14 Jan 2026 Stephen Taylor · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure to assign ownership of urgent risk management across services View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Stephen Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Taylor experienced worsening mental distress linked to work and financial concerns, with escalating risk indicators and repeated contact with health services. He died on 26 May 2025 after deliberately jumping from Louisa Bay Cliffs. The principal concerns were the lack of coordinated escalation and ownership of risk across services, reliance on his denial of immediate intent despite other risk indicators, routine rather than urgent referrals, and the absence of a same-day urgent face-to-face assessment despite family concerns.
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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 assign ownership of urgent risk management across services
Wider context from the report “(5) Responsibility for escalation became diffuse across multiple services , creating a foreseeable risk that no single service took ownership of urgent risk management .
” Source location Stephen Taylor · Prevention of Future Deaths report
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22 Dec 2025 Wendy Siobhan EYLES · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Lack of a consistent protocol for patients receiving private and NHS psychiatry View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Wendy Siobhan EYLES · 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
Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric treatment.
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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 consistent protocol for patients receiving private and NHS psychiatry
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time ...".
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient.
” Source location Wendy Siobhan EYLES · Prevention of Future Deaths report
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22 Dec 2025 Wendy Siobhan EYLES · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Lack of a protocol for patients receiving concurrent private and NHS psychiatry View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHFT
Develop and complete a Trust-wide protocol for managing patients receiving simultaneous NHS and private psychiatric care.
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Wendy Siobhan EYLES · 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
Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated between services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a protocol for patients receiving concurrent private and NHS psychiatry
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust . The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time ..”.
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient.
” Source location Wendy Siobhan EYLES · Prevention of Future Deaths 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 and complete a Trust-wide protocol for managing patients receiving simultaneous NHS and private psychiatric care.
Verbatim wording from the response “Protocol for patients receiving NHS and private psychiatry
Patient safety is of paramount importance to NHFT. We understand that there are risks to a patient’s safety when they are receiving private psychiatric care alongside our own treatment plan. To manage these risks, we are developing a new private care protocol.” Source location 2026-0153 - Response from Northamptonshire Healthcare NHS Foundation Trust
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14 Nov 2025 Suzanne Julia ELLERBY · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Suzanne Julia ELLERBY · 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
Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer
Wider context from the report “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices.
There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services . Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable.
- Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter;
- NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place;
- In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so.
” Source location Suzanne Julia ELLERBY · Prevention of Future Deaths report
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2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Department of Health and Social Care Greater Manchester Mental Health NHS Foundation Trust NHS England North West Ambulance Service NHS Trust Trafford Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Greater Manchester Mental Health NHS Foundation Trust
Revise the repatriation procedure to support communication and continuity of care for international patients.
View source
Greater Manchester Mental Health NHS Foundation Trust
Share the revised community mental health policy’s final draft with the Trafford Strategic Safeguarding Partnership.
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Greater Manchester Mental Health NHS Foundation Trust
Share learning with the overseas hospital consultant and reinforce proactive communication before discharge.
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Care Quality Commission
Continue monitoring how providers work with other agencies during service transitions to prevent gaps in care.
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Michael Sean Heath · 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 Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health 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 Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” Source location Michael Sean Heath · Prevention of Future Deaths 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 Revise the repatriation procedure to support communication and continuity of care for international patients.
Verbatim wording from the response “Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly developed Community Mental Health Transformation policy which outlines the steps necessary to ensure seamless communication and care for international patients. This policy is currently a working draft, and it is anticipated a final draft will be shared with the Trafford Strategic Safeguarding Partnership in early 2025.” Source location Response from Great Manchester Mental Health NHS
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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 Share the revised community mental health policy’s final draft with the Trafford Strategic Safeguarding Partnership.
Verbatim wording from the response “Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly developed Community Mental Health Transformation policy which outlines the steps necessary to ensure seamless communication and care for international patients. This policy is currently a working draft, and it is anticipated a final draft will be shared with the Trafford Strategic Safeguarding Partnership in early 2025.” Source location Response from Great Manchester Mental Health NHS
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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 Share learning with the overseas hospital consultant and reinforce proactive communication before discharge.
Verbatim wording from the response “In response to our learning from Mr Heath’s death, the Trust contacted the Consultant Psychiatrist at Oceanview Hospital in Gibraltar to share learning and reinforce the importance of proactive communication upon discharge. Going forward, this procedure will ensure that overseas providers understand the need to engage with the Trust prior to repatriation.” Source location Response from Great Manchester Mental Health NHS
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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 Continue monitoring how providers work with other agencies during service transitions to prevent gaps in care.
Verbatim wording from the response “Our assessment of services includes how providers respond to patients transitioning between services. We will continue to work with providers to monitor how they are working effectively with other agencies to prevent gaps in a person’s care.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.
