22 Dec 2021 Mark Castley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure to fully assess recurrent impulsive self-harm risks in post-sentencing situations View source
Linked response
HM Prison and Probation Service
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
HM Prison and Probation Service
Revise the probation suicide and self-harm guide to assess current suicide-risk concerns and relevant historic information.
View source
HM Prison and Probation Service
Add guidance to the EQUiP process map directing court staff to complete a Suicide Risk Form when a current concern is identified.
View source
HM Prison and Probation Service
Remind London probation staff to follow the risk-to-self process maps and complete a Suicide Risk Form when a current concern is identified.
View source
HM Prison and Probation Service
Disseminate the directive on following risk-to-self process maps and completing Suicide Risk Forms across the Probation Service nationally.
View source See 1 more action
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AI-generated summary
Mark Castley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Castley died by suicide on 26 June 2019 in St Thomas Hospital after bringing a ████████ into court. The inquest jury identified non-completion of a suicide risk form by the probation officer and non-confiscation of the ████████ by the dock officer as contributing factors. The report raises concern that risks of recurrent impulsive self-harm in the context of sentencing were not fully assessed and that the relevant policy may have required or been interpreted as requiring imminence of risk.
Read the report on judiciary.uk
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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 fully assess recurrent impulsive self-harm risks in post-sentencing situations
Wider context from the report “The evidence suggests that his risks of recurrent impulsive self harm in situations his ex wife described as “when he is cornered” were not fully assessed as applying to the time after he was being sentenced and if they had been, a notification form might have been completed. Whether this was due to the policy requiring imminence of risk at the time of assessment or being erroneously interpreted so, or whether the projection of imminence arising in a future context was not fully considered , is not clear.
” Source location Mark Castley · 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 probation suicide and self-harm guide to assess current suicide-risk concerns and relevant historic information.
Verbatim wording from the response “1) Appendix 1 of the ‘Working with Suicide & Self-Harm; A Guide for Probation Staff’ has been reviewed and the question ‘is there an immediate risk of suicide’ has been changed to ‘has a current concern relating to suicide risk been identified’ (staff are reminded to consider historic information which could be relevant to, or triggered by current circumstances).” Source location Response from HM Prison and Probation Service
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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 Add guidance to the EQUiP process map directing court staff to complete a Suicide Risk Form when a current concern is identified.
Verbatim wording from the response “2) The text above in brackets has now also been added to the Probation EQUiP process map for court staff to trigger the completion of a Suicide Risk Form where a concern has been identified. The Probation Service use a process called EQUiP which holds all national policies, processes and guidance, including process maps.” Source location Response from HM Prison and Probation Service
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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 Remind London probation staff to follow the risk-to-self process maps and complete a Suicide Risk Form when a current concern is identified.
Verbatim wording from the response “3) All probation staff in London have been reminded of the requirement to adhere to the ‘probation risk to self’ EQUiP process maps, including the completion of the Suicide Risk Form, where a current concern is identified. This directive will also be disseminated across the Probation Service nationally.” Source location Response from HM Prison and Probation Service
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 Disseminate the directive on following risk-to-self process maps and completing Suicide Risk Forms across the Probation Service nationally.
Verbatim wording from the response “3) All probation staff in London have been reminded of the requirement to adhere to the ‘probation risk to self’ EQUiP process maps, including the completion of the Suicide Risk Form, where a current concern is identified. This directive will also be disseminated across the Probation Service nationally.” Source location Response from HM Prison and Probation Service
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25 Nov 2021 Joel Robinson · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure to identify key suicide risk factors View source
This report raised 4 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. 2
Army
Introduce digital tools explaining how personnel can identify suicide risk factors.
View source
Army
Deliver mental resilience and mental fitness training across all career-stage courses and ranks.
View source
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AI-generated summary
Joel Robinson · 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
Joel Robinson took his own life on 25 March 2019 after experiencing difficulties and perceived bullying during his military posting in Germany. The report raised concerns about the army’s passive approach to suicide prevention, including the identification and monitoring of risk factors, and about awareness of service complaint procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify key suicide risk factors
Wider context from the report “2. Consideration should be given to identifying key risk factors , and how (in very practical terms) that information can be used to reduce suicide risk.
” Source location Joel Robinson · 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 Introduce digital tools explaining how personnel can identify suicide risk factors.
