30 Nov 2017 Lindsey Theresa Hassall · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to verify and coordinate necessary referrals from the 136 suite to the GP View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Lindsey Theresa Hassall · Prevention of Future Deaths report
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Report summary
Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.
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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 verify and coordinate necessary referrals from the 136 suite to the GP
Wider context from the report “• The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made .
” Source location Lindsey Theresa Hassall · 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 Develop and display a laminated flowchart guiding s136 handover recording, documentation access and referral processes.
Verbatim wording from the response “▪ Flowchart to be developed which reflects guidance in staff briefing – laminated copy to be displayed in 136 suite so it is available to staff coordinating and undertaking s136 assessments.” Source location 2017-0429-Responses
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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 Include the new s136 documentation and referral guidance in staff briefings and local induction processes, and add it to the s136 operating procedure and policy.
Verbatim wording from the response “▪ Advice to be included in staff briefing.” Source location 2017-0429-Responses
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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 junior doctors to state GP referrals clearly in summary letters and assessment teams to make, document and communicate required PCFT referrals.
Verbatim wording from the response “▪ Remind all junior doctors that if a person is to be referred back to the care of their GP they make this clear in the summary letter sent to the GP.” Source location 2017-0429-Responses
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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 Contact patients notified of a RAID s136 assessment and invite them for GP review to ensure appropriate follow-up.
Verbatim wording from the response “The relevant practice policies have been reviewed and, as a result of this case and the Regulation 28 Report, a new policy has been implemented to ensure that when notification of an assessment by the RAID team on a section 136 is received by the practice, patients will be contacted and invited for review with a GP to ensure appropriate follow up is in place.” Source location 2017-0429-Responses
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How this respondent position was interpreted
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PFD Monitor interpretation The practice considers that appropriate GP follow-up was discussed and arranged, and no additional onward referral was necessary at that time.
Verbatim wording from the response “The relevant practice policies have been reviewed and, as a result of this case and the Regulation 28 Report, a new policy has been implemented to ensure that when notification of an assessment by the RAID team on a section 136 is received by the practice, patients will be contacted and invited for review with a GP to ensure appropriate follow up is in place.” Source location 2017-0429-Responses
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Concerns raised 1
Failure to make referrals to the falls team or physiotherapy View source
This report raised 7 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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Peter Blakeney KING · Prevention of Future Deaths report
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Report summary
Peter Blakeney King was admitted to hospital with confusion, headache, fever and limb weakness, and later fell from his bed on 18 March 2017, sustaining fatal head injuries. The concerns included inadequate documentation and implementation of falls precautions, use of bed rails despite an assessment that they were not recommended, failure to provide an observable bed and crash mat, and failure to address falls risk at handover.
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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 referrals to the falls team or physiotherapy
Wider context from the report “(2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy . A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the fall.
” Source location Peter Blakeney KING · Prevention of Future Deaths report
Open source report
Concerns raised 4
Failure to direct screening referrals to the vascular screening team View source Uncertainty within general practice about the screening programme and referral criteria View source Absence of a system to direct screening requests to the correct department View source
Failure by radiology to appropriately process screening referrals View source See 1 more concern
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Michael John Halfpenny · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael John Halfpenny requested screening for an aortic aneurysm in March 2016 because of a strong family history, but the referral was sent to the wrong department, rejected, and not followed up. He later presented with severe abdominal pain on 9 December 2016, but diagnosis was delayed until he was peri-arrest; he died following emergency surgery for a ruptured abdominal aortic aneurysm. Concerns included inadequate referral and follow-up processes, uncertainty about the screening programme, and failures to ensure screening requests reached the correct team.
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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 direct screening referrals to the vascular screening team
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Source location Michael John Halfpenny · 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 Uncertainty within general practice about the screening programme and referral criteria
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Source location Michael John Halfpenny · 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 Absence of a system to direct screening requests to the correct department
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Source location Michael John Halfpenny · 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 by radiology to appropriately process screening referrals
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Source location Michael John Halfpenny · 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 Operate a system for redirecting incorrectly assigned imaging referrals and notifying referrers of the action and any required follow-up.
Verbatim wording from the response “2. We have implemented a new system for redirecting any imaging referrals that inadvertently get sent to the incorrect team. The Imaging Team, led by the Clinical Director for Imaging, has provided clear instructions to their administration and clerical staff to forward screening requests to the relevant service. A rejection letter will be sent to the referrer detailing the action that has been taken and any further actions required by them.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Inform GPs through the monthly newsletter about referral procedures for the Screening Programme.
Verbatim wording from the response “In addition to the above our Head of GP Services has sent out a new communication to GPs in our monthly GP newsletter to explicitly inform them of how to refer in to the Screening Programme.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Deliver rolling Vascular Service awareness sessions for GPs through Protected Learning Time events.
Verbatim wording from the response “The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Add AAA patient referral pathways to the PRISM referral-guidance system in collaboration with Primary Care colleagues.
Verbatim wording from the response “The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Complete and share a significant event analysis on AAA referral and screening learning.
