18 Oct 2024 Mr Robin Andrew Ward · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Excessive distance of out-of-area acute beds from patients’ home addresses View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Robin Andrew Ward · 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
Mr Robin Andrew Ward, a 73-year-old man, died by drowning in a bath at the Warren Crisis House on 4 July 2021; the conclusion was that his death was suicide. He had required an acute inpatient mental health bed, but no local bed was available for four days and he was placed at the crisis house as an interim measure. Concerns included pressures on acute and out-of-area mental health bed availability, the lower clinical capacity and lack of ligature safety in crisis houses, and long waiting times for psychological assessment.
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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 Excessive distance of out-of-area acute beds from patients’ home addresses
Wider context from the report “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”.
b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment . In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment.
c) Another particular problem identified was the long waiting times for psychological assessment.
” Source location Mr Robin Andrew Ward · Prevention of Future Deaths report
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14 Jun 2024 Amina Ahmed Ismail · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in transferring patients from out-of-area independent-provider hospitals View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Run the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme to localise and realign inpatient care.
View source
NHS England
Publish the Commissioning Framework for Mental Health Inpatient Services.
View source
NHS England
Require each Integrated Care Board to develop and publish a three-year plan to localise and realign mental health inpatient care.
View source
Department of Health and Social Care
Continue working with the NHS to maximise mental health service capacity.
View source See 1 more action
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AI-generated summary
Amina Ahmed Ismail · 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
Amina Ahmed Ismail, aged 19, died on 15 September 2023 at Pankhurst Ward, Priory Hospital Cheadle, after self-ligaturing; the medical cause of death was ligature strangulation. The report describes her prolonged stay in a PICU, deterioration in her mental health, shortages of appropriate specialist care beds, and delays in arranging and funding a suitable placement as concerns contributing to the circumstances of her death.
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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 Delays in transferring patients from out-of-area independent-provider hospitals
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units ; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Source location Amina Ahmed Ismail · 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 Run the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme to localise and realign inpatient care.
Verbatim wording from the response “In 2022, NHS England launched the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme. A core aim of the programme is to localise and realign care, harnessing the potential of people and communities. The programme is built upon the cornerstones of good mental healthcare; continuity of care, therapeutic relationships and a relentless commitment to mental health care meeting the needs of all citizens.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Commissioning Framework for Mental Health Inpatient Services.
Verbatim wording from the response “To support this aim, NHS England published the Commissioning Framework for Mental Health Inpatient Services in early 2024 and introduced a requirement in its Operational Planning Guidance (2024/25) that each Integrated Care Board (ICB) develop and publish a 3 year plan to localise and realign care to the evidence-base summarised in the Framework. Local plans need to cover within them how they will cease the practice of sending people to inpatient services at a distance from their home and/or to outdated or risky models of provision – underpinned by the philosophy that ‘all means all’, and people with acute mental health needs should have access to the evidence-based therapeutic offers they need as close to home as possible and adjusted to their needs. This includes acute and rehabilitation inpatient services.” Source location Response from NHSE
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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 Require each Integrated Care Board to develop and publish a three-year plan to localise and realign mental health inpatient care.
Verbatim wording from the response “To support this aim, NHS England published the Commissioning Framework for Mental Health Inpatient Services in early 2024 and introduced a requirement in its Operational Planning Guidance (2024/25) that each Integrated Care Board (ICB) develop and publish a 3 year plan to localise and realign care to the evidence-base summarised in the Framework. Local plans need to cover within them how they will cease the practice of sending people to inpatient services at a distance from their home and/or to outdated or risky models of provision – underpinned by the philosophy that ‘all means all’, and people with acute mental health needs should have access to the evidence-based therapeutic offers they need as close to home as possible and adjusted to their needs. This includes acute and rehabilitation inpatient services.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the NHS to maximise mental health service capacity.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I understand that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.” Source location Response from DHSC
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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 Individual trusts and local health systems are responsible for assessing and managing bed capacity, patient flow and specialist rehabilitation-unit availability.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I understand that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.” Source location Response from DHSC
Open published response
21 Mar 2024 Sarah Elizabeth ADAMS · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Lack of training for practitioners in the discharge process, including issues arising from out of area admissions View source
Linked responses
Berkshire Healthcare NHS Foundation Trust Cygnet Health Care Limited Reading Borough Council
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
Cygnet Health Care Limited
Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.