Verbatim wording from the response “5. The Army continues to maximise the use of extant policy, training and digital tools to aid in the identification and subsequent mitigation of suicide risk factors. The overarching policy, Army General Administrative Instruction 110 (which highlights the risk factors detailed below), is subject to regular reviews to consider all lessons identified in the Service Inquiry process and through internal stocktakes. Specific training on mental health resilience and identifying risk factors is delivered through multiple mechanisms and at a regular frequency during a soldier’s career. Targeted digital communication campaigns on the topic are also linked to specific dates, such as Time to Talk day in February, Mental Health Awareness Week in May and World Suicide Prevention Day in September.” Source location 2021-0398-Response-from-Army_Published
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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 Deliver mental resilience and mental fitness training across all career-stage courses and ranks.
Verbatim wording from the response “5. The Army continues to maximise the use of extant policy, training and digital tools to aid in the identification and subsequent mitigation of suicide risk factors. The overarching policy, Army General Administrative Instruction 110 (which highlights the risk factors detailed below), is subject to regular reviews to consider all lessons identified in the Service Inquiry process and through internal stocktakes. Specific training on mental health resilience and identifying risk factors is delivered through multiple mechanisms and at a regular frequency during a soldier’s career. Targeted digital communication campaigns on the topic are also linked to specific dates, such as Time to Talk day in February, Mental Health Awareness Week in May and World Suicide Prevention Day in September.” Source location 2021-0398-Response-from-Army_Published
Open published response
1 Nov 2021 Neil Peter Bastock · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to sufficiently consider the significance of potential farewell behaviour View source
This report raised 13 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
Neil Peter Bastock · 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
Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to sufficiently consider the significance of potential farewell behaviour
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered .
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” Source location Neil Peter Bastock · Prevention of Future Deaths report
Open source report
16 May 2021 Sarah Margaret Clarke · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to verify the safety of distressed students from self-harm View source
This report raised 11 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. 5
University of Surrey
Implement enhanced safeguarding processes, including a safeguarding policy, broader training access and consideration of all students as potential safeguarding concerns.
View source
University of Surrey
Implement student concern reporting, repeated follow-up and escalation processes, including escalation to health, security or police services when appropriate.
View source
University of Surrey
Provide personalised, student-led action plans for students at risk to support individual safety needs and risk management.
View source
University of Surrey
Use risk assessments as working documents with students to mitigate risk, establish action plans, support follow-up and enable earlier escalation or information sharing.
View source
University of Surrey
Deliver suicide-awareness, mental-health, distressed-student and safeguarding training, including ASIST for relevant security staff and training for personal tutors.
View source See 2 more actions
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AI-generated summary
Sarah Margaret Clarke · 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
Sarah Margaret Clarke, a 23-year-old university student with significant mental health difficulties, was found deceased in her university accommodation on 21 November 2019 after sending an email indicating that she intended to end her life. The concerns included inadequate follow-up after she became extremely distressed, insufficiently robust systems for managing and safeguarding students at high risk of self-harm, and failure to implement relevant national guidance or provide adequate oversight and learning.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to verify the safety of distressed students from self-harm
Wider context from the report “2. Sarah was known to have significant mental health difficulties exacerbated by a recent bereavement and other personal difficulties. On 19th November 2019 after Sarah hung up on the administrator and was knowingly extremely distressed, CWB staff did not take steps to reassure themselves that Sarah was safe from self-harm .
” Source location Sarah Margaret Clarke · 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 Implement enhanced safeguarding processes, including a safeguarding policy, broader training access and consideration of all students as potential safeguarding concerns.
Verbatim wording from the response “With regards to safeguarding, since 2019 the University has updated its safeguarding policy, which all staff are required to follow. In addition, the University has improved access to safeguarding training, considers all students in the service as potential safeguarding concerns, and refers to the safeguarding policy if required. The CWB team’s experience and that of the Designated Safeguarding Lead is called upon to ensure referrals and follow ups are robust.” Source location Response from University of Surrey
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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 student concern reporting, repeated follow-up and escalation processes, including escalation to health, security or police services when appropriate.