Verbatim wording from the response “NC originally brought up this case for discussion in our practice meeting. Obviously following which, I was then able to investigate my involvement in the case. I have reflected on how aortic aneurysm should be investigated and have written with my own concerns about the Radiology Departments dealing of my referral in the hope they will reflect upon this and reach their own lessons on this tragic case. I have discussed the case with my partners and have provided this SEA to be sent with my colleagues report to the Coroner. I will ensure a copy of this and my letter to ████████.” Source location Response from Glenfield Surgery
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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 the significant event analysis to the South Leicestershire locality GP group.
Verbatim wording from the response “In order to disseminate learning to the wider GP community, I have taken the liberty of including a significant event analysis to our locality group which includes a number of practices that work within the South Leicestershire area.” Source location Response from Glenfield Surgery
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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 Include AAA referral and screening learning in the Leicestershire LMC newsletter.
Verbatim wording from the response “Obviously, this tragic case has caused all of us to read up about the screening and ask searching questions as a result of which, I have personally completed an SEA. My partner, ████████, who is Chair of the Leicester Medical Committee has included an article in the LMCs newsletter to disseminate learning to the entire GP community. He has also written a formal report for the Coroner detailing his involvement and including a copy of my letter to yourselves as well as my SEA report.” Source location Response from Glenfield Surgery
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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 Strengthen and update the imaging-referral rejection guideline with mandatory rejection reasons and CRIS documentation of referral letters.
Verbatim wording from the response “1. We have reviewed the process for rejecting imaging within the Trust. The guideline ‘Process for the Rejection of Imaging Referrals’ is being strengthened and updated and will now include an explicit requirement that rejected referrals need to have a clear statement of why the rejection has been made and a comment must be put on CRIS (the Radiology IT system) that a rejection letter has been sent to the referrer. This is being led by our Service Manager for Imaging and it is anticipated that this guideline will be available by the end of July 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
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25 Apr 2017 Linsay Bushell · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Poor coordination and delay in referral review for specialist placement View source
This report raised 15 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
Linsay Bushell · 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
Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.
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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 Poor coordination and delay in referral review for specialist placement
Wider context from the report “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area.
The Jury found:
Para 3
1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital.
2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014.
3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation.
4. Linsay put herself in the position in which she was found however her intention was unclear.
5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder.
6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death.
7. The risk was managed adequately and effectively during Linsay's period as an in-patient.
8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made.
a. In the Trust Position Statement
Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them.
2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015.
3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material.
4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest.
5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity.
6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism.
It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment.
a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour.
b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism.
c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism.
7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust.
8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows:
a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub.
b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour.
c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient.
d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases.
e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package.
9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation.
10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided.
11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels.
12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better.
b. In the implementation of Lessons learnt the Trust further accepts
1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay".
a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:-
b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan.
c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay.
d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all.
e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear.
f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan.
g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time.
h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together.
i. Poor coordination of referral to a specialist provider . The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs.
j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for.
k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission.
l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation.
m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective.
2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation.
Discontinuity of Care/Management of Care
3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B.
4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units.
5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach.
6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager.
7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse.
8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway.
9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible.
Risk Assessment/Care Planning
10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk.
11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required.
” Source location Linsay Bushell · Prevention of Future Deaths report
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17 Feb 2016 Matthew Crowley · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Delays in securing acceptance by an appropriate vascular site 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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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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Matthew Crowley · Prevention of Future Deaths report
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Matthew Crowley, aged 39, presented to Maidstone Hospital acutely unwell with sepsis and multiple organ failure, and died at Pembury Hospital at 06.47 on 10 June 2015 after transfer. The report identified concerns including delays in triage, senior medical review, treatment escalation, decision-making and transfer, as well as inadequate communication with the receiving ITU.
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PFD Monitor interpretation Delays in securing acceptance by an appropriate vascular site
Wider context from the report “(4) Despite a vascular site declining to accept the patient until his renal function was optimised and a CT angiogram performed, a delay was caused by enquiries being made whether a second vascular site would accept the patient
” Source location Matthew Crowley · Prevention of Future Deaths report
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23 Oct 2015 Margaret Anne Ferry · Prevention of Future Deaths report Sunderland
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Concerns raised 2
Lack of an inter-trust policy clarifying responsibility and communication channels for referred patients View source Lack of a policy clarifying responsibilities and communication channels between trusts when patients are referred View source
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Margaret Anne Ferry · Prevention of Future Deaths report
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Report summary
Margaret Anne Ferry was admitted to Sunderland Royal Hospital, underwent a planned toe amputation, and subsequently developed deterioration in her skin integrity before dying on 12 May 2015. The report identified unclear responsibilities between hospitals, poor written and oral communication, differing practices and procedures, and a lack of leadership and a cohesive treatment plan.
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PFD Monitor interpretation Lack of an inter-trust policy clarifying responsibility and communication channels for referred patients
Wider context from the report “1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred .
” Source location Margaret Anne Ferry · 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 Lack of a policy clarifying responsibilities and communication channels between trusts when patients are referred
Wider context from the report “1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred .
” Source location Margaret Anne Ferry · Prevention of Future Deaths report
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PFD Monitor interpretation Develop and establish a standing operational procedure governing inter-organisational plastic surgery referrals, including documentation, response timescales and care responsibilities.