View source
Cygnet Health Care Limited
Update risk e-learning guidance to address risk assessment around discharge.
View source
Cygnet Health Care Limited
Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.
View source
Berkshire Healthcare NHS Foundation Trust
Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
View source See 1 more action
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AI-generated summary
Sarah Elizabeth 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
Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of training for practitioners in the discharge process, including issues arising from out of area admissions
Wider context from the report “That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions
” Source location Sarah Elizabeth ADAMS · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.
Verbatim wording from the response “Care planning and risk assessment training is provided to staff to support them in completing care plans, including discharge care plans. This is via a 4.5 hour face to face session. The session is provided by the Regional Nursing Director to all the Clinical Managers to then be cascaded at each site. At Cygnet Harrow this session has been provided to all members of the multi-disciplinary team (MDT) and is due to be refreshed on an annual basis, or more frequently if a need is identified.” Source location Response from Cygnet Healthcare
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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 Update risk e-learning guidance to address risk assessment around discharge.
Verbatim wording from the response “This training is aligned with Cygnet's broader training offering, particularly our e-learning risk training. This training is provided to all members of the MDT and refreshed on a two-yearly basis. The session provides guidance to staff in assessing risk, utilising the relevant tools and ensuring that risk assessments are of high quality and triangulated with the care plans, continuous notes and information from families and carers. We are acutely aware that risks can increase at discharge and that risk assessments need to be undertaken carefully to ensure that we implement steps to minimise this. The risk training has been reviewed and from 1 July 2024 will include updated and more specific guidance in relation to risk assessing around discharge.” Source location Response from Cygnet Healthcare
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.
Verbatim wording from the response “Further, a supplemental set of training slides for staff induction are in development to provide support to staff in understanding the content of the discharge policy, including the discharge checklist, the key risks to consider, accurate documentation and communication with community teams. These slides will be deployed by 1st June 2024 for all Cygnet Hospital sites to assist new staff with prompt familiarisation with our processes.” Source location Response from Cygnet Healthcare
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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 Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
Verbatim wording from the response “All clinical staff in the Mental Health Divisions undertake Clinical Risk training which includes a focus on admission and discharge from inpatient services. We have now reviewed and revised this training offer across the organisation to ensure that moving forward there will be an increased focus on high-risk situations such as:” Source location Response from Berkshire Healthcare NHS Foundation 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 existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.
Verbatim wording from the response “9. We confirm that all Adult Social Care practitioners involved in discharge planning are required to know and act in accordance with the SOP. Precise processes regarding discharge planning may differ from Trust to Trust.” Source location Response from Reading Borough Council
Open published response
Concerns raised 1
Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities 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
Philip David Taylor · 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
Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities
Wider context from the report “b. There was no joined up planning or joint meeting between the Health Board and Ty Grosvenor prior to the deceased’s discharge .
” Source location Philip David Taylor · 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 Hold formal weekly multidisciplinary out-of-area monitoring meetings with documented actions, escalation and oversight of repatriation, clinical activity and discharge planning.
Verbatim wording from the response “All areas have stood up a formal weekly out of area monitoring meeting. The purpose of this meeting is to promote timely repatriation where possible, assurance that key clinical activity and standards are being met and that discharge plans are being implemented and actioned. These meetings are underpinned by terms of reference, agenda, minutes and a log of actions to be completed. Membership includes the multidisciplinary team, including Health and Social Care, Consultant and Medical staffing, Occupational Therapy, Home Treatment Team and Care Coordinators. Outcomes from the meetings are provided to Divisional Putting Things Right meetings and the weekly Divisional Senior Leadership meeting to ensure appropriate escalation arrangements can be put in place where required.” Source location Response from Betsi Cadwaladr University Health Board
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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 a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
Verbatim wording from the response “The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation.” Source location Response from Betsi Cadwaladr University Health Board
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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 Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
Verbatim wording from the response “A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.” Source location Response from Betsi Cadwaladr University Health Board
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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 described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.
