8 Jun 2026 Barbara Joan COPE · Prevention of Future Deaths report South Yorkshire (West)
View report summary
Concerns raised 1
Lack of clear allocation and recording of responsibility for ongoing patient follow-up and care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Rotherham NHS Foundation Trust
×
AI-generated summary
Barbara Joan COPE · 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
Barbara Joan COPE, a 75-year-old woman, presented to Rotherham Hospital with decreased conscious levels, slurred speech and reduced oral intake, and was later found to have a high paracetamol level. The result was not reviewed or acted upon for approximately 19 hours, delaying time-critical treatment. The principal concerns were failures in communicating and following up abnormal results, reviewing investigations during clinical deterioration, and clearly assigning responsibility for ongoing care.
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 clear allocation and recording of responsibility for ongoing patient follow-up and care
Wider context from the report “(3) This patient was transferred from the emergency department to the care of Surgery. A referral was then made for Gastroenterology input, they then requested a blood test for paracetamol levels. This was not followed up for 17 hours. There needs to be clear communication, understanding and record keeping of who is responsible for patient and the ongoing follow up and care in these circumstances .
” Source location Barbara Joan COPE · Prevention of Future Deaths report
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 Existing electronic records identify the admitting Consultant responsible for patient care and follow-up until responsibility is formally transferred.
Verbatim wording from the response “Mrs Cope was admitted under a surgical Consultant, remained on the surgical ward and therefore under the care of the surgical team who were responsible for her care.” Source location Response from Rotherham District General Hospitals
Open published response
5 Dec 2025 Man Yin ‘Anita’ Ng · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 1
Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Man Yin ‘Anita’ Ng · 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
Man Yin ‘Anita’ Ng attended hospital with a subarachnoid haemorrhage caused by an aneurysm. Her coiling procedure was delayed while staff sought an available neurointerventional catheter lab and anaesthetist; she suffered a re-rupture shortly before the procedure and died on 22 January 2025. The principal concern was that complex arrangements and unclear overall clinical responsibility for managing ruptured aneurysms may place patients at risk, particularly because of variation in access to neurointerventional procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” Source location Man Yin ‘Anita’ Ng · Prevention of Future Deaths report
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 partner organisations to advocate for sustainable workforce planning, clearer clinical governance, and equitable access to specialist interventional services.
Verbatim wording from the response “While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.” Source location Response from The Royal College of Radiologists
Open published response
×
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 update professional guidance and standards supporting timely care and clarifying roles and responsibilities in complex multidisciplinary pathways.
Verbatim wording from the response “While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.” Source location Response from The Royal College of Radiologists
Open published response
×
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 a position statement with SBNS and BNVG recommending how clinical care for subarachnoid haemorrhage patients should be managed.
Verbatim wording from the response “Following this report, the College will work with the SBNS and BNVG to develop a position statement setting out recommendations for the management of the clinical care of SAH patients, and also for the provision of access to the recently published credentialing process for thrombectomy training for non-radiologists, which could allow neurosurgeons with a neurovascular interest to train in both endovascular and open surgical treatment to improve patient-centred decision-making.” Source location Response from Royal College of Surgeons
Open published response
×
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 Neurosurgeons and linked multidisciplinary teams are best placed to manage subarachnoid haemorrhage patients and determine treatment.
Verbatim wording from the response “In asking for our guidance as to who is best to manage patients with this condition, we would state that the neurosurgeons and linked MDT are best placed to manage these patients, especially due to the fact that not all centres have a dedicated neurosurgical service or neuro-interventional service and the importance of such patients being managed by these specialist teams rather than delay treatment options. This enables appropriate protocols to be in place for the safe and effective use of such services and offers the best outcomes for patients. This said, unfortunately the nature of subarachnoid haemorrhages is such that re-rupture is unpredictable, including primary rupture, and even the best neurosurgeons who manage the complex aneurysms cannot predict whether someone may rupture before intervention can be done in a safe and timely manner.” Source location Response from Royal College of Physicians
Open published response
×
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 Existing pathways should remain unchanged, with patients unsuitable for coiling remaining under neurosurgical care.
Verbatim wording from the response “We would strongly support that the pathways remain unchanged and given both complications and the original ruptured aneurysm if coiling is not feasible remain under the care of the neurosurgeons.” Source location Response from Royal College of Physicians
Open published response
×
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 NHS providers, commissioners and national bodies are responsible for organising, resourcing and operationally delivering emergency and specialist services.
