Recurring concern

Inadequate integrated care for people with co-occurring physical and mental health needs

First to latest report 3 Mar 2014 — 15 Jun 2026

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
7

What this concern includes

Includes deficiencies in facilities, care pathways, coordination or delivery that are specifically intended to provide integrated physical and mental healthcare for the same patient group.

What is not included
  • Excludes generic shortages of mental health facilities or placements where co-occurring physical and mental health needs are not identified.
  • Excludes failures concerning substance misuse or other complex needs unless they are explicitly tied to integrated physical and mental healthcare.
  • Excludes generic staffing, training, documentation or communication deficiencies that are not specifically dedicated to this integrated care concern.

Reports and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Alex Ganski · 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

    Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.

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    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 coordinate alerts and subsequent treatment or long-term intervention

    Wider context from the report

    “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”

    Source location

    Alex Ganski · Prevention of Future Deaths report
    Page 4 · concerns

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.

    Verbatim wording from the response

    “As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 August 2026

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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 the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.

    Verbatim wording from the response

    “NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 14 August 2026

    Open published response

  2. West Sussex, Brighton and Hove

    AI-generated summary

    Sarah Louise Healey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sarah Louise Healey was admitted to hospital on 4 May 2024 with severe malnutrition and complex infections after longstanding mental health difficulties and a highly restricted diet. She deteriorated and died on 1 August 2024 from respiratory failure secondary to pleural effusions, hypoalbuminaemia and malnutrition. The principal concerns were inadequate, inconsistent and insufficiently joined-up mental health care, information sharing and collaboration, particularly for patients with physical health issues, neurodiversity or difficulty attending in-person appointments.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of policy, protocols and guidance for safeguarding mental health patients with accompanying physical health issues

    Wider context from the report

    “Whilst I heard evidence that local Mental Health (MH) Services (the Sussex Partnership Foundation Trust) had aimed to ensure the recognised ‘triangle of care’ (MH Services, Individual and Family) was in place, this did not (and I understand that national policy and approach may not extend to other services such as the GP, private counselling, or e.g. social services being formally involved and engaged in a comprehensive assessment and hence effective package of treatment and care. I fully appreciate that there are ethical, legal and patient confidentiality issues in patient care. Without, first, better information sharing and a wider, collaborative and joined-up approach – ideally with one individual [whether MH clinician, GP or even carer/family member] able, empowered and with the right legal authority to ensure they have a comprehensive and detailed knowledge of the individual’s various issues – and, second, the development of policy, protocols and guidance to better safeguard mental health patients with accompanying physical health issues, especially those who may have capacity and are neuro-diverse, there is a risk of patients like Sarah not receiving the right, consistent and individually tailored care and treatment which may prevent self-neglect or other serious self-harm. I also heard evidence that there is, nationally, a move away from traditional in-person or face to face appointments as standard and regular practice, to the increased use of online platforms and tools enabling remote attendance. I completely recognise that there are huge benefits in the use of such systems, which bring savings, efficiency and immediacy of access for a huge number of patients. My concern is that they work for some but not all. I was encouraged by evidence I heard from SPFT that in their development of a Care Plan Approach and the inception of Community Mental Health Teams there will be a local policy requirement for MH Practitioners to see patients in person at least six monthly. Sarah’s case graphically demonstrated that there is no substitute for physically seeing a patient, especially when there are other conditions and lifestyle issues so clearly impacting on or resulting from her mental health, such that it seems that an agreed national approach and similar policy requirement may also further help to prevent future deaths of patients like Sarah. ”

    Source location

    Sarah Louise Healey · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Hertfordshire

    AI-generated summary

    Megan Davison · 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

    Megan Davison was found deceased at home on 4 August 2017 after hanging herself with the intention of ending her life. The report identified concerns about her discharge from mental health care, limited integration between physical and mental healthcare, the absence of recognised diagnosis and care pathways for Type 1 Diabetes with Disordered Eating and Diabetic Ketoacidosis, and incomplete information-sharing between healthcare providers.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of integrated healthcare system for diabetes and eating disorders

    Wider context from the report

    “(b) At a local level in East and North Hertfordshire there is no integrated healthcare system for patients with diabetes and eating disorders as there is in the west of the county. ”

    Source location

    Megan Davison · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with regional partners to learn from national pilots and trial integrated T1DE pathways locally.

    Verbatim wording from the response

    “The ICB is working closely with NHS England’s regional mental health and transformation team, to learn from recent national pilots to trial pathways for T1DE patients and apply this within the Integrated Care System (ICS). The regional team have confirmed they are happy to work with the ICB to ensure any learning from the pilots, as well as relevant national guidance, can be incorporated into our local model. Locally, Mental Health commissioners lead an implementation group with membership from all ICB partners including primary care, community commissioning, regional teams, the voluntary sector, service users, and carers to support quality improvement and delivery of eating disorder services and physical health checks. This work will inform further pathway development and improve access to physical health services for people with serious mental health conditions.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

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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

    Lead a multi-partner implementation group to improve eating-disorder services and physical-health checks.