Verbatim wording from the response “5. This is, therefore, as far as Elysium is concerned, not a case where the facts suggest a risk of future deaths in relation to the role of Elysium. Mr Taylor was an informal patient and was assessed as low risk. His details were already well known to Betsi who had summarised his position when referring him to Elysium in the first place. They had been informed by” Source location Response from Elysium Healthcare
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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 Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.
Verbatim wording from the response “2. The third ward round took place on 14 August. Mr Taylor wished to leave. He was an informal patient. He did not meet the criteria for detention under the MHA. Nor did he lack capacity so a deprivation of liberty under the Mental Capacity Act was not available. He had to be discharged as there was accordingly no lawful basis to refuse this. It was agreed that to enable this to take place in an orderly fashion he would leave the next day. Elysium had no alternative but to proceed with this.” Source location Response from Elysium Healthcare
Open published response
29 Jan 2024 Shahzadi Khan · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure of out-of-area and private providers to coordinate effectively with local discharge arrangements View source Use of out-of-area mental health placements limiting family contact View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Shahzadi Khan · 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
Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.
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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 out-of-area and private providers to coordinate effectively with local discharge arrangements
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Source location Shahzadi Khan · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Use of out-of-area mental health placements limiting family contact
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible . This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Source location Shahzadi Khan · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish statutory guidance for discharge from all mental health inpatient settings.
Verbatim wording from the response “To improve the issue of out of area placements, and to support adult social care and discharge, up to £2.8 billion has been made available in 2023/24 and £4.7 billion in 2024/25. This can be used to support discharge from mental health inpatient settings, reducing bed occupancy and OAPs. The Department has been working with NHS England and other” Source location Response from Department of Health and Social Care
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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 Make funding available to support discharge from mental health inpatient settings and reduce out-of-area placements.
Verbatim wording from the response “To improve the issue of out of area placements, and to support adult social care and discharge, up to £2.8 billion has been made available in 2023/24 and £4.7 billion in 2024/25. This can be used to support discharge from mental health inpatient settings, reducing bed occupancy and OAPs. The Department has been working with NHS England and other” Source location Response from Department of Health and Social Care
Open published response
19 Sep 2023 Lauren Elizabeth Bridges · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Lack of consistent adoption and awareness of delayed-discharge protocols across independent providers View source Out-of-Area patients remaining away from home because of delayed discharge or repatriation View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Dorset Healthcare University NHS Foundation Trust NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Department of Health and Social Care
Develop and publish statutory guidance for discharge from mental health inpatient settings.
View source
Department of Health and Social Care
Provide additional funding to support adult social care and NHS discharges, including from mental health inpatient settings.
View source
Department of Health and Social Care
Work with NHS England to ensure systems prioritise eliminating inappropriate out-of-area placements, focusing on discharge and patient flow.
View source
NHS England
Work towards eliminating adult acute out-of-area placements across the NHS.
View source
NHS England
Publish guidance supporting timely, local, high-quality therapeutic inpatient care and timely discharge.
View source
NHS England
Support health and care systems to operationalise inpatient mental health care localisation plans through regional and national assistance.
View source
Dorset Healthcare University NHS Foundation Trust
Add a dedicated Hospital Overview section identifying out-of-area patients requiring repatriation to support daily bed-allocation decisions.
View source
Dorset Healthcare University NHS Foundation Trust
Appoint a dedicated clinical Out of Area Coordinator.
View source
Dorset Healthcare University NHS Foundation Trust
Implement an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.
View source
Dorset Healthcare University NHS Foundation Trust
Conduct monthly audits of out-of-area patient records against procedure standards, including coordinator input, care coordination, contacts, reviews and repatriation planning.
View source See 7 more actions
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AI-generated summary
Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent 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 consistent adoption and awareness of delayed-discharge protocols across independent providers
Wider context from the report “The protocol is heavily reliant on engagement from, and co-operation of, the numerous NHS commissioning bodies. The protocol requires a low threshold for the escalation of delays to the appropriate manager and/or commissioner at the ‘home service’.
There are over 60 independent providers for in-patient mental health services.