Verbatim wording from the response “The Royal College of Radiologists (RCR) is a charity which works with our members and Fellows to improve medical care across the specialties of Clinical Radiology and Clinical Oncology. The RCR does not commission, fund, manage, or directly deliver clinical services. Responsibility for the organisation, resourcing, and operational delivery of emergency and specialist services lies with NHS providers, commissioners, and national bodies. However, the RCR has an important role in setting professional standards, providing guidance, supporting workforce development, and advocating for system-level change where patient safety and service sustainability are at risk.” Source location Response from The Royal College of Radiologists
Open published response
×
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 RCR cannot mandate service reconfiguration or staffing levels, limiting its ability to implement those changes directly.
Verbatim wording from the response “While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.” Source location Response from The Royal College of Radiologists
Open published response
×
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 multidisciplinary teams may determine how SAH services are delivered, provided neurosurgical and interventional neuroradiology expertise is included.
Verbatim wording from the response “The College recognises that effective decision-making within the multi-disciplinary team (MDT) is key and that any treatment strategy in patients with aneurysmal subarachnoid haemorrhage should be decided by teams with both surgical and endovascular expertise. The specific details of how this service should be delivered by the MDT may vary and can be decided locally provided there is sufficient input by both neurosurgeons and INR colleagues, leading to safe and effective treatment.” Source location Response from Royal College of Surgeons
Open published response
×
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 Neurosurgeons are considered best placed to manage SAH patients across pre-treatment, treatment and post-treatment care.
Verbatim wording from the response “However, we consider that neurosurgeons are best positioned to manage these patients because they are trained to manage the full spectrum of SAH complications, including pre- and post-treatment challenges, regardless of whether the definitive intervention is surgical or endovascular. Neurosurgical team working patterns are also best placed to support continuity of care, which is crucial for these complex patients.” Source location Response from Royal College of Surgeons
Open published response
8 Oct 2025 William King · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1
Absence of clear responsibility for explaining NG tube necessity View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
William King · 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
William King died at Milton Keynes University Hospital on 26 January 2025 following an aspiration episode during preparation for emergency laparotomy for bowel obstruction. The principal concerns were inadequate explanation and documentation of the risks and necessity of a nasogastric tube, failure to implement the relevant consent policy, and unclear responsibility for ensuring this aspect of care was addressed.
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 Absence of clear responsibility for explaining NG tube necessity
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content.
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy . The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care .
I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” Source location William King · Prevention of Future Deaths report
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 Provide consent guidance on supported decision-making, informed consent, treatment options, material risks and patient-specific communication.
Verbatim wording from the response “• The College has produced guidance on Consent: Supported Decision-Making which lays out the key principles that underpin the consent process. This guidance emphasises that for the patient’s consent to be considered informed, surgeons must be satisfied that the patient has received and understood full and sufficient information about the proposed treatment and its implications. This includes presenting the various treatment options and discussing their relative risks and benefits side by side. It makes clear that consent should be patient-specific, and that surgeons should communicate the risks that are material to the particular patient and their circumstances.” Source location Response from Royal College of Surgeons of England
Open published response
×
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 consent guidance to reflect revised Good Surgical Practice.
Verbatim wording from the response “• Advice and guidance: We were concerned to read of the confusion between surgeons and anaesthetists in Billy’s care team around the responsibility for communicating the risks of not placing a nasogastric tube. Although our guidance is clear the surgeon discussing treatment with the patient has the responsibility for communicating the relevant associated risks and complications in the patient’s treatment, we appreciate that, in some cases, some aspects of anaesthetic consent are complex and may require an additional conversation. We are currently in the process of updating our consent guidance to take into account our recent revision of Good Surgical Practice, and we will seek to consult with colleagues at the Royal College of Anaesthetists for coordinated advice in this area.” Source location Response from Royal College of Surgeons of England
Open published response
×
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 Consult the Royal College of Anaesthetists on coordinated advice for complex anaesthetic consent and risk communication.