Verbatim wording from the response “b. Staff who are concerned about students can now expect a smoother process and a robust follow up. They can submit a new ‘report a concern’ or ‘safeguarding concern’ form, and for” Source location Response from University of Surrey
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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 personalised, student-led action plans for students at risk to support individual safety needs and risk management.
Verbatim wording from the response “d. Students at risk are now supported with a personalised action plan to help them understand and manage their own risk. This action plan is student-led and is designed to support a student’s individual safety needs whilst encouraging autonomy” Source location Response from University of Surrey
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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 Use risk assessments as working documents with students to mitigate risk, establish action plans, support follow-up and enable earlier escalation or information sharing.
Verbatim wording from the response “c. Although risk assessments in their basic form are not supported by NICE guidelines, the CWB has changed its use of risk assessments. They are now used as a working document between advisor and student to try, where possible, to mitigate risk and ensure that an action plan is in place. This helps to make sure that support is being received and any escalation can be actioned appropriately. It also provides a lower threshold for sharing of information and robust follow up, sooner.” Source location Response from University of Surrey
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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 Deliver suicide-awareness, mental-health, distressed-student and safeguarding training, including ASIST for relevant security staff and training for personal tutors.
Verbatim wording from the response “f) A focus on training: Mental Health First Aid is now a substantial recommendation for all student-facing staff in professional and academic departments. The Applied Suicide Intervention Skills Training (ASIST) course is undertaken by key staff particularly in security roles. Mental health awareness, distressed student and safeguarding awareness training for all Personal Tutors is in hand.” Source location Response from University of Surrey
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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 CWB staff followed the internal processes then in place to reassure themselves about the student’s safety from self-harm.
Verbatim wording from the response “2. Sarah was known to have significant mental health difficulties exacerbated by a recent bereavement and other personal difficulties. On 19 November 2019 after Sarah hung up on the administrator and was knowingly extremely distressed, CWB staff did not take steps to reassure themselves that Sarah was safe from self-harm.” Source location Response from University of Surrey
Open published response
11 Feb 2021 Valeria Munoz Biggs · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2
Failure to assess suicide risk during the current treatment episode View source Lack of staff training in suicide risk assessment View source
This report raised 10 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
Valeria Munoz Biggs · 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
Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess suicide risk during the current treatment episode
Wider context from the report “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating.
” Source location Valeria Munoz Biggs · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of staff training in suicide risk assessment
Wider context from the report “2. That the Trust staff need training in relation to assessment of suicide risk , how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating.
” Source location Valeria Munoz Biggs · Prevention of Future Deaths report
Open source report
10 Feb 2021 Jason O’Rourke · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jason O’Rourke · 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
Jason O’Rourke died by suicide in his cell at HMP Belmarsh after hanging himself with a bedsheet ligature between 7.28 pm on 1 April 2019 and 9.33 am on 2 April 2019. The jury identified possible contributing factors including inadequate follow-up of his mental health, insufficient sharing and understanding of information about his mental health and self-harm history, and inadequate safety intervention meetings. The report also raised concerns about unclear self-harm and suicide risk assessments on arrival and the lack of robust auditing of nightly roll checks.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway
Wider context from the report “(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified .
The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.
It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”
Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.
” Source location Jason O’Rourke · 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 Implement a revised immediate-needs form with clearer guidance for identifying, communicating and documenting suicide or self-harm risks.
Verbatim wording from the response “Following evidence heard at the inquest you have raised concerns in relation to the ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh. This is a locally produced document created in line with the Prison Service Instruction (PSI) 07/2015 Early days in Custody. You will be aware that the early days in custody is a period in which risk of self-harm or suicide is heightened and the wellbeing of prisoners in our care is the primary concern of staff throughout the reception and first night process. Following the inquest a review of the form has taken place, and a new version is now in use.” Source location 2021-0032-Response-from-HMPPS-Redacted
Open published response
25 Nov 2020 Trinder Kaur Birdi · Prevention of Future Deaths report East London
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Concerns raised 3
Failure to obtain and document a second psychiatric opinion before downgrading suicide risk View source Failure to consult the referring general practitioner before downgrading suicide risk View source Failure to safeguard downgrading of suicide risk by staff unfamiliar with the patient View source
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AI-generated summary
Trinder Kaur Birdi · 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
Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain and document a second psychiatric opinion before downgrading suicide risk
Wider context from the report “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional .
It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor.