The initiative taken by the Priory is to be applauded but it is just one of many independent providers for some 42 separate NHS commissioning bodies. There is a clear danger that it will not be adopted by the other independent providers , indeed there is no reason for them to be aware of its existence . In the premises, Out-of-Area delayed discharge, and its detrimental effect on a patient’s mental health, will remain a matter of concern.
” Source location Lauren Elizabeth Bridges · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Out-of-Area patients remaining away from home because of delayed discharge or repatriation
Wider context from the report “With regard to delayed discharge/repatriation of an Out-of-Area patient I heard evidence that The Priory have devised a protocol/standing operating procedure in respect of delayed discharge, which should reduce the risks of a patient being left miles from home at all and in any event reduce the time taken to repatriate . However, it relies on the ‘home team’s’ engagement in the process.
” Source location Lauren Elizabeth Bridges · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish statutory guidance for discharge from mental health inpatient settings.
Verbatim wording from the response “The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)” Source location Response from Department of Health and Social Care
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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 additional funding to support adult social care and NHS discharges, including from mental health inpatient settings.
Verbatim wording from the response “To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, reducing bed occupancy.” Source location Response from Department of Health and Social Care
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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 Work with NHS England to ensure systems prioritise eliminating inappropriate out-of-area placements, focusing on discharge and patient flow.
Verbatim wording from the response “All systems that still have inappropriate out of area placements have been required to refresh their local plans to ensure these placements are eliminated everywhere as soon as reasonably possible. NHS England continues to work with the worst performing areas and support them to improve and we are working with NHS England to ensure that systems prioritise this, including a focus on discharge and flow.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work towards eliminating adult acute out-of-area placements across the NHS.
Verbatim wording from the response “The NHS remains committed to eliminating the practice of adult acute Out of Area Placements. All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England’s 2023/24 Priorities and Operational Planning Guidance. An ICB is a statutory NHS organisation which is responsible for developing a plan for meeting the health needs of the population, managing the NHS budget, and arranging for the provision of health services within a given geographical area. They replace clinical commissioning groups (CCGs), taking on the NHS planning functions previously held by CCGs, as well as absorbing some planning roles from NHS England.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance supporting timely, local, high-quality therapeutic inpatient care and timely discharge.
Verbatim wording from the response “In July 2023 NHS England published renewed guidance to support the commissioning and delivery of timely access to high quality therapeutic inpatient care, close to home and in the least restrictive setting possible. Key to this are the principles of: timely and purposeful admissions that are local, timely discharge, joined-up care and continuous improvement.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support health and care systems to operationalise inpatient mental health care localisation plans through regional and national assistance.
Verbatim wording from the response “To implement this, all ICBs have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of the mental health, learning disability and autism inpatient quality transformation programme launched in 2022. Health and Care systems across England are currently being supported to operationalise the guidance via 3-year plans with direct support from regional and national teams. The transformation programme is underpinned by a £36 million investment.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a dedicated Hospital Overview section identifying out-of-area patients requiring repatriation to support daily bed-allocation decisions.
Verbatim wording from the response “3. In addition, the Trust has also added a specific section to the daily Hospital Overview template showing patients who are in out of area beds who require repatriation to a local bed. This ensures that Clinical Site Managers are taking these patients into account when making daily decisions on bed allocations.” Source location Response from Dorset Healthcare University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a dedicated clinical Out of Area Coordinator.
Verbatim wording from the response “3. As referred to during the inquest, we have appointed a dedicated Out of Area Coordinator post, which is a clinical post. We have also written and implemented a SOP for the ‘Use of Out of Area Acute and Psychiatric Intensive Care (PICU) Mental Health Inpatient beds: Therapeutic inpatient care and proactive discharge planning’. The SOP includes standards to be met in respect of regular contact and recording of that contact with patients who are out of area, and their families / carers, as well as with clinicians working in out of area providers overseeing that care.” Source location Response from Dorset Healthcare University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.
