Concerns raised 4
Failure to alleviate service users’ distress and improve engagement during repeated crisis contacts View source Failure to provide an evident handover from the crisis team to the community psychiatric nurse View source Insufficient crisis team resources to meet service demand View source
Failure to provide continuity of crisis team care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 10
Action
Review local staff guidance on pre-visit preparation, including prior-entry, risk-assessment, outstanding-action and communication-needs checks.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Review the Crisis-to-CMHT discharge process to establish a documented referral and prioritisation process for immediate CMHT allocation.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Implement the revised discharge process, retaining Crisis responsibility until a CMHT appointment is offered and updating crisis and contingency plans with CMHT.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source
Action
Monitor compliance with the revised Crisis-to-CMHT discharge process through the designated Crisis Service responsibility.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source
Action
Recruit 8.5 whole-time-equivalent registered and 12.6 whole-time-equivalent unregistered Crisis Service staff to increase capacity.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Recruit a full-time psychologist to provide psychological-intervention support, supervision and staff support within the Crisis team.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Review and revise the Keyworker Standard Operating Procedure to define responsibilities for assessment, care planning, monitoring and discharge planning.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Use rostered assessment-only periods for registered clinicians, with clinicians focusing on treatment outside those periods, to increase treatment capacity and continuity.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Audit Crisis patients open between September 2018 and September 2019 to assess staff bands and visit continuity by the end of November 2019.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source
Action
Develop a continuity-of-care improvement plan informed by the Crisis Service continuity audit.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source See 7 more actions
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AI-generated summary
Kim Morris · 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
Kim Morris died from the consequences of suspension by ligature after being found in the garage at home and resuscitated. The report raises concerns about a lack of continuity within the crisis team, inadequate handover to community psychiatric nursing, and whether the service was suitable to support high-risk individuals. It states that these pressures and service concerns remained unresolved.
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 alleviate service users’ distress and improve engagement during repeated crisis contacts
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris. It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member , or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” Source location Kim Morris · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide an evident handover from the crisis team to the community psychiatric nurse
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris. It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment . She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” Source location Kim Morris · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient crisis team resources to meet service demand
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris. It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available . The service remains on the Trust’s “at risk” register .
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care . This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” Source location Kim Morris · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide continuity of crisis team care
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals , and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris . It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” Source location Kim Morris · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review local staff guidance on pre-visit preparation, including prior-entry, risk-assessment, outstanding-action and communication-needs checks.
Verbatim wording from the response “Service response
The additional investment will support our commitment to improving the continuity of care of all patients in Crisis we support. This includes the review of our local guidance for staff on pre-visit preparation, which expects all staff to read the previous visit entry, review any recent risk assessments, confirm outstanding actions from the previous visit have been completed, and check any communication needs prior to the scheduled visit. We will develop a spot check tool to establish that the changes as the result of the review of the local guidance have been imbedded into practice. We will ensure that we are able to offer assurances of our compliance on this through co-producing a spot check tool directly with our service users.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Crisis-to-CMHT discharge process to establish a documented referral and prioritisation process for immediate CMHT allocation.
Verbatim wording from the response “2. It was accepted that Mrs Morris be referred to a Community Psychiatric Nurse to continue her engagement and continuity of care prior to discharge, but no contact was made prior to her discharge, potentially leaving her fearful of a delay.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
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 the revised discharge process, retaining Crisis responsibility until a CMHT appointment is offered and updating crisis and contingency plans with CMHT.
Verbatim wording from the response “Service response
The discharge process for patients under the care of the Crisis team to Community Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and documented referral process with a prioritisation rationale for the patient to be immediately allocated to a CMHT team member. The Crisis team will retain responsibility for the patient until an appointment with the CMHT team member has been offered. The Crisis team will work with the CMHT to ensure that the crisis and contingency plan is updated. Our Town for Crisis Services will have responsibility for ensuring that ongoing monitoring is in place to ensure compliance is adhered to. This new process will be fully in place by the end of December 2019.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
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 Monitor compliance with the revised Crisis-to-CMHT discharge process through the designated Crisis Service responsibility.
Verbatim wording from the response “Service response
The discharge process for patients under the care of the Crisis team to Community Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and documented referral process with a prioritisation rationale for the patient to be immediately allocated to a CMHT team member. The Crisis team will retain responsibility for the patient until an appointment with the CMHT team member has been offered. The Crisis team will work with the CMHT to ensure that the crisis and contingency plan is updated. Our Town for Crisis Services will have responsibility for ensuring that ongoing monitoring is in place to ensure compliance is adhered to. This new process will be fully in place by the end of December 2019.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit 8.5 whole-time-equivalent registered and 12.6 whole-time-equivalent unregistered Crisis Service staff to increase capacity.
