20 Dec 2019 Tomasz Nowosad · Prevention of Future Deaths report Manchester City
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Concerns raised 3
Lack of written rationale for self-harm and suicide risk assessments View source Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment View source Failure to undertake holistic and updated self-harm or suicide risk assessment View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
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Tomasz Nowosad · 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
Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.
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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 written rationale for self-harm and suicide risk assessments
Wider context from the report “5 3 It is suggested that whenever an assessment of risk of self-harm or suicide is undertaken there is a written record made of the factors or issues involved in this or what weight or consideration was given to them and how the risk assessment was arrived at It is suggested that it would be appropriate for GMMH and HMPS to ensure that this is introduced
” Source location Tomasz Nowosad · 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 Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
Wider context from the report “5 1 The context of this case has to be seen in the light of the fact that in 2019 two self-inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above it is suggested that there has been a repeated theme in the majority of these cases that there was an over reliance and emphasis on the assumptions made by a prisoner that they “had no thoughts of self-harm or suicide” This is often simply recorded in ACCT reviews by ticking boxes on the review document . Whilst it is appropriate for this issue to be addressed whenever a prison is on an ACCT either by healthcare staff or at ACCT reviews because in many cases prisoners still go on to harm themselves or commit suicide It should not be regarded as definitive This was recognised and recorded in the latest PPO Investigation Report relating to a death that occurred on 5 April 2019
This was specifically referred to in paragraph 26 of the report which said “In previous investigation into self-inflicted deaths at Manchester, we identified weaknesses in the risk assessment of prisoners at risk of suicide and self-harm We found in particular that staff placed too much emphasis on prisoner’s presentation and did not give sufficient consideration to their risk factors”
” Source location Tomasz Nowosad · 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 undertake holistic and updated self-harm or suicide risk assessment
Wider context from the report “5 2 PSI-64/2011 recognises that there are a number of potential triggers to self-harming behaviour or suicide All staff should be alert to the increased risk of self-harm or suicide posed by prisoners with these risk factors and should act appropriately to address any concerns, including opening an ACCT if necessary However, it is suggested that the list of factors is not exhaustive and everything needs to be considered in light of the overall picture This will usually involve discipline staff and health care staff It is suggested that thereafter, particularly if the prisoner is moved to the HCC, considering all the risk factors and the changing position taking into account the previous recorded history of the prisoner from both a health care and general prison service records This is especially so when ACCTs are being reviewed and a prisoner is being discharged from the ACCT or moved out of the limited number of safer cells available in the prison There has to be consideration of the overall or ‘big picture’ with regards to the risks that the prisoner poses
” Source location Tomasz Nowosad · 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 Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.
Verbatim wording from the response “A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020.” Source location 2019-0445-Response-from-HMPPS
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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 Redevelop ACCT training and deliver it to new staff and as refresher training for existing staff.
Verbatim wording from the response “The associated training packages are currently being redeveloped and will be delivered to all new staff through POEL training and made available as refresher training for existing staff. A specific session on the risks and triggers for self-harm and suicide will form a major part of this training.” Source location 2019-0445-Response-from-HMPPS
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26 Nov 2019 Trevor Albert Oakley · Prevention of Future Deaths report Hampshire
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Concerns raised 1
Failure to identify increased self-harm risk in prisoners due in Court the following morning View source
This report raised 1 other concern. 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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Trevor Albert Oakley · 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
Trevor Albert Oakley was found hanging from a bedsheet ligature in his prison cell on 22 October 2018, shortly before he was due to start his trial. The inquest concluded that his death was suicide. The principal concern was that night staff were not immediately informed which prisoners were due in court the following morning, meaning increased self-harm risks might not be identified.
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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 identify increased self-harm risk in prisoners due in Court the following morning
Wider context from the report “(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the relevant staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system.
(2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified .
