26 Jul 2016 Terence Darren ADAMS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to explore potential triggers for disclosed suicidal thoughts View source
This report raised 8 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
Care UK
Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
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Terence Darren ADAMS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.
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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 explore potential triggers for disclosed suicidal thoughts
Wider context from the report “4. Mr Adams told the GP that he had been suicidal on and off for twenty years, but she did not explore with him the potential triggers for this . In fact, one such trigger was incarceration.
” Source location Terence Darren ADAMS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
Verbatim wording from the response “Response: There is an expectation that nurses undertaking reception duties within the prison complete an assessment of a person’s current risk of self-harm and suicidality when they are initially received into custody. This is particularly relevant as it is known that, for some prisoners, the early days of custody prove particularly stressful and so increase their risk. You heard the evidence of the Deputy Head of Healthcare who explained that, following another recent death in custody, we were already undertaking a review of the current risk assessment that is in use in reception in an attempt to improve its efficacy.” Source location Response from Care UK
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Concerns raised 1
Failure of RMNs to make medical-record enquiries about self-harm or suicide responses 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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Andrew Gus PEEBLES · Prevention of Future Deaths report
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Report summary
The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were 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 of RMNs to make medical-record enquiries about self-harm or suicide responses
Wider context from the report “(1) No enquiries were made by the RMN in the medical records specifically commenting upon the replies to questions in respect of self-harm or suicide , the only significant entries in the medical records on this subject being made by RGNs
” Source location Andrew Gus PEEBLES · Prevention of Future Deaths report
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14 Dec 2015 Daniel Brendan Byrne · Prevention of Future Deaths report Milton Keynes
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Concerns raised 2
Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners View source Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners View source
Linked responses
Central and North West London NHS Foundation Trust 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. 13
Central and North West London NHS Foundation Trust
Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.
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Central and North West London NHS Foundation Trust
Train reception-screening staff, including agency staff where used, to apply the strengthened screening tool.
View source
Central and North West London NHS Foundation Trust
Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.
View source
Central and North West London NHS Foundation Trust
Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.
View source
Central and North West London NHS Foundation Trust
Provide daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.
View source
Central and North West London NHS Foundation Trust
Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.
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Central and North West London NHS Foundation Trust
Provide ongoing support for prison ACCT training and prison-led ACCT management.
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Central and North West London NHS Foundation Trust
Check daily information-sharing and review ACCT records at each planned review meeting.
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Central and North West London NHS Foundation Trust
Audit and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.
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HM Prison and Probation Service
Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.
View source
HM Prison and Probation Service
Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.
View source
HM Prison and Probation Service
Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.
View source
HM Prison and Probation Service
Maintain a dedicated mental health team member on the First Night Centre to interview new prisoners and update identified risk factors.
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Daniel Brendan Byrne · Prevention of Future Deaths report
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Report summary
Daniel Brendan Byrne died at Milton Keynes Hospital on 27 February 2015 after being resuscitated following a suicide attempt by hanging in his cell at Woodhill Prison the previous day. The principal concerns were inadequate assessment of the risk of self-harm and suicide by healthcare staff and prison officers, failure to refer him for an urgent mental health assessment, and an inadequate first ACCT case review.
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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 healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
Wider context from the report “In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says:
“ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT . There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare . Consideration should also be given to the introduction of a formal risk assessment tool.
” Source location Daniel Brendan Byrne · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners
Wider context from the report “In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says:
“ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners .” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT. There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare. Consideration should also be given to the introduction of a formal risk assessment tool.
” Source location Daniel Brendan Byrne · 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 Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.
Verbatim wording from the response “While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.” Source location Daniel-Byrne-Response
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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 reception-screening staff, including agency staff where used, to apply the strengthened screening tool.
Verbatim wording from the response “While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.” Source location Daniel-Byrne-Response
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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 Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.
Verbatim wording from the response “From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.” Source location Daniel-Byrne-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.
Verbatim wording from the response “From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.” Source location Daniel-Byrne-Response
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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 daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.
Verbatim wording from the response “From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.” Source location Daniel-Byrne-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.
Verbatim wording from the response “We have gone further and in the last year CNWL has been developing a new on-line e-learning training package, developed by our mental health staff, which will better equip staff in assessing the risk of self-harm and suicide. We have been concerned to raise the awareness of all staff but particularly those undertaking reception screening about both the risk of suicide and appropriate risk management processes. This package has been trialled across the Trust’s Offender Care services and all CNWL staff in HMP Woodhill will have completed this training by the end of February 2016. Once its effectiveness has been audited, the tool will be shared with NOMS and NHS England for use in prison healthcare services outside of the Trust.” Source location Daniel-Byrne-Response
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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 ongoing support for prison ACCT training and prison-led ACCT management.