” Source location Trinder Kaur Birdi · 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 consult the referring general practitioner before downgrading suicide risk
Wider context from the report “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional.
It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner , second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor.
” Source location Trinder Kaur Birdi · 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 safeguard downgrading of suicide risk by staff unfamiliar with the patient
Wider context from the report “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional.
It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance , such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor.
” Source location Trinder Kaur Birdi · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.
Verbatim wording from the response “1. A requirement will be introduced for a referral to the on-call psychiatrist to be completed where the presenting risk is significantly different to that of another clinician (including GP) who has reviewed the patient on the same day.” Source location 2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
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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 Clinical Risk Advanced training to include differing clinical opinion scenarios and guidance on addressing them.
Verbatim wording from the response “5. A review of the Clinical Risk Advanced level training to include case scenarios that indicate a difference in clinical opinion, and to reiterate guidance how to address these scenarios.” Source location 2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
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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 Amend the Psychiatric Liaison Service assessment template to prompt documentation of concerns, protective factors and the risk management plan.
Verbatim wording from the response “2. The assessment template used within the Psychiatric Liaison Service will be amended to prompt the documentation of the consideration given to concerns raised by friends/family/healthcare staff, protective factors and risk management plan.” Source location 2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
Open published response
12 Nov 2020 Imane Bouasbia · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to complete a self-harm or suicide risk assessment View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Imane Bouasbia · 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
Imane Bouasbia was sexually assaulted on 1 January 2020 and subsequently expressed suicidal thoughts to police. On 3 January 2020, she stepped in front of a moving Central Line tube train at Newbury Park Station and was killed instantly. The principal concerns were failures to communicate her suicidal thoughts, complete a self-harm or suicide risk assessment, and respond adequately to her text message indicating suicidal thoughts.
Read the report on judiciary.uk
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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 complete a self-harm or suicide risk assessment
Wider context from the report “b. The failure of Officer 2 to complete a risk assessment of Ms Bouasbia regarding thoughts of self-harm or suicide .
” Source location Imane Bouasbia · 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 Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.
Verbatim wording from the response “The MPS has introduced a THRIVE+ vulnerability assessment, which is currently being trialled and is anticipated to be rolled out across the organisation in April 2021. It is a set of principles and a framework to assess the type of policing response or investigation required for a particular set of circumstances. THRIVE covers: Threat – Harm – Risk – Investigation – Vulnerability – Engagement + Prevention/Intervention. The framework is a tool that aligns to, and enhances, the National Decision Model and includes the assessment and ongoing review of risk during investigations. It also provides a common language around risk to improve information sharing and decision-making.” Source location 2020-0234-Response-from-MPS-Redacted.pdf
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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 a mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.
Verbatim wording from the response “The MPS has introduced a newly enhanced SOIT risk assessment that specifically covers suicide, cultural complexities and concerns around honour-based violence. It also mandates that the SOIT officer review all police indices including the CAD. The new risk assessment is mandatory for all SOIT officers to complete before speaking to a complainant and must be recorded on the CRIS report and brought to the attention of a supervisor if there is anything of concern.” Source location 2020-0234-Response-from-MPS-Redacted.pdf
Open published response
Concerns raised 1
Failure to reassess altered self-harm risk View source
This report raised 19 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
Andrew Patrick Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to reassess altered self-harm risk
Wider context from the report “The Senior Officer, and the senior prison management accepted that there had been a substantial alteration in risk with every protective factor now being converted into a risk factor. Furthermore, it was accepted that there was a failure to warn the receiving wing of the alteration in risk and that there was a further failure to reassess the alteration in risk .
” Source location Andrew Patrick Jones · Prevention of Future Deaths report
Open source report
21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 2
SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information View source Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment 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
Central and North West London 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
Central and North West London NHS Foundation Trust
Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
View source
Central and North West London NHS Foundation Trust
Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
View source
Central and North West London NHS Foundation Trust
Train all staff during induction to use SystmOne’s problem functionality and audit its use through quarterly care-quality meetings.
View source
Central and North West London NHS Foundation Trust
Deliver SystmOne training through induction and the Learning and Development Zone, including additional training identified through supervision.
View source
Central and North West London NHS Foundation Trust
Require annual Suicide and Self Harm and ACCT training, with successful testing before staff are signed off as compliant.