    Verbatim wording from the response

    “The ICB is working closely with NHS England’s regional mental health and transformation team, to learn from recent national pilots to trial pathways for T1DE patients and apply this within the Integrated Care System (ICS). The regional team have confirmed they are happy to work with the ICB to ensure any learning from the pilots, as well as relevant national guidance, can be incorporated into our local model. Locally, Mental Health commissioners lead an implementation group with membership from all ICB partners including primary care, community commissioning, regional teams, the voluntary sector, service users, and carers to support quality improvement and delivery of eating disorder services and physical health checks. This work will inform further pathway development and improve access to physical health services for people with serious mental health conditions.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

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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 ICB case-discussion support and establish a clearer provider escalation process, with access details due by November 2024.

    Verbatim wording from the response

    “Where necessary, the ICB (via its clinical teams) can help to organise case-based discussions. We are reinforcing the availability of this support and ensuring there is a clearer process for local providers to escalate cases to the ICB. If a patient is assessed as needing joint input from diabetes and mental health services, the ICB can convene a case conference as appropriate, with the relevant teams to develop an agreed management plan. Details on how local providers can access this process will be in place by November 2024, enabling clinicians to make best use of this support.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

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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 an integrated diabetic-care model covering complex cases, multidisciplinary case management and mental-health support.

    Verbatim wording from the response

    “To address variation in service provision within different parts of the ICS, the ICB is working with local providers to develop a new, integrated model of diabetic care reflecting the needs of all diabetic patients. This includes the management of complex cases involving multi-disciplinary case management, including mental health support.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

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  4. East London

    AI-generated summary

    Shirley Alice Moloney · 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

    Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of establishments suitably designed for dual physical and mental health needs

    Wider context from the report

    “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally. This is compounded by an absence of adequately trained staff, to address mental health in residential home settings. The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs. ”

    Source location

    Shirley Alice Moloney · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local authorities and the CQC are responsible for the quality, delivery and availability of suitable care providers.

    Verbatim wording from the response

    “With regard to your concerns around a lack of adequately trained staff in care homes, and a lack of establishments suitably designed for dual physical/mental health needs. The quality, delivery and availability of a suitable care provider sits within the responsibility of the local authority and the CQC. Where concerns on quality or safety are identified, the CQC have a wealth of enforcement powers available and will take swift action to ensure the safety of service users. Under the Care Act 2014 local authorities are responsible for achieving a responsive, diverse and sustainable market of service providers that can provide high quality, personalised care and support, to best meet the needs of people.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 September 2022

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  5. Norfolk

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    Terence Robert TUTTLE · 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 Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inability to care for mentally unwell patients with physical health problems who are refusing to eat

    Wider context from the report

    “4.Inability to care for a mentally unwell patient with physical health problems, including gastric problems, who is refusing to eat. ”

    Source location

    Terence Robert TUTTLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.

    Verbatim wording from the response

    “Out of the concerns listed below I would advise that NSFT are able to respond to the second part, in italics, of the first point only. The other points would be for the QEH to respond to:”

    Source location

    2021-0265-Response-from-Hellesdon-Hospital_Published-1
    Page 1 · response
    Published 12 August 2021

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Mental Health Liaison Teams do not provide direct hands-on physical interventions, including dietary advice or nutritional support.

    Verbatim wording from the response

    “It may be helpful to outline the role of the Mental Health Liaison Teams within our acute general hospitals. The team are a triage assessment team and do not provide direct hands on care specifically in relation to physical interventions, for example dietary advice or nutritional balance activities. The team will advise on mental illness symptoms, diagnosis, compassionate least restrictive care and de-escalation techniques. The team will provide both nursing and medical input in relation to treatment including psychotropic medication and monitoring whilst the patient is on the acute ward. They may also arrange for transfer to a mental health ward once the patient is physically fit for discharge but requires further support in relation to their mental wellbeing.”

    Source location

    2021-0265-Response-from-Hellesdon-Hospital_Published-1
    Page 1 · response
    Published 12 August 2021

    Open published response

  6. Norfolk

    AI-generated summary

    BRIAN STANNARD · 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

    Brian Stannard was a resident at Eversley Nursing Home and was found drowned on a beach at Great Yarmouth on 14 November 2016 after being seen asleep in his room earlier that morning. The report raised concerns about the nursing home’s capacity to manage his mental ill health and threats of self-harm or suicide, as well as incomplete staff records and limited use of the Lorenzo computer system.

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    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 provide adequately trained and equipped staff for people with coexisting mental and physical ill-health

    Wider context from the report

    “(1) Mr Stannard had mental ill health and physical ill health. He was placed at a Nursing Home to manage his physical ill health as this was seen as the priority at the time of admission. Staff at the Home were not adequately equipped to deal with his mental ill health as his physical health improved. This not only raises concern with regard to the safety and well-being of the individual concerned, but also with regard to the staff involved in Mr Stannard’s care. They were not trained mental health individuals and were required to deal with attempts at and threats of self-harm and suicide by Mr Stannard. There did not appear to be a Home available where staff were adequately trained to deal with a person’s mental and physical ill-health. ”

    Source location

    BRIAN STANNARD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with clinical teams to provide sufficient staffing and equipment for consistent, balanced work allocation.

