Recurring concern

Unreliable inter-agency information sharing for coordinated care

First to latest report 29 May 2013 — 15 Jun 2026

Reports that mention this concern
212
Times this concern has been raised
235
Stated actions linked to this concern
492

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.

What is 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 and published responses 212 reports

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

  1. London (East)

    AI-generated summary

    Sophie Holman · 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

    Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.

    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 alert health visitors or safeguarding services to missed routine appointments

    Wider context from the report

    “5) The child’s parents failed on occasion to bring the child to routine appointments; however there was no communication by any health professional alerting the health visitors or safeguarding team regarding this. On the other hand, the child’s asthma attacks were treated in hospital and general practice ‘as an acute illness’, without detailed patient education or a co-ordinated long-term management plan. There were thus little evidence of any patient education – particularly aimed at ensuring that the child’s parents were aware of the fact that she was at risk of poor outcome even asthma death according to her risk factors; perhaps explained the behaviour of her parents. ”

    Source location

    Sophie Holman · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Suffolk

    AI-generated summary

    Mark Harris · 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 Harris was found deceased with a rope around his neck at the home of his ex-partner on 11 January 2016, after expressing suicidal thoughts following his release from police custody. The report identified communication and information-sharing problems between the ambulance service, police control room and attending officers, including the deceased’s name being mis-spelt and uncertainty about the purpose of the police attendance.

    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 the informant's contact details and ambulance service CAD information with the police

    Wider context from the report

    “(3) The police evidence was that in the event of a welfare call, which they could conduct in any event under section 17 powers in the absence of the ambulance service, there was additional information that should be shared including the name and contact telephone number of the informant, and the information recorded in the ambulance service CAD. ”

    Source location

    Mark Harris · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. West Yorkshire (West)

    AI-generated summary

    BARNABY LUKE AYLWARD · 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

    Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.

    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 relevant risk information between agencies

    Wider context from the report

    “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency: a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time; b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed; c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist; d) may have been hampered by issues of confidentiality in communications between agencies. If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed. ”

    Source location

    BARNABY LUKE AYLWARD · 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

    Update the partnership agreement with South West Yorkshire Partnership NHS Foundation Trust.

    Verbatim wording from the response

    “WYFRS has had a formal partnership in place with SWYFT for a number of years. There is a signed agreement dated October 2014 and we have been in the process of updating our partnership agreements following the introduction of the new Safer Communities Strategy in 2017. Our records show that WYFRS have received 86 referrals directly from SWYFT between 2016 and 2018. However, we expect the actual number of referrals from staff working across SWYFT to be higher than this figure as they may refer through their local team or department name but essentially their work falls under the SWYFT umbrella.”

    Source location

    2018-0387-Responses
    Page 2 · response
    Published 13 May 2019

    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 West Yorkshire partnership information-sharing agreement with Together Housing.

    Verbatim wording from the response

    “WYFRS started communication with officials from Together Housing in July 2018 to establish a new partnership information sharing agreement to cover West Yorkshire, expanding the current arrangements. Discussions also took place about the development of training for personnel within both organisations to identify the support available within each service. WYFRS Demenia Resources were also shared with Together Housing to establish whether these would be suitable for their employees to support visits and aid the provision of key fire safety messages.”

    Source location

    2018-0387-Responses
    Page 3 · response
    Published 13 May 2019

    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 responses to referrals concerning people identified as being at risk of fire in their homes.

    Verbatim wording from the response

    “Finally, I am assured that our teams are working with partners across the five districts in the effort to provide our prevention services to those who most need it. We accept that there is still progress to be made around information governance and sharing data across organisational boundaries, and we will continue to make an appropriate response to all of the referrals that we receive in relation to people that are identified as being at risk of fire in their homes.”

    Source location

    2018-0387-Responses
    Page 3 · response
    Published 13 May 2019

    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 partnership agreement with West Yorkshire Fire and Rescue Service to include an information-sharing protocol.

    Verbatim wording from the response

    “5.3 Partnership Agreement with West Yorkshire Fire and Rescue Service – the existing agreement with Together Housing and WYF&R service has been updated and includes an”

    Source location

    2018-0387-Responses
    Page 5 · response
    Published 13 May 2019

    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 and agree the inter-agency information-sharing protocol with West Yorkshire Fire and Rescue Service.

    Verbatim wording from the response

    “The Trust currently has an inter-agency information sharing protocol with West Yorkshire Fire and Rescue service, this protocol is currently under review and it is anticipated that this should be agreed by the end of March 2019.”

    Source location

    2018-0387-Responses
    Page 8 · response
    Published 13 May 2019

    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

    Reinforce consent-based information sharing with housing providers and referrals to fire services when fire risks are identified.

    Verbatim wording from the response

    “Staff will be reminded through the safeguarding training and information governance training that where a service user is in rented accommodation, consent should be sought from the service user to provide information regarding the condition of the property to the housing provider.”