Verbatim wording from the response “• Advice and guidance: We were concerned to read of the confusion between surgeons and anaesthetists in Billy’s care team around the responsibility for communicating the risks of not placing a nasogastric tube. Although our guidance is clear the surgeon discussing treatment with the patient has the responsibility for communicating the relevant associated risks and complications in the patient’s treatment, we appreciate that, in some cases, some aspects of anaesthetic consent are complex and may require an additional conversation. We are currently in the process of updating our consent guidance to take into account our recent revision of Good Surgical Practice, and we will seek to consult with colleagues at the Royal College of Anaesthetists for coordinated advice in this area.” Source location Response from Royal College of Surgeons of England
Open published response
Concerns raised 2
Lack of multidisciplinary assessment and senior consultant oversight of community urology patients View source Failure of senior clinicians to retain responsibility for patients throughout private hospital care View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Keith James Hankin · 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
Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.
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 multidisciplinary assessment and senior consultant oversight of community urology patients
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services. Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other. The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” Source location Keith James Hankin · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of senior clinicians to retain responsibility for patients throughout private hospital care
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” Source location Keith James Hankin · Prevention of Future Deaths report
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 Require consultants to retain responsibility for patients throughout their clinical pathway under the Practising Privileges policy.
Verbatim wording from the response “I can confirm that GHH, as with all CHG sites, operates a consultant-led care model which is adopted across the private sector. Consultants’ responsibilities are clearly and robustly identified in CHG’s Practising Privileges policy, which draws upon the GMC’s Good Medical Practice and associated national guidance with which all doctors are expected to comply. CHG’s policy explicitly states: “The practitioner retains responsibility for patients they have treated during the patient’s entire clinical pathway in the relevant CHG hospital”.” Source location Response from Circle Health Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Care of the Deteriorating Patient policy defining consultant and Resident Medical Officer responsibilities and requiring escalation when consultants fail to respond appropriately.
Verbatim wording from the response “Consultants’ responsibilities are further reiterated within the comprehensive suite of clinical policies that are implemented across the CHG estate. Of particular relevance in this case is CHG’s Care of the Deteriorating Patient policy, which plainly sets out the expectations of both consultants and RMOs when managing patient deteriorations, and is incontrovertibly clear that consultants remain responsible for clinical care throughout a patient’s stay in a CHG hospital. Further, the policy mandates that a failure by a consultant to respond in line with their responsibilities must be escalated to the senior management team within the hospital.” Source location Response from Circle Health Group
Open published response
×
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 Existing policies sufficiently establish consultants’ continuing responsibility for patients and define RMO and consultant responsibilities during deterioration.
Verbatim wording from the response “I can confirm that GHH, as with all CHG sites, operates a consultant-led care model which is adopted across the private sector. Consultants’ responsibilities are clearly and robustly identified in CHG’s Practising Privileges policy, which draws upon the GMC’s Good Medical Practice and associated national guidance with which all doctors are expected to comply. CHG’s policy explicitly states: “The practitioner retains responsibility for patients they have treated during the patient’s entire clinical pathway in the relevant CHG hospital”.” Source location Response from Circle Health Group
Open published response
×
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 CHG considers its consultant-responsibility policies clear and effective, requiring no revision or further action at this time.
Verbatim wording from the response “Consultant compliance with their responsibilities is monitored and ensured through a combination of incident reporting and monitoring, appraisal, biennial review, a wider-reaching and robust audit programme and Freedom to Speak Up escalation channels. Any concerns about consultant performance are addressed appropriately under CHG’s Responding to Concerns about Medical Practitioners policy. I can therefore confirm that CHG has given careful consideration to the concerns identified and is satisfied that its policies are clear, effective in their aim, and that no revision or further action is required at this time. As is the case with all policies, and as mentioned above, these are reviewed regularly to ensure ongoing compliance with best practice.” Source location Response from Circle Health Group
Open published response
×
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 Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Verbatim wording from the response “CQC’s prosecutorial powers only extend to registered persons. A registered person means either the provider or their registered manager. Failures by individuals are not within our remit; therefore, we cannot pursue this matter any further.” Source location Response from Care Quality Commission
Open published response
4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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 Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient .
” Source location Tracey Ostler · Prevention of Future Deaths report
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 Implement and disseminate the Emergency Medicine–Medical–Psychiatry Joint Care Guideline clarifying clinical responsibilities and escalation.
Verbatim wording from the response “Given the situation the NHS currently finds itself in, where demand for mental health services exceeds availability, the Trust and SABP have worked together to ensure there is high quality of oversight where patients awaiting a mental health bed are cared for at the Trust. This is delivered through an Emergency Medicine- Medical–Psychiatry Joint Care Guideline, developed in collaboration with SABP. The guideline makes explicit the responsibilities for clinicians:” Source location Response from Epsom General Hospital
Open published response
×
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 Clinical matters fall outside the commissioning organisation’s remit.
