21 Apr 2021 Susan Janet ADAMS · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1
Failure of cross-county commissioning arrangements to ensure coordinated secondary psychiatric care View source
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Susan Janet ADAMS · 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
Susan Adams was found dead in a hotel in Sutton Coldfield on 4 November 2020 after being unable to live at her home in Tamworth. Her death resulted from the consequences of excessive alcohol consumption, with the inquest recording combined toxicity of ethanol, pregabalin and fentanyl with hepatic cirrhosis and steatosis. The report raised concerns about commissioning difficulties affecting access to regular secondary psychiatric care because her home address and GP practice were in different counties.
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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 cross-county commissioning arrangements to ensure coordinated secondary psychiatric care
Wider context from the report “Mrs Adams and her family lived in Dosthill, Tamworth, Staffordshire. I was told that this was approximately 50 feet from the border with Warwickshire (and not far from West Midlands as well) and that her GP Practice was in Kingsbury Warwickshire. She needed regular psychiatric assistance from secondary mental health services and I was advised there were significant commissioning difficulties with this because of the home address and GP Practice being in different counties . Mrs Adams could access the crisis team in Staffordshire but long term treatment was supposedly to be provided in Warwickshire . This may have impacted on the care that Mrs Adams received and could be relevant for others who live close to county boundaries. I wonder if anything can be done to facilitate arrangements for secondary psychiatric care in these circumstances.
” Source location Susan Janet ADAMS · 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 Forward the county-boundary care concern to commissioners for consideration.
Verbatim wording from the response “However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate.” Source location 2021-0116-Response-from-St-Georges-Hospital_Published
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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 Existing collaborative arrangements between providers ensure people living near county boundaries are not disadvantaged in accessing services.
Verbatim wording from the response “Throughout all of Mrs Adams’ episodes of care, including that in 2020, MPFT has worked well with partners to ensure people living on the county border are not disadvantaged in terms of services offered and in delivering patient-centred collaborative working between organisations.” Source location 2021-0116-Response-from-St-Georges-Hospital_Published
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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 Commissioners are responsible for considering the cross-boundary care arrangements and any resulting action.
Verbatim wording from the response “However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate.” Source location 2021-0116-Response-from-St-Georges-Hospital_Published
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9 Mar 2020 Rebecca Jane Hursey · Prevention of Future Deaths report Inner West London
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Concerns raised 2
Failure to share complex and high-risk patients between units early in the inpatient stay View source Risk of clinical silos between sections of mental health services View source
This report raised 5 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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Rebecca Jane Hursey · 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
Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.
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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 share complex and high-risk patients between units early in the inpatient stay
Wider context from the report “6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service provision.
” Source location Rebecca Jane Hursey · 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 Risk of clinical silos between sections of mental health services
Wider context from the report “6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service provision .
” Source location Rebecca Jane Hursey · Prevention of Future Deaths report
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20 Jan 2020 Samantha Savage-Greene · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of provision of supervision and monitoring for patients falling between RAID and HBTT admission protocols View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Samantha Savage-Greene · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 23 May 2018, Samantha Savage-Greene jumped from a bridge over the M67 motorway and sustained fatal injuries. The principal concern was difficulty obtaining monitoring from the Home Based Treatment Team, with an apparent gap between the RAID and Home Based Treatment Team protocols for patients who were not admitted.
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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 provision of supervision and monitoring for patients falling between RAID and HBTT admission protocols
Wider context from the report “The MATTER OF CONCERN is that despite the concerns of the RAID practitioner that the HBTT refused to accept Samantha, as she did not fit the protocol for acceptance, on the first two requests. The HBTT was the only means by which Samantha could be monitored other than an admission and satisfy the RAID practitioners concerns. Samantha was accepted by the HBTT on the third time of asking. This appears to be because the person receiving the request was prepared to see Samantha, a person rather than restricted by protocol and by the fact that the RAID practitioner was so concerned about Samantha that she was going to review Samantha within the RAID processes, which was not part of its remit. Without monitoring it would not have been possible to prescribe olanzapine.
There is clearly a lacuna in the provision of supervision and monitoring of patients who are not deemed admissible, voluntarily or by section between the RAID and HBTT services. The RAID practitioner should not have experienced such difficulty in obtaining monitoring for Samantha, a patient who appeared to fall between the protocols of two services.
” Source location Samantha Savage-Greene · Prevention of Future Deaths report
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13 Dec 2019 Steven Keith Marsland · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to allocate people moving between borough teams to a community psychiatrist View source
This report raised 5 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
Steven Keith Marsland · 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
Steven Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.