    Source location

    2018-0387-Responses
    Page 9 · response
    Published 13 May 2019

    Open published response

  4. Manchester South

    AI-generated summary

    Joseph James GRANTHAM · 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

    Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare 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 of information systems to make key clinical information available across trusts

    Wider context from the report

    “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available. ”

    Source location

    Joseph James GRANTHAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. North Yorkshire

    AI-generated summary

    ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report

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

    Report summary

    On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family support.

    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 potentially key welfare and safety information between private therapy services and primary care

    Wider context from the report

    “Within the contexts of a) Primary Care and b) acknowledgement that referral access to specialist mental health services is considerably delayed and c) recourse to private therapy was sought in the meantime pending any referral and d) there are resources that can be shared in the ‘waiting’ period then: (1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety; (2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”; (3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis; (4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available ”

    Source location

    ROBIN ANDREW JAMES MCEWAN · 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 primary care referral process for private counselling to obtain timely progress updates, with patient consent.

    Verbatim wording from the response

    “The CCG will review the current process in Primary Care to ensure that when GPs refer an individual for private counselling, they request, with patient consent, a timely update on the patient’s progress to enable a proactive person-centred dialogue to occur regarding the best way to meet the patient’s needs through their episode of care. The CCG needs to ensure that a consistent approach is taken across North Yorkshire to address the issue that private counselling services do not routinely share information back into Primary Care. This is a safeguarding issue which affects a vulnerable group of patients which”

    Source location

    2018-0325-Response-by-Harrogate-CCG
    Page 1 · response
    Published 24 February 2019

    Open published response

  6. Inner North London

    AI-generated summary

    Jacob Sulaiman · 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

    Jacob Sulaiman died at home on 8 December 2017 after a fire started in his bedroom, causing carbon monoxide poisoning. The principal concerns were that response officers did not have complete or readily accessible information about his contacts with other services, including the outcome of a paramedic visit, which may have affected the assessment and management of his mental capacity.

    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 record and share relevant information about contacts with other services and their outcomes

    Wider context from the report

    “(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property. (2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance. (3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am. (4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out. (5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed. ”

    Source location

    Jacob Sulaiman · 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

    Migrate records to a new platform and train staff to support timely, complete recording and mobile working.

    Verbatim wording from the response

    “In preparation for this move, a new IT platform was required to support the”

    Source location

    2018-0252-Response-by-London-Borough-of-Camden
    Page 4 · response
    Published 25 September 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.

    Verbatim wording from the response

    “This change is well underway, migrating records to the new IT system and training staff, so that it will be in place before the end of 2018. As part of working practices, there will be a checklist for referring to the emergency services, including ensuring that a full history is given to London Ambulance Service when a call is made. Caroline, which will now have a full history, will pass on all the information to LAS call centre, to be recorded as a part of the callout.”

    Source location

    2018-0252-Response-by-London-Borough-of-Camden
    Page 5 · response
    Published 25 September 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop information-sharing arrangements with London Ambulance Service.

    Verbatim wording from the response

    “The London Ambulance Service is represented on the Adults Safeguarding Board and we would expect them to participate in any SAR. In addition, the senior manager responsible for the Caroline service has already made contact with LAS to begin discussions about how information could be better shared in future.”

    Source location

    2018-0252-Response-by-London-Borough-of-Camden
    Page 5 · response
    Published 25 September 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Calls not resulting in a Careline visit are not routinely passed to response officers because no action from them is required.

    Verbatim wording from the response

    “Wellbeing pass on information to response officers when there is likely to be a need for a visit. A call that does not result in a visit is not routinely passed on to Careline, as no action from them is required.”

    Source location

    2018-0252-Response-by-London-Borough-of-Camden
    Page 3 · response
    Published 25 September 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Wellbeing coordinated the responses, and there was no evidence that the individual lacked capacity or required mental-health intervention.

    Verbatim wording from the response

    “It is correct to say that none of the individuals attending Mr Sulaiman’s property on the night of his death had a full picture of all the calls that day, however, Wellbeing were aware of, and coordinated the responses, whether they were remotely or in person.”

    Source location

    2018-0252-Response-by-London-Borough-of-Camden
    Page 3 · response
    Published 25 September 2018

    Open published response

  7. Shropshire, Telford and Wrekin

    AI-generated summary

    Jerome Jason Omri JONES · 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

    Jerome Jason Omri Jones was a serving prisoner who died in hospital after being found unresponsive in his cell, following suspected use of a synthetic cannabinoid and in the context of a congenital heart defect. The concerns included the absence of guidance for additional checks after repeated NPS use, no clear method for communicating his increased risk to healthcare or prison officers, and limited access by drug workers to relevant medical information.

    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 elevated NPS-related risk to Healthcare and prison officers

    Wider context from the report

    “(2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect. I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17. ”

    Source location

    Jerome Jason Omri JONES · 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

    Notify staff that healthcare determines when additional checks are needed and must communicate this to prison discipline staff.