Verbatim wording from the response “We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.” Source location Daniel-Byrne-Response
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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 Check daily information-sharing and review ACCT records at each planned review meeting.
Verbatim wording from the response “We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.” Source location Daniel-Byrne-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 and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.
Verbatim wording from the response “We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.” Source location Daniel-Byrne-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 Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.
Verbatim wording from the response “You have identified that the PPO has made repeat recommendations and that there is need for a comprehensive review of the safer custody procedures.” Source location Daniel-Byrne-Response2
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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 Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.
Verbatim wording from the response “In response to the recent deaths in custody at HMP Woodhill, reviews of all aspects of safer custody, and of healthcare services have been commissioned. These reviews are being conducted by staff who are not based in the prison, and the results will inform future developments.” Source location Daniel-Byrne-Response2
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.
Verbatim wording from the response “You may be interested to know that in order to address the issues with reception screening that were identified in the case of Daniel Byrne a new tool is being introduced.” Source location Daniel-Byrne-Response2
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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 Maintain a dedicated mental health team member on the First Night Centre to interview new prisoners and update identified risk factors.
Verbatim wording from the response “6. A dedicated mental health team member is now in place on the FNC Monday to Friday with plans to extend across weekends. All new prisoners will be interviewed by a member of this team. They will review the contents of the ECRA prior to prisoner interview and will also sign for the documents enclosed being present and having been read.” Source location Daniel-Byrne-Response2
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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 NOMS holds policy responsibility for suicide prevention and self-harm management.
Verbatim wording from the response “You stated that “there needs to be a review of the healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare”. In addition, that “consideration should be given to the introduction of a formal risk assessment tool”. We note that you raised similar concerns in Regulation 28 reports in 2014 and have considered the NOMS responses of 12 June and 31 October 2014. We note that the Equality, Rights and Decency Group of NOMS has policy responsibility for suicide prevention and self-harm management and will not repeat the description of the policy frameworks set out in the responses. We do however operate under the national frameworks set out in Prison Service Instructions (PSI) 74/2011 Early Days in” Source location Daniel-Byrne-Response
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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 prison leads the ACCT process and is responsible for regularly assessing prisoners’ risk.
Verbatim wording from the response “It was also recognised that whilst those with complex Mental Health needs are ‘managed well’ there is very little resource available for those inmates who are primarily being supported by GPs. This will be picked up in the benchmarking exercise. There were a number of other recommendations including the need to regularly review and focus on the ACCT process recognising the importance of the prison risk assessing regularly and the quality and organisation of the process.” Source location Daniel-Byrne-Response
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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 No nationally recognised best-practice risk-assessment tool exists beyond the processes specified in Prison Service Instructions.
Verbatim wording from the response “While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.” Source location Daniel-Byrne-Response
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16 Nov 2015 EMMA LOUISE BRAY · Prevention of Future Deaths report East London
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Concerns raised 1
Inadequate staff understanding and tools for self-harm risk assessment View source
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
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EMMA LOUISE BRAY · 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
Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.
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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 staff understanding and tools for self-harm risk assessment
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff.
” Source location EMMA LOUISE BRAY · 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 Ensure AABIT staff are competent in risk assessment and escalation of risk.
Verbatim wording from the response “The plan has five broad objectives within which your specific concerns have been addressed. These are:” Source location 2015-0438-Response-by-NELFT-NHS-Trust
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24 Jul 2015 Simon Peter REYNOLDS · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure to appropriately assess service users' risk of suicide or self-harm View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Simon Peter REYNOLDS · Prevention of Future Deaths report
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Report summary
Simon Peter REYNOLDS was admitted to Mason Unit at Southmead Hospital on 10 November 2014 after being detained under section 136 of the Mental Health Act. While left alone in his room, he forced a fist-sized ball of paper into his throat, causing him to choke; he later died in hospital on 21 November 2014. Concerns included the absence of a documented admission risk assessment, no computerised admission note by the nurse in charge, and the need to consider guidance or training on observation levels, suicide and self-harm risk assessment, risk management, and communication of 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 appropriately assess service users' risk of suicide or self-harm
Wider context from the report “(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff.
” Source location Simon Peter REYNOLDS · 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 Revise 136 suite admission paperwork to incorporate Royal College of Psychiatrists’ risk headings for clearer detainee risk identification.
Verbatim wording from the response “Documented Risk Assessment
It is our policy and standard to have a risk assessment completed at the time of admission. In Mr Reynolds’s case, a risk assessment had taken place with risk indicators linked from the progress notes to the risk assessment, however, this was not in a clear form. The admission paperwork for the 136 suite has been revised to incorporate the risk headings recommended by the Royal College of Psychiatrists. The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.” Source location 2015-0296-Avon-and-Wiltshire-NHS-Trust
Open published response
29 Apr 2015 Finnulla Catherine MARTIN · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to ask patients about thoughts of suicide View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Finnulla Catherine MARTIN · Prevention of Future Deaths report
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Report summary
Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.