Verbatim wording from the response “3. As referred to during the inquest, we have appointed a dedicated Out of Area Coordinator post, which is a clinical post. We have also written and implemented a SOP for the ‘Use of Out of Area Acute and Psychiatric Intensive Care (PICU) Mental Health Inpatient beds: Therapeutic inpatient care and proactive discharge planning’. The SOP includes standards to be met in respect of regular contact and recording of that contact with patients who are out of area, and their families / carers, as well as with clinicians working in out of area providers overseeing that care.” Source location Response from Dorset Healthcare University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly audits of out-of-area patient records against procedure standards, including coordinator input, care coordination, contacts, reviews and repatriation planning.
Verbatim wording from the response “5. A regular audit takes place every month involving reviewing the records of all patients receiving their care out of area against the standards set out within the SOP. This audit is undertaken by our Nursing and Quality Directorate and will remain ongoing. Audit standards include evidence of OOA coordinator input, date of last input, that the patient has an allocated Care Coordinator, date of last input from them, date of last contact with patient and family, date of Care Programme Approach meeting, date of last clinician attendance at a multidisciplinary team review, and whether there is a discharge / repatriation plan.” Source location Response from Dorset Healthcare University NHS Foundation Trust
Open published response
21 Apr 2021 MARY NABILIA GWANYAMA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Difficulty accessing community treatment and support after out-of-area placement View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
MARY NABILIA GWANYAMA · 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
Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.
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 Difficulty accessing community treatment and support after out-of-area placement
Wider context from the report “7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her . There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication.
” Source location MARY NABILIA GWANYAMA · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the CMHRS policy to require ongoing contact during transfers between Trusts, based on SBAR/RAG-rated need, until transfer completion.
Verbatim wording from the response “Our CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust. Our policy is going to ensure that, where a patient is in transition to a neighbouring Trust, we will still provide face to face or telephone/virtual contact as we would base this on the SBAR/RAG rating and identified frequency of need, until the transfer process is complete. If the patient is residing in an area which is relatively local to the team and easily accessible by travel, then we would expect the team to travel to visit the patient if necessary.” Source location 2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide local team visits when transitioning patients are nearby and accessible, where necessary.
Verbatim wording from the response “Our CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust. Our policy is going to ensure that, where a patient is in transition to a neighbouring Trust, we will still provide face to face or telephone/virtual contact as we would base this on the SBAR/RAG rating and identified frequency of need, until the transfer process is complete. If the patient is residing in an area which is relatively local to the team and easily accessible by travel, then we would expect the team to travel to visit the patient if necessary.” Source location 2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refer patients with urgent needs to their local HTT or crisis service for immediate care and risk assessment.
Verbatim wording from the response “Further, where a patient’s needs are considered urgent, then the CMHRS will be guided to make a referral to the patient’s local HTT/Crisis service (as this does not require a CPA transfer), to ensure their immediate care needs are met and risks assessed and appropriately supported.” Source location 2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Open published response
4 Oct 2018 Michael William Cooper · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Out-of-area mental health beds disrupting patient support and continuity of care View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Michael William Cooper · 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
Michael William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in mental health services.
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 Out-of-area mental health beds disrupting patient support and continuity of care
Wider context from the report “1. The Home Treatment Team advised on the 13th March 2018 that Mr. Cooper should be admitted for inpatient mental health treatment. However, this could not happen on the day as there was no bed available. The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives. In the absence of an inpatient bed, Mr. Cooper was managed with medication and home treatment team visiting twice a day. Whilst awaiting admission, he was offered an out-of-area bed on the 16th March 2018 but he declined this as he felt it would be detrimental to him to be so far from his wife and family. The Coroner is aware, although this was not an issue that came out in evidence in this case, that placing patients in out of area beds not only causes difficulty for maintaining the patient's support and visits from family and friends which can be prejudicial to their mental health, but also affects their continuity of care thus creating a risk to life .
” Source location Michael William Cooper · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the system-wide mental-health commissioning strategy, including plans to reduce service fragmentation.
Verbatim wording from the response “8.1.10 Updating the system wide mental health commissioning strategy, including developing plans to reduce fragmentation of services and to ensure care is delivered in the most appropriate setting.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
Verbatim wording from the response “5.4.1 An independent system simulation modelling exercise, which was jointly commissioned with FTB and BSMHFT, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional investment to expand commissioned mental-health service capacity and provision.