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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 allocate people moving between borough teams to a community psychiatrist
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made;
” Source location Steven Keith Marsland · Prevention of Future Deaths report
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1 Oct 2019 Oliver Sharp · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Variation and limited transition provision in post-16 mental health services View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Oliver Sharp · 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
Oliver Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 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 Variation and limited transition provision in post-16 mental health services
Wider context from the report “The inquest was told that the provision of mental health services post 16 varies widely across the country . In some areas there is a CAMHS 16-25 mental health service provision similar to the national 16 and under service whereas in other areas there a limited transition service or move back to primary care for re-referral to adult services . The inquest was told that this creates a cliff edge high risk situation for adolescents . The reason for the difference was resources and decisions taken by CCGs.
” Source location Oliver Sharp · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of urgent mental health service provision for 16- and 17-year-olds View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS South Yorkshire Integrated Care Board Sheffield Children'S NHS Foundation Trust Sheffield Health 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. 6
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Complete and approve the business case for the CAMHS Home Intensive Treatment Team.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.
View source
Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.
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Aryan Akhgar · 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
Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.
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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 urgent mental health service provision for 16- and 17-year-olds
Wider context from the report “5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues , such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and so a referral to Adult Mental Health Services was made in order to obtain this. The adult service refused to take the referral because Aryan was still a child . This gap in the provision between the two services meant that Aryan did not receive the urgent mental health input which he required and there is a risk that other under 18’s in his situation might also suffer the same problem .
” Source location Aryan Akhgar · 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 Complete and approve the business case for the CAMHS Home Intensive Treatment Team.
Verbatim wording from the response “At the time of writing, the business case for the HITT team has been completed and was approved by the CCG on 7th May 2019, with a plan to begin a phased implementation from the autumn 2019. The service will be evaluated to ensure that it meets the needs of the young people who are its service users.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
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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 Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.
Verbatim wording from the response “Sheffield Children’s NHS Foundation Trust and NHS Sheffield Clinical Commissioning Group have been working collaboratively to develop a robust long term solution to the issues you have highlighted. The two organisations have considered the potential models and have agreed the most appropriate way forward to be through the reconfiguration of the existing Sheffield Treatment and Recovery (STAR) Service into a CAMHS Home Intensive Treatment Team (HITT).” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.
Verbatim wording from the response “The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
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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 Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.
Verbatim wording from the response “This new team will be responsible for children and young people up to the age of 18 years and will be aligned with, and where appropriate, undertake, joint working with the Home Intensive Treatment Services provided by Sheffield Health and Social Care NHS Foundation Trust. In addition the Mental Health Liaison Team will support 0-18 year olds attending either Sheffield Children’s or the Northern General Hospital’s Emergency Departments. Access to the HITT will be within 24 hours when required whilst the Liaison Team will operate to meet the demands through the Emergency Departments with an on call rota in place for out of hours.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.
Verbatim wording from the response “The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
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 Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.
Verbatim wording from the response “1. An addendum to the Transitions Policy has been jointly approved by both Trusts that ensures that emergency home treatment will be provided to 16/17 year olds by Sheffield Health and Social Care’s adult services, should they require crisis intervention out of hours and where they are not known to Child and Adolescent Mental Health Services which mirrors that already present for those known to the Services. This was implemented with effect from January 2019.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-Trust
Open published response
Concerns raised 1
Inadequate interface between Addaction and community mental-health teams View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
PAUL MATTHEW GILLAM · 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
Paul Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery plan.
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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 Inadequate interface between Addaction and community mental-health teams
Wider context from the report “(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT .
” Source location PAUL MATTHEW GILLAM · 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 implement a robust multi-agency implementation plan for the dual diagnosis strategy.
Verbatim wording from the response “A multi-agency steering group has been set up to review the strategy and develop an implementation plan. The steering group consists of key organisations (including CFT and Addaction) and is being supported by the commissioning organisations. The steering group will report progress into the Mental Health Crisis Care Concordat who will report to Safer Cornwall. The Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis and sets out how organisations will work together. These arrangements will ensure the review of the strategy and its implementation, as well as appropriate oversight of progress and effectiveness.” Source location 2019-0045-Response-by-Kernow-CCG
Open published response
Concerns raised 1
Failure of mental health services to accept responsibility for providing professional care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Cornwall and the Isles of Scilly 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
NHS Cornwall and the Isles of Scilly Integrated Care Board
Review the Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults.
View source
NHS Cornwall and the Isles of Scilly Integrated Care Board
Develop a robust multi-agency implementation plan for the Dual Diagnosis Strategy.