Verbatim wording from the response “Service Response
We acknowledge your concerns that we are not able to offer a service to support such high risk individuals, and would like to reassure you that, as a Trust we take these concerns seriously. We have received additional investment to further enhance the Crisis Service, to enable us to improve the service we deliver.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
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 Recruit a full-time psychologist to provide psychological-intervention support, supervision and staff support within the Crisis team.
Verbatim wording from the response “equivalent unregistered staff. These additional staff will increase the capacity of the team, and alleviate some of the known high demand and pressures. A full time Psychologist is also being recruited to support psychological interventions and will provide supervision and support to staff in the team. We are expecting that this additional support will be fully in place by the end February 2020.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the Keyworker Standard Operating Procedure to define responsibilities for assessment, care planning, monitoring and discharge planning.
Verbatim wording from the response “1. There were numerous visits and telephone encounters with many different individuals and the role of the key worker did not reduce these.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
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 Use rostered assessment-only periods for registered clinicians, with clinicians focusing on treatment outside those periods, to increase treatment capacity and continuity.
Verbatim wording from the response “Service response
We accept our continuity of care is challenged and want to assure you we are committed to improve this area of care with the new investment outlined above. We have already implemented new ways of allocating registered clinicians for assessments to increase the time available to deliver treatment. Registered staff members are now rostered four weeks of carrying out assessments only. Outside of these blocks they will then focus on treatment. This process was implemented in” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit Crisis patients open between September 2018 and September 2019 to assess staff bands and visit continuity by the end of November 2019.
Verbatim wording from the response “June 2019 and the team are currently monitoring the impact this has on continuity of care.
In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
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 a continuity-of-care improvement plan informed by the Crisis Service continuity audit.
Verbatim wording from the response “June 2019 and the team are currently monitoring the impact this has on continuity of care.
In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
13 Mar 2019 Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to provide continuity in the number of staff involved in care View source
This report raised 1 other concern. 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.
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AI-generated summary
Tamsin Rebecca Lianne GRUNDY · 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
Tamsin Rebecca Lianne Grundy, who had a history of depression and was under the care of Mental Health Services, was found dead at home on 26 July 2018 with a weightlifting bar across her neck. Concerns included her difficulty relating to the more than 25 members of the Crisis Resolution Home Treatment Team involved in her care and the lack of a definitive, timed action or named person responsible for addressing this issue.
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 provide continuity in the number of staff involved in care
Wider context from the report “1.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team . It is understood Miss Grundy saw 25 plus members of the Team in some 14 months . The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service .
2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action.
” Source location Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.
Verbatim wording from the response “Notwithstanding this challenge, it was the expressed experience of Ms Grundy that having such numbers of staff involved made it difficult to form therapeutic relationships. To support continued development of the service provided, the CRHT team is using a national 39 point fidelity scale to help it reflect on current practices identifying areas of focus and improvement. One of the points refers directly to this matter and the team are working to apply this on a consistent basis, using daily planning to match clinicians with individual visits where a positive therapeutic relationship has developed. The scale is being used more widely across the Trust.” Source location 2019-0088-Response-by-Norfolk-Suffolk-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.
Verbatim wording from the response “Ms Grundy was in contact with the Trust’s Youth Service since 2016. She was allocated a staff member whose role was to coordinate her care. This member played an important role in forming a therapeutic relationship with the service user, working together to implement plans to help respond to the individual’s needs. There are occasions where an individual’s need changes requiring a period of more intensive support which is provided by the Trust’s acute services. The CRHT provide intensive periods of support in the community for short periods, supplementing the care provided by the community team. This means the team have to be flexible and adaptable in approach requiring staff to work over a 24 hour period, seven days per week. Appointments with users may range from multiple contacts in a day to every few days.” Source location 2019-0088-Response-by-Norfolk-Suffolk-NHS-Trust
Open published response
27 Feb 2018 David John Ireland · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Failure to advise about emergency department presentation when mental health crisis concerns continue View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David John Ireland · 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
David John Ireland experienced an acute-onset psychosis, forced entry into a house, climbed from a first-floor window while detained by residents, and sustained serious injuries in the fall. He died shortly after admission to hospital; a concern was raised that the crisis team did not advise him or his friend that he could attend the emergency department for an urgent mental health assessment.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to advise about emergency department presentation when mental health crisis concerns continue
Wider context from the report “(1) Contact was made by Mr Ireland’s friend on the day of his death with the crisis team. Mr Ireland also spoke with them during the same telephone contact call. No advice was given that Mr Ireland could present at the emergency department should concerns continue about his mental health crisis.
