5 Feb 2026 Kallum Josh REED · Prevention of Future Deaths report West London
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Concerns raised 1
Crisis team gatekeeping and rejection of referrals for crisis care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care West London NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
West London NHS Trust
Pilot trusted assessments for Ealing referrals to the crisis, assessment and home treatment team.
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West London NHS Trust
Recruit a Clinical Lead to support trusted-assessment changes and improvements across the relevant Ealing services.
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Department of Health and Social Care
Provide universal access to urgent mental health helplines through NHS 111 and alternative crisis services.
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Department of Health and Social Care
Invest up to £120 million to expand mental health emergency departments to 85.
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AI-generated summary
Kallum Josh REED · 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
Kallum Josh REED died after being found fully suspended during a police search following his disappearance on 11 February 2025. The report raises concerns about delays in autism spectrum disorder and ADHD referrals, assessments and diagnoses, and about crisis-care referral pathways and coordination between mental health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Crisis team gatekeeping and rejection of referrals for crisis care
Wider context from the report “(2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service , notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceding the death), to present to ED (which he did but was discharged home to remain under the community team).
The pathways essentially failed as the crisis team still able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued . The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasised the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution. The situation appears not to have changed in the 12 months following this death.
There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him.
I am therefore raising this concern with the WLNHS Trust
” Source location Kallum Josh REED · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot trusted assessments for Ealing referrals to the crisis, assessment and home treatment team.
Verbatim wording from the response “As part of the work flowing from this reorganisation, and to maximise benefits arising from this organisational change, the Trust decided that integrated pathways and whole person care would be a key element of the Trust Quality Priorities for 2025-2028 (supporting a refreshed Clinical Strategy). As part of this work and directly linked to your” Source location 2026-0061 - Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit a Clinical Lead to support trusted-assessment changes and improvements across the relevant Ealing services.
Verbatim wording from the response “To fully support this roll-out, we have adjusted the management portfolios in Ealing and brought the Psychiatry Liaison and CAHTT teams together under a single new senior manager with previous experience of working within a trusted assessment framework. We have also recruited a new Clinical Lead who will work across the same portfolio to support the new service manager and implement all necessary changes and improvements supporting the medical staff. This interface and smooth transition remain a priority for the Clinical and Associate Directors within the borough.” Source location 2026-0061 - Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide universal access to urgent mental health helplines through NHS 111 and alternative crisis services.
Verbatim wording from the response “More widely Government has been working to build more robust crisis care pathways across all ages ensuring that people in mental health crisis have access to timely and appropriate support. Key developments include:” Source location 2026-0061 - Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest up to £120 million to expand mental health emergency departments to 85.
Verbatim wording from the response “• Investing up to £120m to bring the number of mental health emergency departments up to 85. Mental Health Emergency Departments will provide reactive, short term intensive support for people in acute MH crisis as an alternative to A&E. Mental Health Emergency Departments, or Crisis Assessment Centres, are specialist NHS services that operate alongside emergency departments to provide access to high quality, safe and compassionate care for those in mental health crisis. Crisis Assessment Centres will be usually accessed via self-referral, direct referral from other UEC mental health services, or ‘a walk-in’ where patients choose to do so.” Source location 2026-0061 - Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation West London NHS Trust is handling the specific local issues arising from Kallum’s death and responding separately to the report.
