation and sharing of information.”

Source location
Response from Probation Service
Page 1 · response
Published 17 May 2022
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 information-sharing arrangements with partner organisations to remove barriers to effective inter-agency cooperation.

Verbatim wording from the response
“Response – Probation is committed to having in place relevant and up to date Information Sharing Agreements to cover all areas of its work which provide a legal framework within which information can be passed to and from partner agencies. Probation is reviewing the position in this regard with the other IP organisations to ensure there are no barriers to sound and effective inter agency co-operation and sharing of information.”

Source location
Response from Probation Service
Page 1 · response
Published 17 May 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing named workers, duty workers and out-of-office arrangements provide central points of contact for information sharing and crisis queries.

Verbatim wording from the response
“Response to matters of concern 4 & 5 In FTB both the service user’s named Core Worker and Lead Professional act as central point of contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts as a point of contact if the service user’s named Core Worker or lead professional is not available this ensures that there is always a specific allocated point of contact in the working day to share essential information. FTB is committed to ensuring information is shared across agencies to support patient safety and we have agreed to grant licences to CGL that will enable them to access important clinical patient details.”

Source location
Response from Birmingham Women's and Children's NHS Foundation Trust
Page 4 · response
Published 17 May 2022
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
CGL disputes that it lacks a central contact or accepts only GP referrals, citing established contacts and referrals from multiple agencies.

Verbatim wording from the response
“We would like to reassure you that CGL have an established central point of contact and have accepted referrals from any individual and agency since March 2015 when the service was commissioned in Birmingham. Referrals can be made via the telephone or the CGL website at the following link https://www.changegrowlive.org/drug-alcohol-service-birmingham/referrals.”

Source location
Response from Birmingham Women's and Children's NHS Foundation Trust
Page 4 · response
Published 17 May 2022
Open published response
29 Apr2022
South Yorkshire (Western)
Concerns raised1
1. Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Draft a detailed patient-release information template covering substance misuse, Naloxone, mental health and other relevant support needs.
  Stated by Practice Plus GroupStated completed
2. Action
  Implement a tracked, consent-based process for quality-assured Approved Premises information reports, recording requests and completed reports on SystmOne.
  Stated by Practice Plus GroupStated completed
3. Action
  Update the Naloxone refusal disclaimer and require refusals to be signed, scanned onto SystmOne and recorded in third-party medical reports.
  Stated by Practice Plus GroupStated completed
AI-generated summary

Jamie Lee Bennett · 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

Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency services.

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
Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises
Wider context from the report
“There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park. I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise, specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere other than an Approved Premise during the first 48 hours It is my opinion there is a risk that future deaths may occur unless such a process is developed ”
Source location
Jamie Lee Bennett · 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
Draft a detailed patient-release information template covering substance misuse, Naloxone, mental health and other relevant support needs.

Verbatim wording from the response
“Following the Inquest, PPG Healthcare reflected on the type of information being requested and determined that more information should be shared. Therefore, Healthcare have drafted a more detailed template (attached for reference), which provides more specific information including, medical conditions, medication, COVID vaccinations, social services input, mental health concerns including history of self-harm, and specific equipment the patient may require, substance misuse involvement including SMS history, any current substance misuse work, any detox or re-toxification processes undertaken, whether the patient has been offered and trained for Naloxone and details of any community drugs service referrals that may have been made.”

Source location
Response from Practice Plus Group
Page 2 · response
Published 12 May 2022
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 a tracked, consent-based process for quality-assured Approved Premises information reports, recording requests and completed reports on SystmOne.

Verbatim wording from the response
“• A process has been immediately implemented for managing all Approved Premises information requests: – Requests for patient information received are logged onto a spreadsheet for tracking the process. – All information/medical report requests received are scanned onto the patient record on SystmOne. – Consent to share information is signed by the patient and scanned onto the patient record (SystmOne). – The Medical Record template is completed by a manager, quality assured and shared with the requesting provider. – The completed report is scanned onto the patient record (SystmOne) providing an audit trail.”

Source location
Response from Practice Plus Group
Page 2 · response
Published 12 May 2022
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
Update the Naloxone refusal disclaimer and require refusals to be signed, scanned onto SystmOne and recorded in third-party medical reports.