Verbatim wording from the response “As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.” Source location Response from NHS South West London Integrated Care Board
Open published response
×
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 Clinical matters are the responsibility of the relevant Trusts.
Verbatim wording from the response “As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.” Source location Response from NHS South West London Integrated Care Board
Open published response
30 Jun 2025 Thomas Raymond Mallinson · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1
Lack of clear responsibility for care of patients during illness 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
Carlisle Central Practice Cumbria Health Limited Department of Health and Social Care North West Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
North West Ambulance Service NHS Trust
Maintain established pathways for circumstances in which a receiving provider passes a referral back to NWAS.
View source
Cumbria Health Limited
Implement an overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
View source
Cumbria Health Limited
Continue discussions with the ICB, practices and primary-care representatives on formal arrangements for safely handing cases between daytime and out-of-hours services.
View source
Department of Health and Social Care
Introduce outcomes-based funding, integrated digital records and personalised care plans.
View source See 1 more action
×
AI-generated summary
Thomas Raymond Mallinson · 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
Thomas Raymond Mallinson became unwell with vomiting and diarrhoea and, after repeated contacts with health services over four days, was admitted to hospital gravely ill. He developed cardiogenic shock and acute kidney failure and died on 23 November 2024. The report raised concerns about delays and gaps in responsibility and communication across general practice, out-of-hours care, and ambulance services, and described the delay as amounting to neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear responsibility for care of patients during illness
Wider context from the report “(1) To SSP Health, owners and operators of Carlisle Central Practice, 65 Warwick Road, Carlisle.
I wish to thank ████████ for his attendance and and assistance at the hearing. It was acknowledged that on 18th the advice "to call back tomorrow" should never have been given and that the telephone appointment the following day really ought to have been a face to face assessment either in surgery or at Thomas's home. I am concerned that no body or organization has taken responsibility for Thomas, an elderly man with significant co-morbidities, during his illness. Should this responsibility ultimately rest with a patients general practitioner, if not where does it rest?
” Source location Thomas Raymond Mallinson · Prevention of Future Deaths report
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 Maintain established pathways for circumstances in which a receiving provider passes a referral back to NWAS.
Verbatim wording from the response “There was no subsequent pass back to NWAS in Mr Mallinson's case, but if there had been NWAS also have established pathways for these circumstances.” Source location Response from North West Ambulance Services
Open published response
×
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 overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
Verbatim wording from the response “In terms of the updated policy, we have put in place a clear process for managing calls that we cannot deal with overnight to reduce the risk of simply handing them all back to the daytime GP practices (page 13 in Clinical Operational Policy). We now provide a welfare call to patients in the overnight period in whom we have breached their response times. If there are concerns of deterioration then the case is escalated to a Clinician as priority. As discussed at inquest we will be adopting an automated text system to do the welfare checks with Adastra (our patient record software provider) when it becomes available which we understand will be by the end of the year.” Source location Response from Cumbria Health
Open published response
×
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 discussions with the ICB, practices and primary-care representatives on formal arrangements for safely handing cases between daytime and out-of-hours services.
Verbatim wording from the response “2. The ICB have been informed of the receipt of the Regulation 28. I have had meetings with their quality team looking at how we manage the “shoulder time” at the daytime practice/Out of Hours interface. These discussions are ongoing as currently there is no formal agreement on how cases are managed and I have raised the possibility with the ICB about an MOU with all practices that would” Source location Response from Cumbria Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce outcomes-based funding, integrated digital records and personalised care plans.
Verbatim wording from the response “The plan also commits to a whole-system reform by creating a new NHS operating model, outcomes-based funding, integrated digital records, and personalised care plans, ensuring services work together rather than in isolation. It aims to reduce overcomplexity through system-wide working and joined-up pathways. With respect to clinical neglect, the plan outlines a commitment to a new era of transparency, improved quality of care for all, and stronger inclusion of patient and staff voices. This effort aims to address and prevent unnecessary suffering caused by healthcare failures and broader issues within the NHS.” Source location Response from Department for Health and Social Care
Open published response
×
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 Wider risks from fragmented responsibility across NHS services should be addressed by national stakeholders through national guidance and structural changes.