Verbatim wording from the response “In terms of the specific local issues that resulted in Kallum slipping between the gaps and not receiving the potentially life-saving care he needed, I understand that West London NHS Trust has undertaken a Patient Safety Incident Investigation to learn important lessons from this event, which I welcome. I believe that they are responding separately to your report.” Source location 2026-0061 - Response from Department of Health and Social Care
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26 Jun 2025 CALLAN NORMAN COLLINS ATKINS · Prevention of Future Deaths report Gloucestershire
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Concerns raised 1
Failure to enquire about additional resources when the local crisis team has no capacity View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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CALLAN NORMAN COLLINS ATKINS · 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
Callan was found hanging at his home on 18 May 2023 and was confirmed dead at the scene. The report identified a missed opportunity for a face-to-face mental health assessment the previous day, although it found no possible or probable contribution to his death from this. Concerns were raised that crisis-team staff capacity could determine whether patients were assessed when clinically needed, and that additional resources might not be explored when the team lacked capacity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to enquire about additional resources when the local crisis team has no capacity
Wider context from the report “That the Trust will not make any enquiries as to additional resources when their local Crisis team has no capacity .
” Source location CALLAN NORMAN COLLINS ATKINS · Prevention of Future Deaths report
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14 Oct 2024 Stephen Frederick DULLING · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 2
Failure to establish whether an assessed risk of harm had increased and required emergency intervention View source Failure to provide practical emergency-care advice to carers View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Stephen Frederick DULLING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish whether an assessed risk of harm had increased and required emergency intervention
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered , nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” Source location Stephen Frederick DULLING · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide practical emergency-care advice to carers
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance , nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” Source location Stephen Frederick DULLING · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of crisis support and specialist assessment access for patients over 65 View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Rotherham Doncaster and South Humber NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Rotherham Doncaster and South Humber NHS Foundation Trust
Issue a written operating protocol requiring crisis referrals for older people to be accepted and assessed regardless of age or time of day.
View source
Rotherham Doncaster and South Humber NHS Foundation Trust
Remove age-based access barriers from mental health services through revised service arrangements and additional staff training.
View source
Rotherham Doncaster and South Humber NHS Foundation Trust
Disseminate revised crisis pathways, referral routes and advice arrangements to staff, primary care, NHS111, communities, carers and patients.
View source
Rotherham Doncaster and South Humber NHS Foundation Trust
Roll out DIALOG/DIALOG+ to replace the Care Programme Approach and support outcome-focused care planning across services.
View source
Rotherham Doncaster and South Humber NHS Foundation Trust
Embed the revised crisis and community mental health arrangements in local team induction.
View source
Rotherham Doncaster and South Humber NHS Foundation Trust
Work with clinical audit to consider evaluating older adults’ access to crisis presentations in the 2025/26 audit programme.
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Carol Ann Guest · 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
Carol Ann Guest died by suicide after hanging herself at home on 24 March 2024, before a planned consultant visit could be arranged following an urgent mental health referral. The principal concerns were inadequate crisis support for patients over 65, delays in sending and responding to the urgent referral, and the provision of a crisis number that was not available to people over 65.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of crisis support and specialist assessment access for patients over 65
Wider context from the report “During the course of the evidence from both family and medical witnesses it became clear that there were no adequate systems in place for providing crisis support to patients over the age of 65 . The family were very concerned and very frustrated by the futile attempts they made to secure psychiatric input and support when they could see a rapidly deteriorating picture. There was no explanation as to why individuals in crisis who were 65 or under had access to the crisis service but once a person is over 65 that service is no longer available to them . It is not clear whether access to such services would have altered the outcome but the current structure and services available in my view denied Ms Guest with the opportunity of obtaining specialist assessment support at a much earlier stage . A further concern was that the GP surgery provides patients with the crisis number seemingly without appreciating that this would only be available to those who were 65 or under. Furthermore, the family's evidence was that when they called 101 seeking medical input and support for Ms Guest, they were told they would be referred to the crisis team but as soon as Ms Guest's age was mentioned they halted that process and said that they would not be able to refer her after all because of her age .
” Source location Carol Ann Guest · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a written operating protocol requiring crisis referrals for older people to be accepted and assessed regardless of age or time of day.
Verbatim wording from the response “We have found that our arrangements for accepting crisis referrals for older people are inconsistent within RDaSH, and do not benefit from agreed written protocols. This will change with issue of a new operating protocol to those working clinically on November 7th 2024 – effective immediately.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove age-based access barriers from mental health services through revised service arrangements and additional staff training.