Verbatim wording from the response “Within your listed matters, you have raised over-arching concerns regarding Policing, the management of mental health patients, the quality of collaboration between mental health services both abroad and in the UK upon repatriation whilst the patient remains ill and GP decision-making – and I note that there is no specific reference to the actions of Trafford Council within those listed concerns. As these concerns do not relate to the actions nor decision-making of Trafford Council, you will appreciate that I am unable to specifically address these with a respective timetable for action.” Source location Response from Trafford Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Overseas healthcare providers cannot be mandated to share clinical information when patients are medically repatriated.
Verbatim wording from the response “Regarding your concern over the apparent lack of connectivity between mental health services abroad and the UK, whilst it would be NHS England’s hope that, in the patient’s best interests, when a patient is medically repatriated there will be appropriate sharing of clinical information between the discharging and receiving healthcare providers, this cannot be mandated for overseas healthcare providers.” Source location Response from NHSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A provider cannot reasonably be expected to know about a patient’s return when the patient independently arranged travel and gave no notification.
Verbatim wording from the response “Further, where a patient makes their own arrangements to return to the UK independent of an overseas healthcare provider, there can be no expectation that a provider would be aware of the patient’s travel arrangements unless the patient themselves notifies the relevant provider of their return. In this case, it is our understanding that Michael made his own travel arrangements independent of an overseas healthcare provider, and did not notify a provider in England of his return.” Source location Response from NHSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.
Verbatim wording from the response “Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not be able to provide any assistance with those concerns.” Source location Response from NWAS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental-health repatriation is not provided for by the Mental Health Act and presents infeasible data-protection, language and logistical challenges.
Verbatim wording from the response “You have also raised concerns around a lack of connectivity between mental health services abroad and the UK upon repatriation to the UK. I should explain that the Mental Health Act does not include provision for repatriation of individuals back to the UK (other than in certain cases where individuals have been diverted from the justice system to the hospital system by an order of a court following a criminal offence). This would present a number of challenges in terms of data protection, language and logistical practicalities which would not be feasible.” Source location Response from DHSC
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7 Dec 2023 KATHARINE ANNE FOX · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to provide continuity and handover between hospital and community psychology services View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Essex Partnership University NHS Foundation Trust
Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
View source
Essex Partnership University NHS Foundation Trust
Regularly audit handovers to verify safe transfer of psychological care to community teams.
View source
Essex Partnership University NHS Foundation Trust
Review the operational model for transitions and handovers between inpatient and community psychological services.
View source
Essex Partnership University NHS Foundation Trust
Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
View source
Essex Partnership University NHS Foundation Trust
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
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AI-generated summary
KATHARINE ANNE FOX · 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
Katharine Fox died by hanging in October 2022 after being discharged from hospital, having been unable to access community psychology services during the following months. Concerns related to the lack of handover and continuity between hospital and community psychology services, substantial waiting times, and possible inability of clinicians to access notes held on different computer systems.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide continuity and handover between hospital and community psychology services
Wider context from the report “(1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community , including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively.
” Source location KATHARINE ANNE FOX · Prevention of Future Deaths 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 Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
Verbatim wording from the response “Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner. The Community Team psychological practitioner will discuss the care and treatment with the community mental health team to ensure the patient receives appropriate care and support in the community. The care in the community can be provided by the psychological practitioner or other appropriate team member under the supervision of a qualified registered psychological practitioner.” Source location Response from Essex Partnership University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regularly audit handovers to verify safe transfer of psychological care to community teams.
Verbatim wording from the response “The process of handover will be regularly audited to ensure that the care is safely transferred to the Community Team.” Source location Response from Essex Partnership University NHS Foundation Trust
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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 operational model for transitions and handovers between inpatient and community psychological services.
Verbatim wording from the response “Further, the Unit is currently reviewing the operational model to improve the transition and handover of care between inpatient and community psychological services, with the aim of streamlining this provision.” Source location Response from Essex Partnership University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
Verbatim wording from the response “The new process will include a joint consultation between the inpatient and community psychological services in order to aid care planning and formal handover of appropriate inpatient cases prior to discharge across each locality in Essex. Handover will be recorded on the patient’s electronic notes.” Source location Response from Essex Partnership University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Verbatim wording from the response “Further, the Court is advised that it is commissioning a unified Electronic Medical Records System, in the interim Psychological Services will now have access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing between inpatient and community clinicians. This will be achieved through the aforementioned joint forum which will incorporate a formal handover of all required information. Should access to more detailed clinical information be required, this can be requested.” Source location Response from Essex Partnership University NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.