Verbatim wording from the response “We also recognise your wider concerns about fragmented care across the NHS services. During the inquest, we noted that Mr Mallinson's case involved repeated transfers between 111, 999, Out-of-Hours and the GP surgery. In our view, this case exemplifies the complexity and lack of clarity that can occur when multiple providers share responsibility without a single clear point of accountability. We therefore support your decision to address this Regulation 28 to national stakeholders and would welcome further national guidance and structural changes to reduce these risks for vulnerable patients in future.” Source location Response from NHS Services
Open published response
×
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 Contractual arrangements with partner organisations are considered sufficient to ensure continuity after NWAS transfers care.
Verbatim wording from the response “In Mr Mallinson's case NWAS handed over the episode of care to Cumbria Health on Call (CHOC) in line with the established clinical pathway. It is not possible for NWAS to follow up on every call once care has been transferred, and the service relies on the contractual arrangements that are in place with partner organisations to ensure appropriate continuity of care.” Source location Response from North West Ambulance Services
Open published response
×
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 Once a referral is accepted, responsibility for the patient's care rests with the receiving provider rather than NWAS.
Verbatim wording from the response “In this case, Mr Mallinson was referred to community-based care and CHOC accepted responsibility for the referral. I understand this was confirmed by CHOC during the inquest, and there was no dispute regarding the transfer of care. Once a referral has been accepted, the duty of care then rests with the receiving provider, and NWAS' responsibility appropriately ends at that point.” Source location Response from North West Ambulance Services
Open published response
23 Jun 2025 REDACTED Deceased · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 1
Lack of clear accountable oversight of outpatient care View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
49 Marine Avenue GP Surgery (NPC Surgery NHS North East and North Cumbria Integrated Care Board Northumbria Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
49 Marine Avenue GP Surgery (NPC Surgery
Review internal referral processes to clarify responsibilities and improve timely specialist referrals.
View source
49 Marine Avenue GP Surgery (NPC Surgery
Develop and implement eating-disorder management and under-18 safe-management policies covering weight-loss presentations.
View source
Northumbria Healthcare NHS Foundation Trust
Implement Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.
View source
Northumbria Healthcare NHS Foundation Trust
Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.
View source See 1 more action
×
AI-generated summary
REDACTED Deceased · 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
The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.
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 clear accountable oversight of outpatient care
Wider context from the report “6.Oversight of care in an Outpatient setting
There is a lack of clarity regarding oversight of care in an outpatient setting .
The Patient Safety Incident Investigation report identified that there was a lack of oversight of care . The early help assessment team were stepped down in 2022 and they may have been the appropriate team to maintain oversight of care. The SI report comments that the referrals between services were all appropriate but it was unclear who had oversight of all the care and that the investigation team felt that oversight was unclear and that arrangements around risk assessment escalation safeguarding and GP involvement could have been better through improved communication.
I heard that in an inpatient setting there are key NHS standards set around what was described as “the name at the end of the bed” which healthcare professionals work within.
I am concerned that in an outpatient setting there is no specific guidance regarding oversight of care within the NHS. No one department or clinician has overall responsibility or accountability .
” Source location REDACTED Deceased · Prevention of Future Deaths report
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 Review internal referral processes to clarify responsibilities and improve timely specialist referrals.
Verbatim wording from the response “We are reviewing internal processes to clarify responsibilities and improve timely referrals for specialist input.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
Open published response
×
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 implement eating-disorder management and under-18 safe-management policies covering weight-loss presentations.
Verbatim wording from the response “• New Processes and Policies: We have developed an Eating Disorders Management Standard Operating Procedure (SOP) and a Safe Management of Under-18s with Eating Disorders Policy. These cover the management of patients presenting with weight loss (attached). An initial audit has been undertaken to review all under-18s who have an eating disorder at 49 Marine Avenue Surgery and ensured our management is compliant with the new SOP and policy and that we have a robust review and recall system in place.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
Open published response
×
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 Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.
Verbatim wording from the response “2. Internal management re-structure within Dietetics Service to introduce, and empower, a Community Team Lead to oversee and manage all the outpatient work from triage and clinic capacity to reporting, monitoring and planning. This facilitates the provision of alternative outpatient offers, including home visits where concern is raised regarding” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.