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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 ask patients about thoughts of suicide
Wider context from the report “3. The doctor did not ask Ms Martin about thoughts of suicide within the context of her earlier declaration that she would die that night.
” Source location Finnulla Catherine MARTIN · 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 Pilot the mental health assessment proforma and make it available to mental health colleagues.
Verbatim wording from the response “b) To implement use of a mental health Proforma to improve the quality of assessments and ensure this is available to mental health colleagues” Source location 2015-0173-Whittington-Health-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 triage assessment was recorded electronically, including the patient’s arrival, assessment, police attendance and high risk of self-harm.
Verbatim wording from the response “Whittington Health response – all triage assessments are recorded electronically. Patient FM was triaged. Arrived with police at 21:00 and was assessed and triaged at 21:15:
Pt brought in by police c/o suicidal ideations. Family concerned about patient. Patient voluntary. pmh: unknown.
National Triage category – mental illness – category 2 very urgent- discriminator – high risk of self-harm” Source location 2015-0173-Whittington-Health-NHS-Trust
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24 Mar 2015 Stuart Megginson BAUMBER · Prevention of Future Deaths report Peterborough
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Concerns raised 1
Failure to comprehensively assess suicide and self-harm risk using documented risk factors and information View source
This report raised 6 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
Stuart Megginson BAUMBER · 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 Megginson BAUMBER died by hanging in his cell at HMP Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013, after being remanded in custody for arson. The jury found that occasions existed when the ACCT process should have been initiated and that inadequate understanding and training contributed to this not happening. The report also raised concerns about ligature points on cell doors, healthcare screening that did not mention section 136 detentions, and items available to prisoners that could facilitate suicide.
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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 comprehensively assess suicide and self-harm risk using documented risk factors and information
Wider context from the report “8. There appears to be on occasions an over reliance on assessment of current risk as emphasised in the QTLB of 2012 by considering demeanour and presentation at the reception stage. The PPO bulletin of March 2015 highlights deficiencies in this approach. There are known risk factors for suicide and self-harm and active identification of relevant risk factors from documentation and information (e.g. SASH forms and PERs and medical records and an EME report) should be fully considered and balanced against apparent mood so that there is a comprehensive risk assessment.. A pro forma document could record what factors and information have been considered and the reasons for the decision.
” Source location Stuart Megginson BAUMBER · Prevention of Future Deaths report
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29 Aug 2014 Stephen Philip Owen Farrar · Prevention of Future Deaths report Milton Keynes
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Concerns raised 2
Failure to complete formal self-harm or suicide risk assessments on prison admission View source Unavailability of a formal self-harm or suicide risk assessment tool in prisons 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
Continue improving risk identification, assessment and management processes.
View source
HM Prison and Probation Service
Remind reception and first-night staff to gather relevant information and consider relevant risk factors.
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HM Prison and Probation Service
Improve the healthcare staff risk-assessment process.
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HM Prison and Probation Service
Train healthcare staff to use the improved risk-assessment process.
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AI-generated summary
Stephen Philip Owen Farrar · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Philip Owen Farrar was found hanging in his cell at HMP Woodhill on 12 December 2013 and was pronounced dead later that evening. The report raised concerns that no formal self-harm or suicide risk assessment had been completed on admission despite his previous self-harm history and past mental health problems, and that no formal risk assessment tool was available in prisons.
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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 formal self-harm or suicide risk assessments on prison admission
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression . Almost any risk assessment tool would have identified him as high risk.
(2) I was told that there is no formal risk assessment tool available in any of our prisons.
” Source location Stephen Philip Owen Farrar · 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 Unavailability of a formal self-harm or suicide risk assessment tool in prisons
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression. Almost any risk assessment tool would have identified him as high risk.
(2) I was told that there is no formal risk assessment tool available in any of our prisons .
” Source location Stephen Philip Owen Farrar · 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 Continue improving risk identification, assessment and management processes.
Verbatim wording from the response “In response to your renewed expression of concern, I would like to assure you that reducing the number of self-inflicted deaths in prisons remains a priority for NOMS, and that we continue to work to improve our risk identification, assessment and management processes. In response to the recent rise in the number of deaths, additional dedicated resources are being provided for safer custody work in a number of prisons, and we have put in place additional staff at regional level to support staff in prisons and to share good practice. A learning and knowledge management team at headquarters provides further support to prisons in learning from deaths in custody and for safer custody work more generally.” Source location 2014-0386-Response-by-NOMS
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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 reception and first-night staff to gather relevant information and consider relevant risk factors.
Verbatim wording from the response “Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.” Source location 2014-0386-Response-by-NOMS
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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 Improve the healthcare staff risk-assessment process.