Verbatim wording from the response “Local service specifications from commissioning bodies do appear to create age-based parameters for who can access which services. The Trust committed earlier in 2024/25 to remove such externally directed barriers to our services, both for children and young people, and older adults. We are working to a programme to do this by spring 2025, as the changes involved require us to provide additional training to staff in different presentations and techniques. To be clear, services will still have specialists focusing on particular conditions, but the distinctions between teams will not be driven by age-parameters.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate revised crisis pathways, referral routes and advice arrangements to staff, primary care, NHS111, communities, carers and patients.
Verbatim wording from the response “We will set out our revised arrangements in writing for those providing the services, but also for local GPs. We will also ensure that, during November, relevant primary care leadership meetings are advised of the changes. That is because we suspect that, over a period of years, pathway changes have been made, and practices have varied knowledge of them. The arrangements will also be clarified in our triage-SPA and to NHS111. This work will be complete before the end of November. In putting this change into place, we will also clarify for local practices, the best routes through which themselves to seek advice, and how to make referrals including urgent referrals. Importantly this will be shared with our communities, carers and patients through all our communication channels.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out DIALOG/DIALOG+ to replace the Care Programme Approach and support outcome-focused care planning across services.
Verbatim wording from the response “Through 2025/26, the Trust is introducing DIALOG/DIALOG+ into our services and replacing the Care Programme Approach (CPA). The intention of this change, adopted by some other mental health providers nationally, is to better support patients and their carers, with plans of care that are outcome focused. Introducing DIALOG should help us too to have a more accessible” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the revised crisis and community mental health arrangements in local team induction.
Verbatim wording from the response “• Induction arrangements for our local crisis teams, and wider community mental health teams, take account of what is described in this letter. This month the Trust introduced new induction arrangements across the organisation, with a dedicated day for in-team local induction complimented by a much more in-depth institutional induction, taking place in our communities.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with clinical audit to consider evaluating older adults’ access to crisis presentations in the 2025/26 audit programme.
Verbatim wording from the response “• The Trust’s Equity and Inclusion Group, which I chair, is already auditing the work to replace age-specific policies in our pathways. We will work with clinical audit to consider how best, in our 2025/26 programme of audit, evaluation of access for crisis presentations in older adults. This should help us to have a better picture of patterns of demand, through which to further refine services.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Crisis provision was not considered a relevant factor in what happened; missed referrals to the established older people’s community team were the issue.
Verbatim wording from the response “I should be direct that we do not believe that crisis provision was a relevant factor in what happened to Carol. It is apparent from the attached case summary from ████████ that there were missed opportunities to refer her to the established older peoples’ community team. Having received a referral on March 15th, an appointment was expedited to take place on March 26th. Carol was unaware of both the referral (not issued to her, and the appointment, owing to her death). It is deeply regrettable that relatives who cared for Carol may have been left, in evidence before you, with the impression that crisis services were a primary cause of harm. We will be seeking to meet with family members to hear from them and to share our conclusions with them.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A compelling case for creating dedicated older people’s crisis services has not been identified, so existing teams should improve their response instead.
Verbatim wording from the response “There is some evidence that dedicated older peoples’ crisis services have merit. Whilst we will keep the introduction of such services under review, we have not found a compelling case to create such services and, to do so, would require significant investment from the Integrated Care Board locally. We consider it unlikely that this will occur over the next two years, and as such it is important our existing teams are better able to respond to needs among all adults.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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Concerns raised 1
Failure to review patients’ records before CRISIS team MDT meetings View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Marie ZARINS · 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
Marie Zarins, aged 42, was reported missing by her family and found suspended in Leicestershire; her death was confirmed at the scene on 24 November 2021. The report raised concerns about flawed multidisciplinary team discussions, inaccurate understanding and documentation of her medication status, failures to prescribe antidepressants and sleeping tablets, and inadequacies in the subsequent serious incident investigation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review patients’ records before CRISIS team MDT meetings
Wider context from the report “1) I am concerned about the CRISIS team MDT meetings and their functionality. It is difficult to understand how a meeting attended by around 7 people agreed a treatment plan which was based upon incorrect information relating to the patient’s medication status. This is particularly difficult to understand when the correct medication status is clearly documented in the patient’s core assessment paperwork (which was completed by the Liaison Team on 22 November 2021 and sent to the CRISIS Team).