Verbatim wording from the response “5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).” Source location Birmingham-and-Solihull-CCG-Response
Open published response
13 Dec 2017 Rebecca Jay ROMERO · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2
Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care View source Lack of guidance for managing children receiving out-of-area psychiatric inpatient care View source
This report raised 4 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
Rebecca Jay ROMERO · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric services.
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 Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area . Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team .
” Source location Rebecca Jay ROMERO · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of guidance for managing children receiving out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area. Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team.
” Source location Rebecca Jay ROMERO · Prevention of Future Deaths report
Open source report
Concerns raised 1
Difficulty for nearest relatives and Responsible Medical Officers to carry out statutory functions during distant placements View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
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
Department of Health and Social Care
Eliminate clinically unnecessary out-of-area placements for adult acute mental health care by 2020/21.
View source
NHS England
Develop an evidence-based adult acute mental health treatment pathway and accompanying commissioning support tools with the NCCMH and stakeholder group.
View source
NHS England
Publish a national definition of acute out-of-area placements following consultation.
View source
NHS England
Monitor progress toward eliminating inappropriate non-specialist adult acute out-of-area placements and provide targeted support to local areas.
View source See 1 more action
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AI-generated summary
David Knight · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Knight, who was detained under the Mental Health Act for chronic mental health issues, died on 23 May 2015 after walking onto a railway track in front of an oncoming train while on Section 17 leave. Concerns included a limited risk assessment before leave, no notification to local community and home treatment teams, and the difficulties associated with his out-of-county placement, including reduced family involvement and communication challenges.
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 Difficulty for nearest relatives and Responsible Medical Officers to carry out statutory functions during distant placements
Wider context from the report “At the inquest the Consultant Psychiatrists (including Expert Psychiatrist) gave evidence that it was not best practice to treat patients out of county. This was particularly relevant to patients with chronic mental health issues (as with Mr Knight) where they were well known to the local mental health service and their needs and issue had successfully been addressed in the past ████████ Another issues raised, was the difficulties of the “nearest relative” and the Responsible Medical Officer to adequately carry out their statutory function at such distances .
” Source location David Knight · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Eliminate clinically unnecessary out-of-area placements for adult acute mental health care by 2020/21.
Verbatim wording from the response “We will eliminate clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and will reduce significantly delayed transfers of care.” Source location 2016-0414-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an evidence-based adult acute mental health treatment pathway and accompanying commissioning support tools with the NCCMH and stakeholder group.
Verbatim wording from the response “To deliver on these commitments, NHS England is working with the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists (RCPsych) to develop an evidence-based treatment pathway and accompanying commissioning support tools for adult acute mental health care from referral through to discharge. This work is led by a multi-stakeholder Expert Reference Group (ERG) convened by the NCCMH involving patient experts, carers, and professionals from different NHS services, social care, public health, policing and the voluntary sector.” Source location 2016-0414-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national definition of acute out-of-area placements following consultation.
Verbatim wording from the response “Further, we have been working with the Department of Health, NHS Digital and NHS Improvement to gain a better understanding in relation to where and why out of area placements happen. As a first step, we have published a national definition of an acute OAP following extensive consultation. As well as the distance patients have to travel, the definition is about whether someone is admitted to an inpatient bed where their usual network of support (e.g. family, pets, care coordinator from their community mental health team) is unable to engage as often as if they were admitted in a local bed. Further to this, we have recently established the first national data collection dedicated to better understanding non-specialist acute OAP activity.” Source location 2016-0414-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor progress toward eliminating inappropriate non-specialist adult acute out-of-area placements and provide targeted support to local areas.
Verbatim wording from the response “The first report was published in December 2016, but we expect to have a reliable national baseline position for OAPs by the end of Q4 16/17, when data quality has improved after the adjustment period following the introduction of the new collection is over. Going forwards, this will allow us to monitor progress against the national ambition to eliminate inappropriate OAPs for non-specialist adult acute mental health care by 2020/21, enabling targeted support to be provided to local areas as required.” Source location 2016-0414-Response-by-NHS-England
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.