View source
Central and North West London NHS Foundation Trust
Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
View source See 3 more actions
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AI-generated summary
Andrew Goldstraw · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.
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 SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT . Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Source location Andrew Goldstraw · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment
Wider context from the report “G. There also appeared to be a lack of training in relation to the effective use of SystmOne . In particular, it was not clear whether any steps had been taken to ensure that the staff who were working at the prison at the time of Mr Goldstraw's death had been retrained or had their competencies assessed in light of the failures identified. There is a real concern that some staff are still failing adequately to carry out assessments of a prisoners risk of suicide / deliberate self-harm.
H. The Head of Healthcare at HM Prison, Winchester has indicated that she intends to provide (in conjunction with the Prison Governor) a joint learning bulletin to all staff, stressing the importance of sharing information, most notably in reception and during the early days in custody. However, this does not address the technical shortcomings of SystmOne which present a matter of considerable concern, even if healthcare staff undertake all reasonable steps to ascertain a prisoner's previous mental health history as part of the prison induction process.
” Source location Andrew Goldstraw · 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 Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Verbatim wording from the response “The Trust has sent out guidance to all offender care sites in relation to the search function. Whilst this is a function owned by SystmOne CNWL has given staff directions on how to best utilise this function. For instance, when trying to get a history of suicide attempts rather than searching suicide the clinician should search ‘suic’ which will bring up results for suicide, suicidal, suicidal thoughts.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-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 Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Verbatim wording from the response “We will also remind staff that other organisations use SystmOne and that they may not enter data in an easy to view way. Staff have been advised to use search functionality to find data that may have not been entered properly by staff from other organisations.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-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 Train all staff during induction to use SystmOne’s problem functionality and audit its use through quarterly care-quality meetings.
Verbatim wording from the response “This functionality has the potential to be very helpful if used appropriately as, for instance, every episode of self-harm could be linked to a problem “Self-harm” meaning all episodes are collated in one place. CNWL has sent out guidance to all staff on how to manage problems on SystmOne. Training will be provided on “problems” for every member of staff during their induction. The use of problems on SystmOne will be audited through the Offender Care, Care Quality Meetings initially on a quarterly basis to review progress of this function.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-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 Deliver SystmOne training through induction and the Learning and Development Zone, including additional training identified through supervision.
Verbatim wording from the response “All staff are trained in SystmOne during their induction. SystmOne training is now available on the Trust’s Learning and Development Zone (LDZ) and all staff identified as requiring additional training (through six weekly supervision) will complete the SystmOne training on LDZ.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-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 Require annual Suicide and Self Harm and ACCT training, with successful testing before staff are signed off as compliant.
Verbatim wording from the response “All staff are now required to complete annual Suicide and Self Harm training and annual ACCT training. In these training packages, identification of suicide and deliberate self- harm risk are covered and all staff have to successfully pass a test which covers these areas to be signed off as compliant.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
Verbatim wording from the response “Additionally, Offender Care is carrying out quarterly review of risk assessments. Mental Health risk assessments have been developed across CNWL offender care services and have been uploaded onto SystmOne. These risk assessments include a patient’s risk of harm to themselves and to others. These risk assessments should be updated whenever there is a recognised change in a patients risk and should form the basis of a care plan. Both risk assessments and the care plans they help formulate are audited every three months and also form part of the annual medical records audit to provide assurances that risks are being appropriately identified.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.
Verbatim wording from the response “SystmOne is the medical records system for all prisoners and this contract with TPP is managed by NHS England and not directly by CNWL. However, with internal training and audit we hope to be able to overcome a significant proportion of the limitations identified. We will also be raising the Coroner’s concerns and our work around with TPP so that they can consider them in any future developments of the system” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Verbatim wording from the response “Whilst the risk assessment template on SystmOne does ask pre-set questions the clinician is not reliant solely on the information disclosed during the assessment. When completing the risk assessment there is a section on the right hand side of the template with previous values that have been entered in relation to these questions. This allows the clinician to have an understanding of previous answers to these questions and gives them some context when considering a response to a question. For instance if a patient’s response contradicts a previous statement they have made the staff will be able to ascertain this and ask appropriate follow up. When the cursor is put in the box relating to risk incidents and triggers previous entries about this come up on the right hand section of the template.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.