Verbatim wording from the response “Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.” Source location Response from Essex Partnership University NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Verbatim wording from the response “The Court is respectfully advised that EPUT (like a number of NHS Trusts) uses multiple Electronic Medical Records Systems, which includes PARIS and MOBIUS. Staff within the Inpatient Psychological Services team have access to both systems, as well as Health Information Exchange (HIE) and can therefore access all records/reports. Our IT department has recently confirmed that all clinical staff in Adult Community Psychological Services can also access both systems.” Source location Response from Essex Partnership University NHS Foundation Trust
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Concerns raised 1
Fragmented connectivity between mental health and physical or neurodivergence services View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Hampshire and Isle of Wight Healthcare NHS Foundation Trust NHS Hampshire and Isle of Wight Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Establish a single community and mental health provider through Project Fusion.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Develop a countywide neurodiversity best-practice network and working groups to create measurable, sustainable operating procedures.
View source
NHS Hampshire and Isle of Wight Integrated Care Board
Recommission autism and ADHD assessment and prescribing pathways to provide a cohesive population-wide service.
View source
NHS Hampshire and Isle of Wight Integrated Care Board
Operate an all-age autism and ADHD improvement group to oversee transformation of the neurodiversity pathway.
View source See 1 more action
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AI-generated summary
Kirsty Clare TAYLOR · 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
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
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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 Fragmented connectivity between mental health and physical or neurodivergence services
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity . It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients .
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty. There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow . More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths prevented.
” Source location Kirsty Clare TAYLOR · 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 Establish a single community and mental health provider through Project Fusion.
Verbatim wording from the response “There is consensus that we will be more likely to achieve this future by joining up the disparate, often inconsistent services and pathways delivered by four different community and mental health providers. It has therefore been concluded that the best way to enable our vision is by working together to establish a new, single community and mental health provider, while, at the same time, accelerating collaboration and transformation, led by our clinical experts, to reduce the significant pressures in our system. The creation of this new provider is progressing at pace (Project Fusion) with the new legal entity due to be in place by 1 April 2024.” Source location Response from Southern Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a countywide neurodiversity best-practice network and working groups to create measurable, sustainable operating procedures.
Verbatim wording from the response “In addition to the training, we intend to build a network across the county to share best practice and tackle issues collectively and we have a number of working groups in place, which include broad input across clinical and corporate services and the service user voice, with a remit is to ensure what we have designed is measurable, tested and sustainable for the future.” Source location Response from Southern Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recommission autism and ADHD assessment and prescribing pathways to provide a cohesive population-wide service.
Verbatim wording from the response “2. Autistic Spectrum Condition (ASC) and Attention Deficit Hyperactivity Disorder (ADHD) pathway developments” Source location Response from Hampshire and Isle of Wight
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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 an all-age autism and ADHD improvement group to oversee transformation of the neurodiversity pathway.
Verbatim wording from the response “secondary care provider of mental health services and future ASC/ADHD assessment and prescribing provider(s) to establish much stronger and collaborative working arrangements.” Source location Response from Hampshire and Isle of Wight
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24 Apr 2023 Samuel Thomas Howes · Prevention of Future Deaths report South London
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Concerns raised 1
Failure of Child & Adolescent Mental Health Service teams to work together effectively View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
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AI-generated summary
Samuel Thomas Howes · 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
Samuel Thomas Howes died from fatal injuries after jumping in front of a train on 2 September 2020. The inquest found that his ongoing mental health issues, drug use and alcohol dependency probably contributed to his death. Substantive concerns included inadequate mental health and social care responses, failures to share risk information between agencies, inadequate custody safeguarding and failures in the missing-person investigation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of Child & Adolescent Mental Health Service teams to work together effectively
Wider context from the report “(1) Samuel’s case should be a stimulus for some level of Child & Adolescent Mental Health Service reflection on how different Child and Adolescent Mental Health Service teams are organised and work together.
” Source location Samuel Thomas Howes · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local commissioners and providers are responsible for addressing local support provision and service integration concerns.
Verbatim wording from the response “This response focuses on the national NHS policy and programmes relevant to the matters of concern you have identified in your Report. Most of the matters of concern raised in your Report are in respect of the provision of local support and the actions taken in providing that support to Mr. Howes and his family. These local concerns would need to be addressed by the relevant local commissioners and providers.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is mainly responsible for addressing the concerns about care provision for children and young people with complex needs.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England as the matters of concern you have raised are mainly for NHS England to address. I understand that NHS England has already provided you with a comprehensive response, setting out what progress is being made to improve children and young people’s mental health services, and how the Framework for Integrated Care (Community) Framework is helping young people with the most complex needs.” Source location Response from Department of Health and Social Care
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31 Aug 2022 Gareth WILLIAMS · Prevention of Future Deaths report Gwent
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Concerns raised 1
Failure to establish clear ownership of care between mental health and ENT teams 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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Gareth WILLIAMS · 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
Gareth Williams, who had worsening tinnitus and declining mental health with suicidal thoughts, was discovered hanging on 23 August 2021 and could not be revived. The concern was that he was left without sufficient support because mental health and ENT services transferred him between teams without directly communicating.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish clear ownership of care between mental health and ENT teams
Wider context from the report “Gareth Williams found himself in a no-win situation. His mental health could not be improved without a resolution to his hearing problems and his tinnitus was untreatable. During the course of his treatment, Gareth was regularly transferred back to the “other” team , being told that either mental health or ENT was the most appropriate speciality .