Had such advice been given it may have impacted on the course of events and facilitated an urgent mental health assessment. This opportunity was lost as Mr Ireland was not able to make any such decision and his friend was unaware that this was an option available with sudden onset mental health symptoms.
” Source location David John Ireland · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include advice about giving options for further support in local induction for temporary workers in the relevant teams.
Verbatim wording from the response “We will be including the need to give this advice in our local induction for temporary workers (agency staff) within these teams.” Source location 2018-0057-Response-by-Devon-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review relevant answer-machine messages and add references to all appropriate sources of further support.
Verbatim wording from the response “We have asked the relevant teams to review any answer machine messages they use and include appropriate reference to all sources of further support.” Source location 2018-0057-Response-by-Devon-Partnership-NHS-Trust
Open published response
28 Dec 2017 Michael Richard Drewry · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure to ensure consistency and continuity of care View source
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.
×
AI-generated summary
Michael Richard Drewry · 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 Richard Drewry had a history of anxiety and low mood, with deteriorating mental health and episodes involving knives shortly before he was found with a ligature around his neck on 3 April 2017. He sustained fatal injuries, suffered an unsurvivable hypoxic brain injury, and died in hospital on 8 April 2017. The substantive concerns were failures by the Crisis Team to provide consistent and continuous care, make accurate and prompt records, and escalate concerns appropriately and promptly.
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 ensure consistency and continuity of care
Wider context from the report “(1) The failure of the Crisis Team to ensure consistency and continuity of care for the deceased, in particular the changing personnel who visited the deceased ;
” Source location Michael Richard Drewry · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Modified Modified Continuity Index into routine reporting, trial it in one team, and then implement it across Crisis Teams.
Verbatim wording from the response “The Trust is shortly to introduce the Modified Modified Continuity Index (MMCI) into its routine reporting systems, at both individual and team levels. This is a measure calculated using the total number of patient visits and the number of different clinical staff visiting the patients and gives a resulting score between 0 and 1, the more staff providing care to the patient the lower the score will be.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continuity of staff cannot always be provided because 24-hour crisis response requirements and high-intensity care create operational constraints.
Verbatim wording from the response “Continuity of care is a challenge within our Crisis Resolution and Home Treatment Teams due to the service operating 24 hours a day, 7 days a week. Staff work 12 hour shifts and need to be able to respond swiftly to urgent referrals, within 4 hours and 24 hours whilst also maintaining robust care and treatment for those patients already on their caseload.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-Trust
Open published response
23 Oct 2017 Siân Louise WITHERIDGE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Disjointed coordination of care between crisis house and crisis team services View source Failure to arrange crisis team follow-up meetings View source
This report raised 5 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.
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AI-generated summary
Siân Louise WITHERIDGE · 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
Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Disjointed coordination of care between crisis house and crisis team services
Wider context from the report “6. The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dovetailed between OneHousing and Camden & Islington NHS Trust .
For example, the crisis team members who gave evidence did not have any knowledge of the crisis house procedure for risk assessing before allowing leave .
” Source location Siân Louise WITHERIDGE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to arrange crisis team follow-up meetings
Wider context from the report “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.
False reassurance appeared to have been drawn from the latter. No arrangement was made for the crisis team to meet Ms Witheridge on 30 May .
” Source location Siân Louise WITHERIDGE · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.
Verbatim wording from the response “We agree that Highbury Grove Crisis House staff should have access to our clinical records. To this end, we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.” Source location 2017-0305-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce joint risk assessments completed by OneHousing and Camden and Islington staff.
Verbatim wording from the response “We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&I staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&I staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient.” Source location 2017-0305-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce detailed feedback to OneHousing staff and agreement of a written action plan when crisis team staff complete risk assessments.
Verbatim wording from the response “We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&I staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&I staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient.” Source location 2017-0305-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.