Verbatim wording from the response
“• Patients are provided with advice on discharge, where appropriate, about Naloxone. I understand this occurred in the case of Jamie Lee Bennett. However, in order for greater clarity and clinical safety, the disclaimer form for Naloxone has now been updated to make the risks of not accepting Naloxone clearer, please see Appendix B. When a”

Source location
Response from Practice Plus Group
Page 2 · response
Published 12 May 2022
Open published response
25 Apr2022
North Yorkshire and York including North Yorkshire Western District
Concerns raised1
1. Failure of communication and shared information across autism and mental health teams
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Work with TEWV to resolve internal and external communication issues affecting patient care.
  Stated by NHS Humber and North Yorkshire Integrated Care BoardStated planned
2. Action
  Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
3. Action
  Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
1. Action
  Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated planned
2. Action
  Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
  Stated by NHS Humber and North Yorkshire Integrated Care BoardRedirects responsibility
AI-generated summary

Zoe Emma ZAREMBA · 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

Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of communication and shared information across autism and mental health teams
Wider context from the report
“The evidence indicated: 1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that. 2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”). 3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship. 4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood. 5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe. 6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:- A no multidisciplinary clinical assessment and formulation addressed her autism; B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all; C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians. D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences; E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts; F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide; G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services; H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations; Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs. ”
Source location
Zoe Emma ZAREMBA · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with TEWV to resolve internal and external communication issues affecting patient care.

Verbatim wording from the response
“The CCG/ICB are aware; from reviewing the evidence from the inquest and from discussions with TEWV that there are communication issues internally and externally which need to be resolved for the benefit of the patient. This appears to go beyond incompatibility of IT systems (for example within the inquest there is reference to the autism service provided to other geographical parts of TEWV but not being available within the North Yorkshire part of the organisation). Both TEWV and the ICB are committed to working closely to resolve this. It is anticipated that ultimately the establishment and development of Provider Collaboratives within the ICB will support with these type of issues in the future.”

Source location
Response from Humber and North Yorkshire Health Care Partnership
Page 4 · response
Published 27 April 2022
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
Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.

Verbatim wording from the response
“Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).”

Source location
Response from TEWV
Page 3 · response
Published 27 April 2022
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
Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.

Verbatim wording from the response
“Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).”

Source location
Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
Page 3 · response
Published 27 April 2022
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
Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.

Verbatim wording from the response
“Our new patient recording information system (CITO) will not only allow a greater clarity around active and discounted diagnoses but will importantly also support patient access to their own records improving mutual understanding and effective”

Source location
Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Page 2 · response
Published 27 April 2022
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
Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.

Verbatim wording from the response
“We have learned from Zoe’s sad death and shared with our clinical teams the importance of communication with our partners, to ensure that patients’ needs are addressed in a more cohesive and person-centred manner.”

Source location
Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Page 6 · response
Published 27 April 2022
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
TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.

Verbatim wording from the response
“This is therapy which is beyond that which TEWV can provide as the primary mental health provider. That does not change the expectation that TEWV be in a position to make appropriate adjustments to their mental health support for those with any neuro development diagnosis. By this we mean that we would expect TEWV to be in a position to support those with a mental health condition even where they have a diagnosis of autism spectrum disorder however it is recognised by the CCG/ICB that there may be cases where there is additional specialist input required. This is when IFR requests are made. The CCG/ICB accepts that this is becoming more frequent and the reasons for this are not clear but are sufficient for the CCG/ICB to be considering the commissioning pathway for this type of therapy.”

Source location
Response from Humber and North Yorkshire Health Care Partnership
Page 2 · response
Published 27 April 2022
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of communication and information sharing between Primary Mental Health Services and Tier 2 therapy providers

Concerns raised1

Failure to share dependence information with the mental health trust

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people

Unavailability of a shared database for agencies to input common concerns

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure to communicate specialist referral priorities to local hospitals

Concerns raised1

Lack of a shared regional system for cross-site sharing of radiology images

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to make systematic enquiries for care plans and other relevant documentation between agencies

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Actions described in response 1

Respondent positions 1

Actions described in response 6

Respondent positions 4

Actions described in response 1

Respondent positions 1

Actions described in response 9