I found that Gareth was left without sufficient support, falling between 2 teams, who did not directly communicate with each other.
” Source location Gareth WILLIAMS · 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 Expand Adferiad through recurrent funding, broader eligibility and a multidisciplinary team providing assessment, care planning and rehabilitation expertise.
Verbatim wording from the response “I am pleased to share that Welsh Government has confirmed that a Health Board service - ‘Adferiad’ - originally developed for people experiencing the effects of ‘Long Covid’ will be receiving substantive, recurrent funding from April 2023 which will also allow it to broaden its inclusion criteria to people with other medical and long-term conditions for whom there are no existing care pathways. This service will be delivered by a team of medical, nursing and Allied Health Professionals – including Health and Clinical Psychologists, thus offering a multi-disciplinary perspective from the point of referral and for consultation to other disciplines & specialties. Part of the expansion of the service will be to map existing services to ensure the person is on the ‘right’ pathway, with a ‘bespoke’ approach to each person’s needs.” Source location Response from Aneurin Bevan University Health Board
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 Map existing services to support appropriate pathway allocation for people referred to the expanded Adferiad service.
Verbatim wording from the response “I am pleased to share that Welsh Government has confirmed that a Health Board service - ‘Adferiad’ - originally developed for people experiencing the effects of ‘Long Covid’ will be receiving substantive, recurrent funding from April 2023 which will also allow it to broaden its inclusion criteria to people with other medical and long-term conditions for whom there are no existing care pathways. This service will be delivered by a team of medical, nursing and Allied Health Professionals – including Health and Clinical Psychologists, thus offering a multi-disciplinary perspective from the point of referral and for consultation to other disciplines & specialties. Part of the expansion of the service will be to map existing services to ensure the person is on the ‘right’ pathway, with a ‘bespoke’ approach to each person’s needs.” Source location Response from Aneurin Bevan University Health Board
Open published response
Concerns raised 1
Failure of communication and shared information across autism and mental health teams View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Humber and North Yorkshire Integrated Care Board Tees, Esk and Wear Valleys NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS Humber and North Yorkshire Integrated Care Board
Work with TEWV to resolve internal and external communication issues affecting patient care.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.
View source See 2 more actions
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AI-generated summary
Zoe Emma ZAREMBA · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of communication and shared information across autism and mental health teams
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working , that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Source location Zoe Emma ZAREMBA · Prevention of Future Deaths report
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 TEWV to resolve internal and external communication issues affecting patient care.
Verbatim wording from the response “The CCG/ICB are aware; from reviewing the evidence from the inquest and from discussions with TEWV that there are communication issues internally and externally which need to be resolved for the benefit of the patient. This appears to go beyond incompatibility of IT systems (for example within the inquest there is reference to the autism service provided to other geographical parts of TEWV but not being available within the North Yorkshire part of the organisation). Both TEWV and the ICB are committed to working closely to resolve this. It is anticipated that ultimately the establishment and development of Provider Collaboratives within the ICB will support with these type of issues in the future.” Source location Response from Humber and North Yorkshire Health Care Partnership
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 Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Verbatim wording from the response “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Response from TEWV
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 Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Verbatim wording from the response “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
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 the CITO recording system across all services to clarify diagnoses and support patient record access.
Verbatim wording from the response “Our new patient recording information system (CITO) will not only allow a greater clarity around active and discounted diagnoses but will importantly also support patient access to their own records improving mutual understanding and effective” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.
Verbatim wording from the response “We have learned from Zoe’s sad death and shared with our clinical teams the importance of communication with our partners, to ensure that patients’ needs are addressed in a more cohesive and person-centred manner.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
Verbatim wording from the response “This is therapy which is beyond that which TEWV can provide as the primary mental health provider. That does not change the expectation that TEWV be in a position to make appropriate adjustments to their mental health support for those with any neuro development diagnosis. By this we mean that we would expect TEWV to be in a position to support those with a mental health condition even where they have a diagnosis of autism spectrum disorder however it is recognised by the CCG/ICB that there may be cases where there is additional specialist input required. This is when IFR requests are made. The CCG/ICB accepts that this is becoming more frequent and the reasons for this are not clear but are sufficient for the CCG/ICB to be considering the commissioning pathway for this type of therapy.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.