Verbatim wording from the response “We have recognised that there were significant gaps in the provision of services to Margaret therefore, Anne Ferry, City Hospitals Sunderland, and the Trust have worked closely with our colleagues at City Hospital Sunderland to address the issues raised. In collaboration we have developed a new standing operational procedure to provide a comprehensive approach to inter organisational referrals for plastic surgery opinions. The standard procedure provides a process to ensure that the referral is clearly documented; that a suitable response is provided within clearly defined timescales, and that it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team. I have included this for your information.” Source location 2015-0450-Response
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PFD Monitor interpretation Patients on Sunderland Royal wards remain under the admitting consultant’s care, not the plastics team’s responsibility.
Verbatim wording from the response “We have recognised that there were significant gaps in the provision of services to Margaret therefore, Anne Ferry, City Hospitals Sunderland, and the Trust have worked closely with our colleagues at City Hospital Sunderland to address the issues raised. In collaboration we have developed a new standing operational procedure to provide a comprehensive approach to inter organisational referrals for plastic surgery opinions. The standard procedure provides a process to ensure that the referral is clearly documented; that a suitable response is provided within clearly defined timescales, and that it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team. I have included this for your information.” Source location 2015-0450-Response
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Concerns raised 1
Failure to dispatch secondary care referral letters View source
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James Bewick Graham · Prevention of Future Deaths report
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Report summary
James Bewick Graham, who had peripheral vascular disease and recurring problems with his left foot, was admitted to hospital after his condition deteriorated, underwent an amputation, and died on 2 November 2014. The report identified concerns about delayed referral to secondary care, poor communication between healthcare professionals, unclear responsibility for making the referral, and administrative failures that meant the referral was not dispatched.
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PFD Monitor interpretation Failure to dispatch secondary care referral letters
Wider context from the report “(3) The GP who agreed to make a referral to secondary care gave evidence that she had wrote out a letter of referral and handed it to a member of the administrative team for typing and gave verbal instructions that this needed to be dealt with quickly and that if there were any problems she was to be contacted. For an unknown reason the letter of referral was not dispatched. Some consideration has been given to this issue following the publication of the PPO report but in the light of the evidence given in court the thoroughness and robustness of that letter of direction, particularly bearing in mind there have been a number of changes to the providers of healthcare in the prison, should be considered.
” Source location James Bewick Graham · Prevention of Future Deaths report
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PFD Monitor interpretation Issue referral guidance requiring the referring doctor to complete and monitor referrals, retain responsibility, and avoid delegating urgent referrals.
Verbatim wording from the response “A Directive has been issued by Spectrum Community Health CIC, that states;” Source location James-Graham-Response
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17 Jun 2014 SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to make direct written Trust-to-Trust referrals when transferring patients to another Trust View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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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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SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report
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Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.
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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 direct written Trust-to-Trust referrals when transferring patients to another Trust
Wider context from the report “I heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust’s Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP , given the complex needs and history of Sol and that this should have been planned in advance. Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, I am nevertheless concerned that a similar circumstance to arise in the future an preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. I was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust.
” Source location SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report
Open source report
21 Nov 2013 Peter Galea · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Limited mechanisms for breaking referral cycles between agencies 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.
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
Peter Galea · 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
Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the outcome.
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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 Limited mechanisms for breaking referral cycles between agencies
Wider context from the report “Mr Galea was not known to mental health services and experienced multiple presentations to a number of professionals and agencies within a 72 hour period and had 3 mental health assessments, all of which placed him at a low risk.
Whilst it is a tragedy that the professionals and agencies did not have more of an opportunity to work with Mr Galea before he took his own life, I was concerned, that: -
1) there appeared to be limited mechanisms available to break the cycle of referrals between agencies without more positive action being taken whereby Mr Galea could be in a safe place whilst a more detailed assessment of his needs could be carried out possibly involving a psychiatrist . The family described the referral between agencies as “ping pong”.
2) there were limitations upon the GP making a direct referral to have Mr Galea admitted to Cherry Knowle Hospital, because to do so Mr Galea would have had to go back to the Mental Health Team, with whom he had had three contacts within a 72 hour period. From the evidence it was clear that the GP had a positive relationship with his patient (for 4 years) and although prospectively acquiescing to the patient’s wishes, in exceptional circumstances, it may be that a GP should be able to achieve an admission to a place of safety, even if only for a limited period of time. I readily acknowledge some of the disadvantages which may come into play by way of admission but in raising it there may also be advantages which would promote a patient’s welfare.
3) I was grateful for the assistance of ████████ Consultant Psychiatrist, but he was not able to offer to me any view about what may have been done differently for Mr Galea to avoid this very tragic outcome. In raising the matter with you, it may be that some solution to enhance patient’s welfare and wellbeing can be found to prevent future deaths.
” Source location Peter Galea · Prevention of Future Deaths report
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Includes failures in the dedicated coordination of referrals between healthcare teams or organisations, including unclear or unshared referral criteria, missing responsibility and communication arrangements, restricted or inappropriate referral routes, and failures to accept, transfer or coordinate referrals.