    Verbatim wording from the response

    “Your report confirmed the findings of the RCA report that aspects of Mr Stannard’s health record had not been maintained to the expected standard, notably risk assessment and care plans. The Trust are engaged in a program to improve its performance in this area with active monitoring at all levels of the organisation. The Trust recognises there are many influencing factors affecting this and are working with clinical teams to ensure they have the right number of staff and equipment to ensure work can be allocated in a consistent and balanced way.”

    Source location

    2017-0394-Response
    Page 1 · response
    Published 15 February 2018

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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

    Providing accommodation supporting individuals with complex and fluctuating needs is outside the Trust’s direct control.

    Verbatim wording from the response

    “You raise an important issue regarding the provision of a range of accommodation services that can support individuals with complex and fluctuating needs. Such provision of accommodation is outside of the direct control of the Trust. The Trust’s role is to continually monitor the service user’s presentation and to help facilitate changes where these are required. For Mr Stannard, this would have involved working with him, his family, the care home, continuing healthcare services and the GP. The Trust’s Root Cause Analysis (RCA) investigation identified there was evidence of inter-agency working noting a routine review meeting was held on 7 November 2016. This meeting observed Mr Stannard’s continued physical and mental health presentation, identifying plans to assist with his benefit entitlement and to seek advocacy support to assist with decisions about potential future physical events.”

    Source location

    2017-0394-Response
    Page 1 · response
    Published 15 February 2018

    Open published response

  7. South Wales Central

    AI-generated summary

    Deidre Harvey · 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

    Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of active input from outside consultants into mental health unit patient care

    Wider context from the report

    “Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”

    Source location

    Deidre Harvey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Yorkshire Eastern

    AI-generated summary

    Margaret Elizabeth Conway · 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

    Margaret Elizabeth Conway, aged 68, was admitted to Pinderfields Hospital with diarrhoea, acute kidney injury and pancolitis after being transferred from Fieldhead Hospital. She suffered a cardiac arrest and died at 0110 hours on 3 September 2016; the inquest recorded natural causes, including acute myocardial infarction and acute severe colitis. The substantive concerns related to the challenges of transferring and caring for patients with both serious mental and physical health problems across geographically and operationally separate services.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Difficulties in transferring patients with serious mental and physical health problems

    Wider context from the report

    “With the assistance of Professor Stephen Curran, Consultant in Old Age Psychiatry and Clinical Lead who is based at Fieldhead Hospital and who was involved in Mrs Conway’s care, I wish to address the issue of patients experience in mental health issues and who are in-patients at Fieldhead Hospital but who have or developed physical health problems acutely which require treatment. (1) The Acute Medical Wards Mental Health Services are geographically and operationally separate. (2) Transfers of patients who are experiencing both serious mental and physical health problems can sometimes be very challenging. (3) PLT Services are now more actively involved in patients transferring to the Acute Wards. (4) Closer working such as joint ward rounds and NDT working should be explored as well as the development of a clear pathway/flowchart to facilitate closer working and in the longer-term the development and use of a shared resource with a small number of jointly funded and managed beds. Such measures would improve the care of patients with both severe physical and mental illness and also reduce the need for multiple transfers between the two organisations. ”

    Source location

    Margaret Elizabeth Conway · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Inner South London

    AI-generated summary

    Sadik Miah · 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

    Sadik Miah, who had schizophrenia and was detained in hospital, collapsed suddenly and died in Lambeth Hospital on 15 October 2011 despite resuscitation. Concerns included the monitoring of ECG abnormalities and antipsychotic-related arrhythmia risk, delays in obtaining specialist advice about hyponatraemia, and the lack of regular physician support for psychiatric in-patients with physical health problems.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of consultant physician input into management of in-patients with physical health problems

    Wider context from the report

    “(1) ████████ said that consultant psychiatrists caring for in-patients with physical health problems did not have the benefit of a fellow consultant physician visiting, examining and advising on management, as would occur in a DGH. This did create a risk of other deaths occurring and should be a concern for the coroner. ”

    Source location

    Sadik Miah · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. West Sussex

    AI-generated summary

    Janet BLACKMAN · 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

    Janet Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide seamless physical and mental healthcare including DVT prophylaxis within a single unit

    Wider context from the report

    “(4) It should be possible to develop a system enabling a seamless delivery of care covering both the physical and mental health treatment including DVT Prophylaxis to a patient in a single unit without the need to move patients physically from one unit to another, even if different aspects of care are delivered by different trusts. ”

    Source location

    Janet BLACKMAN · Prevention of Future Deaths report
    Page 2 · concerns

    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 of psychiatric units to deliver required physical healthcare

    Wider context from the report

    “(1) The HKU like other units dedicated to the delivery of essentially psychiatric care are not able to deliver at least some of the elements required of the patient for her physical healthcare. ”

    Source location

    Janet BLACKMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026