Verbatim wording from the response “5. Development of a Nutrition Multi-disciplinary Team (MDT) meeting which includes medical oversight from Gastroenterologists for complex and vulnerable Dietetic outpatients and mental health oversight from colleagues from the mental health Trust. The first meeting took place on 15 July 2025, scheduled to meet fortnightly and is on track with scheduling. The initial meetings were held with Dietetics and the Trust Gastroenterology consultants to review the current caseloads. Concerns may also be raised to this group outwith the scheduled meetings. This MDT will include mental health colleagues from going forward. The terms of reference are currently being established and will be in place for joint meetings to be scheduled from September 2025.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Open published response
×
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 Overall and specialty-specific outpatient care responsibilities rest with GPs, dieticians, named consultants and care teams, with escalation as needed.
Verbatim wording from the response “Based on the timeline detailed in your report, it appears at the time of ████████ death, she was under the care of the dietician. The GP remains responsible for the overall medical care of the patient, whilst the dietician would manage the specific around the patient's weight. If the dietician had concerns it would be expected that these would be escalated to a senior dietician, the GP, or emergency care services, depending on severity.” Source location 2025-0314 - Response from North East and North Cumbria Integrated Care Board
Open published response
Concerns raised 1
Failure to establish clear responsibility for patient care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Andrew James Tizard-Varcoe · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.
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 establish clear responsibility for patient care
Wider context from the report “(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care . It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe.
” Source location Andrew James Tizard-Varcoe · Prevention of Future Deaths report
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 Continue collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.
Verbatim wording from the response “It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.” Source location Response from NHS Somerset
Open published response
×
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 Existing cross-organisational clinical collaboration generally provides sufficient coordination, with shared care used where specifically requested.
Verbatim wording from the response “It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.” Source location Response from NHS Somerset
Open published response
24 Sep 2024 Kelly Marie STEVENS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Failure to ensure overall consultant responsibility for patients receiving care from multiple teams View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Kelly Marie STEVENS · 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
Kelly Stevens, who had profound learning and physical disabilities and received nutrition, hydration and medication via a PEG tube, was admitted to hospital on 28 December 2023. She suffered a seizure on 3 January 2024 caused by an excessively low, unrecognised sodium level, aspirated vomit, developed aspiration pneumonia and died in hospital later that night. Concerns included the absence of clear overall consultant responsibility, failure to monitor electrolytes and record fluid intake and output properly, and the copying of outdated care plans in her notes.
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 ensure overall consultant responsibility for patients receiving care from multiple teams
Wider context from the report “1) Despite being under the care of the medical team, Ms. Stevens did also receive input from the surgical team. Her situation was further complicated by the fact that for most of her admission she was placed as a medical outlier on a surgical ward. In the event, no one consultant was in overall charge of her care , which meant that the issues identified in this case were not picked up on. I heard evidence that there was no policy in place at the Trust to give guidance as to how this sort of situation should be resolved , but instead that it was expected that consultants would liaise with each other in order to do so . That did not happen in this case ;
” Source location Kelly Marie STEVENS · Prevention of Future Deaths report
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 Share, approve and implement the agreed policy for managing medical outliers and assigning overall responsibility for their care.
Verbatim wording from the response “1) At the time of the incident, there was no policy in place for the management of medical outliers. In the action plan of the report the Chief Medical Officer (CMO) has an action relating to the review of a patient outlier policy and to taking over patient care. These actions are almost completed. Meetings were held between the senior clinical leaders and the Chief Medical Officer on 11th October 2024 and the 4th November to review the policy. The policy has been agreed and will be shared through the Improving Safety Actions Group (ISAG) on 14th November 2024 and approved through Trust Management Board on 20th November 2024 with immediate implementation thereafter.” Source location Response from Worcestershire Acute Hospitals NHS
Open published response
19 Jun 2024 Aaron James DEELEY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
×
AI-generated summary
Aaron James DEELEY · 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
Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.
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 Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act .
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” Source location Aaron James DEELEY · Prevention of Future Deaths report
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 Code of Practice does not require a Responsible Clinician for patients held under section 5(2), and the Trust complied with applicable provisions.
Verbatim wording from the response “The Mental Health Act 1983 Code of Practice at paragraph 36.1 refers to the identification of Responsible Clinician for patients being assessed and treated under the Act (i.e. section 2 for assessment and treatment, section 3 for treatment). There is no mention of the need for the identification of a Responsible Clinician requirement for patients who are subject to a holding power under section 5 (2). It is therefore respectfully submitted that the Trust adhered to the above provisions when applying the requirements of the Mental Health Act 1983 to the care and treatment of Mr Deeley.” Source location Response from Essex Partnership NHS
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.