” Source location Trevor Albert Oakley · Prevention of Future Deaths report
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30 Oct 2019 David John KIRSCH · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to conduct direct assessment of suicide and self-harm risk during ACCT reviews View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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David John KIRSCH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David John Kirsch was found deceased in his cell on 19 March 2018 after inflicting a large wound to his neck with the lid of a tin. The principal concerns were the lack of allocated case-manager oversight for his ACCT document, deficiencies in recording and addressing risks, failure to escalate the case, and inadequate staff knowledge and assessment of his suicide risk.
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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 conduct direct assessment of suicide and self-harm risk during ACCT reviews
Wider context from the report “(5) The Supervising Officer who conducted the last ACCT review on 16.3.18 conceded in evidence that, in the course of that review, he may not have asked Mr. Kirsch about his state of mind or whether he was having any thoughts of suicide or self-harm . When asked how he had proposed to assess Mr. Kirsch's level of risk and to complete the Caremap, he stated that he would have done so on the way Mr. Kirsch presented at that review, and by the fact that he was calm, collected and polite throughout their conversation .
” Source location David John KIRSCH · 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 Deliver Introduction to Suicide and Self Harm Prevention training to HMPPS staff with prisoner contact and offer it to partner and contractor staff.
Verbatim wording from the response “Introduction to Suicide and Self Harm Prevention (SASH) training is being delivered to all HMPPS staff with prisoner contact, and is also offered to staff of partners and contractors. The course is made up of six modules, including ‘Recognising Risks and Triggers’, ‘Opening ACCT Documents’, and ‘An Introduction to Mental Health Awareness’.” Source location 2019-0362-Response-from-NOMS_Redacted
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29 Jul 2019 Alistair Patrick McDonald · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Inadequate specific deliberate self-harm or suicidal ideation criteria View source
This report raised 7 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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Alistair Patrick McDonald · 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
Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.
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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 specific deliberate self-harm or suicidal ideation criteria
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” Source location Alistair Patrick McDonald · Prevention of Future Deaths report
Open source report
3 Apr 2019 Stuart Michael CLARK · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Failure to assess disclosed risk of self-harm or suicide 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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Stuart Michael CLARK · 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
Stuart Michael CLARK died shortly after being recovered from a canal on 3 October 2017, after entering the water wearing a rucksack filled with weights. During a hospital admission before his death, he disclosed that he was a vulnerable adult and a suicide risk, but this was not escalated or followed by an assessment of his risk of self-harm or suicide. The report identified that senior clinical staff were not directly informed and that the relevant medical record entry was not available to other staff at the time.
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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 assess disclosed risk of self-harm or suicide
Wider context from the report “(1) The evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Canpere) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk. This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent, plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services.
Senior clinical staff were not directly informed of the disclosure. The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide, and if appropriate she would have referred him to the mental health services.
The nurse made an entry in the medical records; however, the medical notes were not made up until the end of the day and therefore the information was not available to the other staff at the relevant time.
” Source location Stuart Michael CLARK · 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 Review current training and support for recognising risk, escalating concerns and safeguarding adults.