View source
NHS Cornwall and the Isles of Scilly Integrated Care Board
Operate a monthly Multiagency Implementation Steering Group with rotating provider leadership to develop the implementation plan.
View source
NHS Cornwall and the Isles of Scilly Integrated Care Board
Review contract requirements for providers supporting people with dual diagnosis under the new contract commencing April 2019.
View source See 1 more action
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AI-generated summary
Benjamin Colin Williamson · 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
Benjamin Colin Williamson had a long history of alcohol-related issues and was receiving treatment, with regular GP contact. He died on 4 April 2018, and the inquest recorded a conclusion of suicide, with asphyxia by hanging and alcohol intoxication. Concerns included fragmented mental health services for people with both mental health and alcohol problems, and inadequate liaison and feedback between Addaction and the GP.
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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 mental health services to accept responsibility for providing professional care
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care , and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Source location Benjamin Colin Williamson · 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 Review the Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults.
Verbatim wording from the response “An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a robust multi-agency implementation plan for the Dual Diagnosis Strategy.
Verbatim wording from the response “An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a monthly Multiagency Implementation Steering Group with rotating provider leadership to develop the implementation plan.
Verbatim wording from the response “An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review contract requirements for providers supporting people with dual diagnosis under the new contract commencing April 2019.
Verbatim wording from the response “NHS Kernow is reviewing the contract requirements for new contract commencing April 2019, in relation to providers supporting individuals with a dual diagnosis. Whilst current contracts and the multi-agency strategy already specify how providers should meet the needs of people” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
14 Sep 2018 Daniel Hubert Collins · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3
Transfer of necessary mental health care placing responsibility for initiating contact on patients View source Failure to follow up with receiving services and patients after mental health care transfers View source Failure to notify the receiving mental health service about care transfers View source
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
Daniel Hubert Collins · 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
Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Transfer of necessary mental health care placing responsibility for initiating contact on patients
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” Source location Daniel Hubert Collins · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to follow up with receiving services and patients after mental health care transfers
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient . Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” Source location Daniel Hubert Collins · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to notify the receiving mental health service about care transfers
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” Source location Daniel Hubert Collins · Prevention of Future Deaths report
Open source report
25 Jul 2018 Paul Robert Allan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2
Failure to consult or work with drug and alcohol advisory services View source Failure to transfer people between community mental health teams when they move View source
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AI-generated summary
Paul Robert Allan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 July 2017, Paul Robert Allan walked onto the track at Oxford Circus tube station and was struck by a westbound train. Concerns included his discharge from the Rochdale Community Mental Health Team without transfer to the corresponding team in Stoke, and a failure to consult or work with drug and alcohol advisory services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consult or work with drug and alcohol advisory services
Wider context from the report “2) The Rochdale community Mental Health Team failed to consult or work with the Drug and Alcohol advisory services in relation to Paul Robert Allan as it is required to do.
” Source location Paul Robert Allan · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transfer people between community mental health teams when they move
Wider context from the report “1) The Rochdale Community Mental Health Team discharged Paul Robert Allan from their care instead of transferring him to the Community Mental Health Team in Stoke where Paul Robert Allan was moving to.
” Source location Paul Robert Allan · 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 new posts to bridge dual-diagnosis service gaps and establish pathways and effective working practices between mental health and drug and alcohol services.
Verbatim wording from the response “The Trust has recognised the gap in services for dual diagnoses clients and the difficulties experienced in Rochdale as a result of the commissioning arrangements around Drug and Alcohol services being delivered by third sector organisations. As such the Trust has recently been successful in their application for Greater Manchester funding from the transformation fund, to develop new posts to bridge this gap. The new posts will develop and establish pathways between Mental Health and Drug and alcohol services and work with the most complex clients and develop effective working practices. Further development meetings with the operational manager of the drug and alcohol services and Rochdale mental health services are supporting and enhancing this model.” Source location 2018-0251-Response-by-Pennine-Care-NHS-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 Continue development meetings between drug and alcohol and Rochdale mental health operational managers to support and enhance the dual-diagnosis model.
Verbatim wording from the response “The Trust has recognised the gap in services for dual diagnoses clients and the difficulties experienced in Rochdale as a result of the commissioning arrangements around Drug and Alcohol services being delivered by third sector organisations. As such the Trust has recently been successful in their application for Greater Manchester funding from the transformation fund, to develop new posts to bridge this gap. The new posts will develop and establish pathways between Mental Health and Drug and alcohol services and work with the most complex clients and develop effective working practices. Further development meetings with the operational manager of the drug and alcohol services and Rochdale mental health services are supporting and enhancing this model.” Source location 2018-0251-Response-by-Pennine-Care-NHS-Trust
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.