An LPT staff member was candid about the fact that he did not have enough time to review patients’ records before the MDT meetings , this is a grave concern.
” Source location Marie ZARINS · Prevention of Future Deaths report
Open source report
22 Jun 2023 Lucy Anne Walles · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure to ensure crisis-team discharges include additional support when needed View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Lucy Anne Walles · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure crisis-team discharges include additional support when needed
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” Source location Lucy Anne Walles · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and accept referrals for Elmore floating support for people with complex needs who risk falling between existing services.
Verbatim wording from the response “• Elmore complex needs floating support service.
This is a charity we have commissioned to provide support to people with a wide range of complex needs, who are at risk of falling between the gaps of existing services. Alongside the Trust’s existing offer Elmore provides innovative ways to build trust, increase patients’ engagement with relevant agencies and deliver support tailored to the people who need it. The target group is those who have multiple support needs and complexity. For example, homelessness and rough sleeping, substance misuse, offending, physical disability, self-harm, learning difficulties, domestic abuse, sex working, or experience of abuse and neglect. A motivated team, with wide ranging expertise has been identified to work as part of our personality disorder pathway to provide this individual support.” Source location Response from Berkshire Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make outreach workers fully operational to provide short-term support and safety planning for people unable to access existing services.
Verbatim wording from the response “• Outreach workers
These workers are able to offer short term support and safety planning to those who do not meet threshold or who are unable to access community mental health teams and/or psychological therapy. Will be fully operational by December 2023” Source location Response from Berkshire Healthcare NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient was not discharged without additional support; community support, group support, online support and a medication review were already arranged.
Verbatim wording from the response “At the time Lucy was discharged from CRHTT on the 2nd of February 2022, she had a 16 hours per week of community support in place provided by Adult Social Care (ASC) with a planned move to accommodation with support available 24/7. Lucy also had access to the Service User Network (SUN) which provides group support, and Shout (which provides support with stress, anxiety, suicidal thoughts, and links to many other sources of support for example autism and mental health, bullying, relationships). A Pharmacist review of medication was planned for 17th February 2022. In the new model the following additional support could also be offered in” Source location Response from Berkshire Healthcare NHS Foundation Trust
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20 Jun 2023 Michael Brian Sullivan · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays between Crisis Review Team referrals and patient assessments View source
Linked response
NHS Greater Manchester Integrated Care Board
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Michael Brian Sullivan · 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 Brian Sullivan had schizophrenia and bipolar disorder, took lithium, and deteriorated at home before being admitted to Stepping Hill Hospital, where he was found to have pneumonia and lithium toxicity. He deteriorated despite treatment and died in hospital on 17 December 2022. The report raised concerns about delays between referrals to the Crisis Review Team and patient assessments, including uncertainty about referral processes, prioritisation and triage.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays between Crisis Review Team referrals and patient assessments
Wider context from the report “The evidence before the inquest was that Mr Sullivan was a vulnerable person with a complex mental health history. The inquest heard evidence that GPs could access a Crisis Review Team to assess patients such as Mr Sullivan. However, the evidence before the inquest was that there seemed to be delays between referrals and assessments . It was unclear if these were due to a lack of understanding by GPs on how the CRT could be used or how patients were prioritised within the CRT or a lack of effective triage by GPs before referral or the CRT following referral. In his case the concern was raised by his family on 13th December 2022 with the GP. The GP referred him to the CRT that day indicating he needed an assessment on 14th December 2023 for confusion following a fall and a possible UTI. At the assessment on 14th December 2023 at 11am Mr Sullivan was seriously unwell.