Verbatim wording from the response ““review procedures and training related to the actions to be taken when a disclosure is made to ward staff giving rise to the suspicion of the risk of self-harm or suicide”.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
Verbatim wording from the response “However, the Trust is always seeking to improve safety for its patients. We will be reinforcing individual responsibility and accountability for patient safety and suicide prevention to all staff. In June 2019, the Trust is running a two day ‘Care Matters’ professional leadership forum for Nurses, Allied Health Professionals and midwives. These sessions will be run and delivered in person by ████████
████████ Deputy Chief Executive/Chief Nurse, and will reach over 100 leads who will then cascade to their respective teams. The focus of this forum is Professional Safety and this case will be used during this forum as an example to reiterate the importance of escalating concerns about vulnerable patients to ensure the appropriate assessments and support can be provided to them.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Verbatim wording from the response “The Trust is satisfied that this was an isolated incident and staff are aware of their safeguarding obligations. However, the Safeguarding Team is going to issue a reminder to all staff in an upcoming newsletter (which reaches all clinical staff) about safeguarding procedures when there is a disclosure about possible suicidal intent. This briefing will include information about the ‘It’s safe to talk about suicide’ leaflet, a copy of which is attached. This is available on the Trust’s safeguarding intranet page but we want to raise awareness further of this issue. The leaflet was produced by Exeter Medical School in conjunction with Suicide Charities and Devon County Council for staff to use to support people when suicidal intention is disclosed.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
Verbatim wording from the response “The Trust is satisfied that this was an isolated incident and staff are aware of their safeguarding obligations. However, the Safeguarding Team is going to issue a reminder to all staff in an upcoming newsletter (which reaches all clinical staff) about safeguarding procedures when there is a disclosure about possible suicidal intent. This briefing will include information about the ‘It’s safe to talk about suicide’ leaflet, a copy of which is attached. This is available on the Trust’s safeguarding intranet page but we want to raise awareness further of this issue. The leaflet was produced by Exeter Medical School in conjunction with Suicide Charities and Devon County Council for staff to use to support people when suicidal intention is disclosed.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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21 Mar 2019 John Wright · Prevention of Future Deaths report Oxfordshire
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Concerns raised 1
Lack of guidance for reducing observations of newly arrived prisoners from constant watch 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
Care UK 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. 7
Care UK
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
View source
Care UK
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
View source
Care UK
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
View source
HM Prison and Probation Service
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
View source
HM Prison and Probation Service
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
View source
HM Prison and Probation Service
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
View source
HM Prison and Probation Service
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
View source See 4 more actions
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John Wright · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Wright, aged 32, died at Bullingdon Prison on 15 December 2017 after being found partially suspended by an electrical cable in his cell. He had expressed suicidal thoughts and had previously been kept on constant watch, but observations were reduced to twice hourly during reception. The concerns relate to the receipt and sharing of information about heightened suicide risk and the guidance and decision-making processes for reducing observation levels.
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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 guidance for reducing observations of newly arrived prisoners from constant watch
Wider context from the report “The second matter I wish to raise, also to the prison and healthcare, is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case, Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact that there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment will not have taken place yet, there should in my view be some guidance to staff when reducing observations from constant watch .
I note that the Prison and Probation Ombudsman stated at the beginning of her report that ……. ‘Mr Wright had been under constant watch by police and court staff because he said he wanted to take his life at the earliest opportunity. Although prison staff started suicide and self-harm prevention procedures when Mr Wright arrived at Bullingdon, they reduced the level of observations from constant to twice an hour. In my view, this decision was misjudged and taken far too quickly, without a proper assessment of Mr Wright’s risk.’
I appreciate there is a great deal of responsibility on prison and healthcare staff when making assessments. Much depends on how they assess the prisoner in front of them. It may be appropriate to reduce a newly arrived prisoner from constant cell watch to less frequent observations on occasions. The concern which I raise relates to such decisions being made in reception and I enquire if there should be some guidance available to assist staff in their decision-making process? For example, should such a decision be postponed until a further assessment has been carried out the following day?
I realise that this issue is not straightforward and there are significant resource implications in keeping a prisoner under constant watch.
” Source location John Wright · 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 Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
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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 Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
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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 Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Verbatim wording from the response “Staff meetings are held every two weeks to continue to improve and share knowledge and lessons learned regarding the management of prisoners in custody. Currently HMPPS are providing specialist HMPPS training for both healthcare and discipline staff; “Understanding Risk: Why is Risk Risky?” and “Defensible Decision Making”, both of which seek to reinforce rational and appropriate decisions when applying the ACCT process and understanding suicide risk. Care UK are providing ASIST - Applied Suicide Intervention Skills Training, which is an internationally accredited and licensed 2-day course to all patient-facing staff to increase their confidence in identifying suicide risk. This improved learning, supported by SASH training will better inform decision making in all cases, including those cases where removal from constant watch is being considered.” Source location 2019-0175-Response-by-CARE-UK
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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 Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-HM-Prison-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 Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-HM-Prison-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 Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-HM-Prison-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 Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
18 Dec 2018 Mrs Ruth Ellen Edwards · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Inadequate risk history-taking during clinical consultation View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mrs Ruth Ellen Edwards · 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
Mrs Ruth Ellen Edwards died at home on 31 August 2018 after hanging herself from an attic ladder, following a long history of mental health problems and previous suicide attempts. Concerns included her discharge after a drug overdose without psychiatric liaison assessment, inadequate risk assessment and inaccurate communication about the overdose, and potentially insufficient medication reviews despite access to many medications at home.