    Verbatim wording from the response

    “establishment. All staff were notified of this last month by way of a Notice to Staff which also reminded them that healthcare staff are responsible for determining when additional checks of prisoners at risk from repeated use of psychoactive substances are necessary, and that this must be communicated by them to all prison discipline staff.”

    Source location

    2018-0369-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 10 May 2019

    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

    Issue a notice reminding Forward Trust drug workers how to share information with prison and healthcare staff.

    Verbatim wording from the response

    “In September, a staff notice was also issued by the Governor to all Forward Trust Drug workers at the establishment to remind them of how to share information with prison and healthcare staff. To further improve communication between Forward Trust drug workers and healthcare staff, every member of Forward Trust will be given access to SystmOne by April 2019, in order that they can both enter information onto the system and access it.”

    Source location

    2018-0369-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 10 May 2019

    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

    Give every Forward Trust member access to SystmOne to enter and access information.

    Verbatim wording from the response

    “In September, a staff notice was also issued by the Governor to all Forward Trust Drug workers at the establishment to remind them of how to share information with prison and healthcare staff. To further improve communication between Forward Trust drug workers and healthcare staff, every member of Forward Trust will be given access to SystmOne by April 2019, in order that they can both enter information onto the system and access it.”

    Source location

    2018-0369-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 10 May 2019

    Open published response

  8. Manchester South

    AI-generated summary

    Robert Thomas Wrinch · 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

    Robert Thomas Wrinch deteriorated with severe back pain and reduced mobility associated with an undiagnosed metastatic spinal malignancy, and developed bronchopneumonia. The report raised concerns about delays and inadequate tracking in pathology sample processing and reporting, reliance on paper reports, inconsistent departmental tracking systems, incompatible information technology systems between trusts, and pathology backlogs linked to shortages of pathologists.

    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

    Incompatibility of pathology information technology systems between hospital trusts

    Wider context from the report

    “4. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult. ”

    Source location

    Robert Thomas Wrinch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Southampton and New Forest

    AI-generated summary

    Nigel Malloy · 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

    Nigel Malloy fell from a second-floor window on 29 October 2017 while intoxicated with alcohol, suffered severe head injuries, and died in hospital two days later. He was alcohol dependent and had depressive symptoms, with previous similar falls and multiple hospital admissions, but concerns were raised that there was no information sharing or coordinated treatment plan between the relevant alcohol-support 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 share information between alcohol liaison and inclusion services

    Wider context from the report

    “The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence. ”

    Source location

    Nigel Malloy · 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

    Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.

    Verbatim wording from the response

    “• A 24 hour referral service and dedicated pathway with Inclusion”

    Source location

    2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
    Page 3 · response
    Published 23 September 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.

    Verbatim wording from the response

    “• Regular telephone liaison between Inclusion and the Trust when one of their users is an inpatient or in relation to referrals”

    Source location

    2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
    Page 3 · response
    Published 23 September 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.

    Verbatim wording from the response

    “As per our response to point 2 above, the Trust made the initial referral to Inclusion on 21.09.17 and subsequently liaised with them to arrange Mr Malloy’s first attendance and ensure that Mr Malloy had attended as planned.”

    Source location

    2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
    Page 2 · response
    Published 23 September 2018

    Open published response

  10. Surrey

    AI-generated summary

    Henry James Heselton · 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

    Henry James Heselton died by hanging in a field off Down Lane, Guildford, on 28 September 2016. The report identified concerns about unclear electronic mental health records and poor communication between mental health teams and his general practitioner, which meant relevant information was not available to inform clinical judgement.

    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 relevant recent mental health information between mental health teams and general practitioners

    Wider context from the report

    “2. There was a lack of communication between the mental health teams and the general practitioner. The fact that contact had been made by ████████ with both the acute and community mental health team was not shared with his General Practitioner. This left her without relevant recent history to inform her clinical judgement when she was contacted by ████████ on the 7th September 2016. ”

    Source location

    Henry James Heselton · 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

    Develop GP access to mental health records.

    Verbatim wording from the response

    “Electronic communication has being developed to allow access to CHIE (formerly the Hampshire Health Record) and GP summary patient records and is being developed to allow access for GPs to the mental health record. But this does not mean that communication described above will be superseded.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 2 · response
    Published 8 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Embed GP communication requirements in acute and community mental health team procedures, instruct managers, and monitor compliance after referral triage.

    Verbatim wording from the response

    “To address the shortcomings in the care provided to Mr Heselton, these principles have been included in the review of the Acute Mental Health Team and Community Mental Health Team Standard Operating Procedures, and the team managers instructed to ensure that staff are aware of the requirement to communicate with GPs after triaging referrals and to regularly monitor that it is occurring.”

    Source location

    2018-0152-Response-by-Southern-Health-NHS-Trust
    Page 2 · response
    Published 8 July 2018

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026