” Source location Michael Brian Sullivan · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There were no delays between the Crisis Response Team referral and assessment; the referral requested assessment the following day.
Verbatim wording from the response “• There were no delays between referral to CRT and assessment at the time of this referral.” Source location Response from Greater Manchester Integrated Care
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25 Jan 2023 Andrew Mark Largin · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure of the crisis team to reassess patients and reopen crisis-team cases when clinically indicated View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Andrew Mark Largin · 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
Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the crisis team to reassess patients and reopen crisis-team cases when clinically indicated
Wider context from the report “2. The report also identified that, despite receiving an email from the Homerton University Hospital community rehabilitation team on 2 February, saying that Mr Largin had been seen on 1 February and was still very depressed, the crisis team failed to reassess him or to re-open his case to the crisis team , but instead referred the community team to the neighbourhood team.
” Source location Andrew Mark Largin · Prevention of Future Deaths report
Open source report
26 Aug 2020 Toby Peter Edward Nieland · Prevention of Future Deaths report Lincolnshire
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Concerns raised 1
Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Lincolnshire County Council Lincolnshire Partnership NHS Foundation Trust WithYou
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
WithYou
Review Dual Diagnosis pathways across the treatment system jointly with partner organisations and commissioners.
View source
Lincolnshire County Council
Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.
View source
Lincolnshire Partnership NHS Foundation Trust
Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.
View source
Lincolnshire Partnership NHS Foundation Trust
Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.
View source See 1 more action
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Toby Peter Edward Nieland · 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
Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
Wider context from the report “8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis ;
” Source location Toby Peter Edward Nieland · Prevention of Future Deaths report
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Dual Diagnosis pathways across the treatment system jointly with partner organisations and commissioners.
Verbatim wording from the response “I can confirm that we have participated in ‘Planned Dual Diagnosis Work” meetings with LPFT and our respective commissioners. And we have jointly agreed to review Dual Diagnosis pathways across the treatment system.” Source location 2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.
Verbatim wording from the response “i. A joint working protocol is in place but has not been widely implemented across all services. The CCG, LPFT, We Are With You and Public Health should work together to review this protocol and implement a more robust” Source location 2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
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PFD Monitor interpretation Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.
Verbatim wording from the response “Learning from the death of Mr Nieland, the Trust will strengthen the policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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PFD Monitor interpretation Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.
Verbatim wording from the response “We have summarised below the actions the Trust will take to learn from Mr Nieland’s death and enhance services for patients with a complex dual diagnosis presentation: To review internal policies and protocols as well as work together with “We Are With You” to embed care pathways between the two organisations to address gaps in services. (Leads: Clinical Director for Community Division and Quality Lead for the Community Division)” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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29 Jan 2020 Thiago Araujo · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to make arrangements to address risks when closing crisis team referrals View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Thiago Araujo · 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
Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make arrangements to address risks when closing crisis team referrals
Wider context from the report “1. On 24 January 2020 Mr Araujo had discharged himself from psychiatric inpatient care he was to be supervised by the Camden and Islington NHS trust crisis team. Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo’s referral . In the course of this closure no arrangements were made to address the risks presented by Mr Araujo .
” Source location Thiago Araujo · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require senior multidisciplinary review, documented communication, and updated crisis and contingency plans before closing non-engagement referrals.
Verbatim wording from the response “Additional Recommendation: Any service user of the Crisis Team who is being considered for discharge because of non-engagement must be discussed in the Crisis Service Multi-Disciplinary Meeting with senior overview of the decision to discharge. The decision and rationale to discharge because of non-engagement must be clearly communicated to the” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.