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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 risk history-taking during clinical consultation
Wider context from the report “(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20.
” Source location Mrs Ruth Ellen Edwards · 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 Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.
Verbatim wording from the response “The care and attention to detail taken by doctors and other healthcare professionals when taking histories and information from mental health patients.” Source location 2018-0395-Response-by-University-Health-Board
Open published response
6 Dec 2018 John Michael KIRBY · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2
Failure to consider relevant substance use and suicide risk before prescribing Concerta View source Failure to obtain sufficient details of a reported suicide attempt View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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John Michael KIRBY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Michael KIRBY took his own life, according to the conclusion of the inquest. The concerns included delays in his care, the handling of an ADHD diagnosis and Concerta prescribing, inadequate monitoring, and failures to respond appropriately to information about suicidal thoughts, a reported suicide attempt, substance use and an A&E admission.
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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 consider relevant substance use and suicide risk before prescribing Concerta
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking . This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” Source location John Michael KIRBY · 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 obtain sufficient details of a reported suicide attempt
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke ?
” Source location John Michael KIRBY · 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 Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.
Verbatim wording from the response “As your concern centres on clinical decision-making I asked the Trust’s Chief Medical Officer ████████ to set up a group of senior medical colleagues to review ████████ medical practice in relation to ADHD. The terms of reference of that medical decision-making group (DMG) included consideration of the use of ADHD questionnaires for diagnosis as well as consideration of the assessment and diagnosis of ADHD and recommended prescribing.” Source location 2018-0379-Response-by-Sussex-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 Publish a Patient Safety Matters story covering the case and issues surrounding co-morbid substance misuse.
Verbatim wording from the response “In addition to the above, the DMG took a number of further steps to establish wider learning. Firstly, the ADHD NICE guidance was shared with all doctors via Mediconnect which is our doctors’ intranet forum for highlighting items of importance/interest/learning etc. Additionally, the issues arising from this case are to be presented for learning and discussion at the Trust’s forthcoming Effective Care & Treatment Conference next month. Furthermore, we are to publish a story, based on this case and to specifically include the issues surrounding co-morbid substance misuse, in our Patient Safety Matters; this is an internal learning publication that we use to improve patient safety.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
24 Oct 2018 Maximilien Conrad Kohler · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Over-reliance on questionnaires causing underestimation of self-harm risk View source
This report raised 7 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
Maximilien Conrad Kohler · 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
Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.
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 Over-reliance on questionnaires causing underestimation of self-harm risk
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place, and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular .
” Source location Maximilien Conrad Kohler · Prevention of Future Deaths report
Open source report
3 Oct 2018 Simon Anthony Graham · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Use of unqualified support workers for suicide risk assessments View source Absence of a scoring system or guide for suicide risk assessments 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. 1
NHS England
Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
View source
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AI-generated summary
Simon Anthony Graham · 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
Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.
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 Use of unqualified support workers for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk assessments .
” Source location Simon Anthony Graham · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a scoring system or guide for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk assessments.
” Source location Simon Anthony Graham · 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 Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
Verbatim wording from the response “b. Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG will identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate. This will be undertaken by the CCG and providers at established monthly quality review meetings.” Source location NHS-England-Response.pdf
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.