Verbatim wording from the response “Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.” Source location 2014-0386-Response-by-NOMS
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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 healthcare staff to use the improved risk-assessment process.
Verbatim wording from the response “Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.” Source location 2014-0386-Response-by-NOMS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing processes, including limited screening tools, are considered sufficient without a formal risk-assessment tool across the prison estate.
Verbatim wording from the response “I note that you raised similar concerns in a Regulation 28 Report following an inquest held in February 2014 into a death at HMP Woodhill in May 2013, and that you received a detailed response to that report from my colleague ████████ on 12 June 2014. I will not repeat the description of the policy framework given there. In summary there is a comprehensive set of systems for identifying and assessing prisoners at risk that includes some specific tools, such as a healthcare reception screening tool that has been made available to all prison establishments, but, of necessity, such tools form only a small part of the very broad set of processes involved in this complex task.” Source location 2014-0386-Response-by-NOMS
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Concerns raised 1
Unclear recording of self-harm risk assessment and conclusions View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jeffrey Gash · 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
Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.
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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 Unclear recording of self-harm risk assessment and conclusions
Wider context from the report “5. The clinical risk assessment and management policy document (Version 5) which was presented in evidence fails to clarify the nature and detail of what form of risk assessment needs to be completed when a one in-person face to face is being undertaken. Thus, the notes entered on the PARIS system were unclear as to their author’s view of risk of self harm where it was accepted in evidence that full details of the assessment of risk and its conclusion are central to the Crisis Team process . The Trust has carried out an SUI. Certain recommendations have been made and are being implemented. The inquest however, as evidenced above, revealed other issues not dealt with by the SUI and therefore a complete re-evaluation of the deceased’s contact with the Trust should be undertaken taking into account the evidence given at the inquest so that a complete overview of Trust policy dealing with the above matters and any other such review might uncover can be considered by management and if agreed, implemented.
” Source location Jeffrey Gash · 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 Reinforce recording of colleague-reported risks and home-visit decisions in electronic care-record alerts.
Verbatim wording from the response “In relation to recording the information from colleagues, and the individual nurse’s decision making on the shift in question, there is already an ‘alerts’ section in our electronic care record which staff are asked to use to document risks in a way that this information is available to all staff working with a specific patient. The Team Manager has previously highlighted the importance of recording this with the team, but since Mr Gash’s inquest has further reinforced this via team meetings. In addition, the Head of Service for Durham and Darlington AMH Services has asked the Crisis Team Manager to share your recommendations with the Specialty's Acute Care Group in order that the Trust standard operational policy for Crisis Teams can be strengthened accordingly.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the Trustwide review of clinical risk assessment and management policy and practice, incorporating investigation and inquest information.
Verbatim wording from the response “A Trustwide review of the clinical risk (CRAM) policy and practice is currently underway, with initial reports due in the spring; the information from this Serious Untoward Incident investigation and the inquest will be fed into that review.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
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7 Aug 2014 Noleen Mary McPHARLANE · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to directly assess thoughts of taking one's life View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Noleen Mary McPHARLANE · 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
Noleen Mary McPHARLANE had longstanding contact with mental health services and a history of overdoses and self-inflicted wounds. She died after ingesting an excess of a drug purchased on the internet, although her intentions were unclear. Concerns included that her suicide thoughts and continued illicit amitriptyline use were not directly explored, and that there was no consideration of input from an alternative healthcare professional despite limited therapeutic engagement.
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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 directly assess thoughts of taking one's life
Wider context from the report “1. Ms McPharlane had a long history of overdoses and self inflicted wounds, her last admission to hospital for treatment for the consequent physical injuries being in May 2013. However, in the year following that until her death, the clinical specialist who looked after never once asked her directly if she had thoughts of taking her life .
” Source location Noleen Mary McPHARLANE · 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 Update the clinical risk assessment and management policy.
Verbatim wording from the response “The Trust has a clinical risk assessment and management policy in place. It has been reviewed and updated in September 2014 and is currently being consulted upon. The Trust believes that effective risk assessment and management is crucial to the delivery of high quality services across all parts of the Trust and is a core component of mental” Source location 2014-0370-Response-by-Camden-Islington-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise with supervisors that risk-assessment content must be checked during supervision.
Verbatim wording from the response “The Head of the Personality Disorders Service will raise with supervisors in the service that the content of risk assessments are checked during supervision.” Source location 2014-0370-Response-by-Camden-Islington-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct clinical staff to assess risks to self and others and address identified risks in care plans.
Verbatim wording from the response “The Director of Nursing & People and the Interim Medical Director will ensure that all clinical staff are instructed to ensure that the risk assessments of all services users include asking about risks to self and others and, if risks are identified, that these are addressed in care plans. The deadline for this is November 2014.” Source location 2014-0370-Response-by-Camden-Islington-NHS
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.