Verbatim wording from the response “We are aware that Highbury Grove has sent you our ‘Working Protocol’ setting out how our teams work together. As set out earlier, we accept that there have been challenges with information sharing. We are confident however that this has been rectified and Highbury Grove and staff will in the future have ready access to all the relevant clinical information.” Source location 2017-0305-Response
Open published response
5 Sep 2016 John Gerard JONES · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2
Delays in notifying GPs of Crisis Team discharge View source Lack of clear Crisis Team training, structural or protocol provision for discharge communication View source
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.
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AI-generated summary
John Gerard 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
John Gerard JONES had been receiving support because of a perceived risk of suicide, and admission to hospital was recommended but not undertaken. He later took his own life by drowning in the River Avon on or around 1 February 2016. The principal concern was that his GP was not notified of his discharge from the Crisis Team for approximately a week, leaving uncertainty about community support during that period.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in notifying GPs of Crisis Team discharge
Wider context from the report “(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.
” Source location John Gerard JONES · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear Crisis Team training, structural or protocol provision for discharge communication
Wider context from the report “(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.
” Source location John Gerard JONES · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to provide immediate written discharge and high-risk notification to the crisis team View source
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.
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AI-generated summary
Anthony John Preston · 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
Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide immediate written discharge and high-risk notification to the crisis team
Wider context from the report “(3) There was no immediate follow up by email or fax to the Crisis Team to notify the discharge, and the fact that Mr Preston was at high risk because of the anxiety created when he was living at home.
” Source location Anthony John Preston · Prevention of Future Deaths report
Open source report
1 Jun 2015 Mark Patrick DANIELS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5
Lack of clinical direction in crisis care View source Lack of cohesion in crisis care View source Failure of communication within the crisis team and with crisis houses View source
Delays in progressing referrals to a crisis house View source Failure to conduct twice-daily crisis team visits in accordance with the care plan View source See 2 more concerns
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.
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AI-generated summary
Mark Patrick DANIELS · 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 Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clinical direction in crisis care
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction .
” Source location Mark Patrick DANIELS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of cohesion in crisis care
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” Source location Mark Patrick DANIELS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of communication within the crisis team and with crisis houses
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses ;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” Source location Mark Patrick DANIELS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in progressing referrals to a crisis house
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly ;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” Source location Mark Patrick DANIELS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct twice-daily crisis team visits in accordance with the care plan
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do ;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” Source location Mark Patrick DANIELS · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
Verbatim wording from the response “████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several” Source location 2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Open published response
23 Mar 2015 Barbara Mary Anne Mayer · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to provide continuity of care View source
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.
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AI-generated summary
Barbara Mary Anne Mayer · 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
Barbara Mary Anne Mayer had a history of depression and was found drowned in a nearby pond on 16 November 2014 after leaving her house during the early hours. Concerns included carer fatigue not being followed up, lack of continuity in her care, treatments not being adequately discussed with her, and no urgent mental health assessment being available when she needed help on 14 November 2014.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide continuity of care
Wider context from the report “(2) Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relationship could be established . She had to repeat her history at each visit to a different person about personal details.
” Source location Barbara Mary Anne Mayer · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Crisis Resolution and Home Treatment team functions, including ways to improve consistency of staff contact with service users.
Verbatim wording from the response “The Crisis Resolution and Home Treatment (CRHT) team provide a 24 hour service, assessing and supporting service users with intensive treatment for defined periods of time. It has a team of fifty staff supporting a significant number of people across a large geographical area. These factors mean that planning and coordinating consistent staff contact with a service user is a challenge.” Source location 2015-0113-Response-by-Norfolk-Suffolk-NHS-Trust
Open published response
Concerns raised 1
Failure to ensure crisis team responsibility for providing assistance View source
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.
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AI-generated summary
Barrie Lewis · 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
Barrie Lewis was found by his family hanging from a rope attached to a garage rafter on 31 August 2014. The inquest concluded that his death was suicide. Concerns included the absence of a specific risk assessment for suicidal ideation, poor communication between mental health services, no reliable system assigning responsibility for assistance, and a lack of clinical records of crisis-team contact.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure crisis team responsibility for providing assistance
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that:
a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm.
b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death.
c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department .
d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them.
” Source location Barrie Lewis · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a procedure defining the role of the duty officer.
Verbatim wording from the response “2. Actions implemented” Source location 2015-0065-Response-by-University-Health-Board
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Includes failures of the named crisis team care process involving insufficient capacity, staffing or demand management, fragmented or unreliable continuity, delayed handover, or other dedicated controls that prevent reliable support for people requiring crisis team care.
