Recurring concern

Failure of the Emergency Department mental health liaison assessment pathway to provide timely and safe assessment

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First reported 11 Mar 2014•Latest report 18 Aug 2025

Definition

What this concern includes

Includes failures of the named Emergency Department mental health liaison assessment pathway, including referral acceptance and tracking, timely specialist attendance, assessment and escalation, handover, and dedicated observation or safety arrangements for patients awaiting assessment.

Not included

  • Excludes generic Emergency Department overcrowding, staffing or capacity problems unless the report explicitly ties them to the mental health liaison assessment pathway.
  • Excludes failures in general clinical assessment, treatment or discharge that are not specific to mental health liaison assessment in the Emergency Department.
  • Excludes Mental Health Act assessment or community mental health pathway failures unless they concern the Emergency Department mental health liaison assessment pathway.
Reports
7

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
9

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Central and North West London NHS Foundation Trust1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
East Lancashire Hospitals NHS Trust1
Lancashire & South Cumbria NHS Foundation Trust1
Milton Keynes University Hospital1
Milton Keynes University Hospital Litigation1
NHS Kent and Medway Integrated Care Board1
NHS Medway Clinical Commissioning Group1
NHS Swale Clinical Commissioning Group1
Sandwell and West Birmingham Hospitals NHS Trust1
Thames Valley Police1
West Hertfordshire Teaching Hospitals NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Nottinghamshire

    AI-generated summary

    Emily · 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

    Emily died at Bassetlaw DGH on 6 May 2024 after developing unrecognised dehydration, acute kidney injury, ileus and sub-acute small bowel obstruction following bowel surgery for Crohn’s disease. She experienced vomiting, aspiration pneumonitis and cardiac arrest, with the report identifying concerns about inadequate hydration assessment, fluid-balance recording, recognition of deterioration, clinical assessment and escalation, and response to family concerns. The report also raises concerns about clinical assessment in the Emergency Department before mental health referral or discharge home.

    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 clinical assessment before referral for mental health assessment in Emergency Department patients

    Wider context from the report

    “3. That there continues to be a risk that no clinical assessment will be undertaken, in patients attending the Emergency Department at Bassetlaw DGH, prior to referral for a mental health assessment , and that there continues to be a risk that no clinical assessment will occur in Emergency Department prior to a patients discharge home ”

    Source location

    Emily · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Communicate the requirement for medical review before Emergency Department referral to mental health services.

    Verbatim wording from the response

    “████████ Divisional Director, has formally communicated via email to all Emergency Department (ED) medical staff the requirement that all patients attending the ED must undergo a medical review prior to any referral to mental health services.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 3 · response
    Published 29 August 2025

    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

    Audit compliance monthly with medical review before Emergency Department referral to mental health services and report results through governance.

    Verbatim wording from the response

    “This process is subject to monthly audit, and the most recent audit demonstrated 100% compliance, with all patients referred to mental health services having received a documented medical review. This audit is part of an ongoing quality assurance initiative and is reported through the Audit and Effectiveness Forum to ensure sustained oversight and continuous improvement.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 3 · response
    Published 29 August 2025

    Open published response

  2. Milton Keynes

    AI-generated summary

    Brian Thomas RINGROSE · Prevention of Future Deaths report

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

    Report summary

    Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.

    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

    Delays in mental health team assessment in the Emergency Department

    Wider context from the report

    “Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

    Source location

    Brian Thomas RINGROSE · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Accept emergency-department referrals before medical clearance to enable earlier engagement, risk planning and support, with timely referral-response monitoring.

    Verbatim wording from the response

    “a. Delay in Assessment We have revised our approach to ensure that referrals are accepted even when patients are not yet medically cleared. This enables earlier engagement, risk planning, and support. A key performance indicator for the HLT is timely response to referrals. In the past six months, over 95% of ED referrals have been responded to within one hour. This reflects not only operational improvements but a cultural shift towards proactive, parallel working with ED colleagues.”

    Source location

    Response from Central and North West London NHS Foundation Trust
    Page 2 · response
    Published 4 August 2025

    Open published response

  3. North London

    AI-generated summary

    Mr Paz Ogbe-Millar · 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 Paz Ogbe-Millar died on 2 December 2021 after jumping in front of a high-speed train at Harrow and Wealdstone station, during a relapse in cannabis-induced psychosis. Concerns included his discharge from community mental health services, inadequate recording of police information about his self-harm risk, not allowing his mother to remain with him in the Emergency Department, referral-system problems, and insufficient observation arrangements for mental health patients awaiting assessment.

    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 consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department

    Wider context from the report

    “a. Evidence was heard regarding the appropriate level of observation by Emergency Department staff of mental health patients waiting in the Emergency Department (operated by WHTHNT) to be seen by the Mental Health Liaison Team (operated by HPUNFT). There was confusion amongst the WHTHNT witnesses as to the appropriate level of observation. This was contributed to by a lack of clarity in WHTHNT’s (a) Standing Operating Procedure entitled: “Management of Mental Health Patients in the Emergency Department (ED) at Watford General Hospital (WGH): Standing Operating Procedure (SOP), Issue date August 2021”; when compared with (b) WHTHNT’s “Emergency Department Adult Mental Health Pro-forma” Version 3, Undated (“EDP”); b. The SOP states in a section titled “5. Procedure” (on page 4 of 16) “Patients at moderate or high risk of self-harm or of leaving before assessment and treatment should be observed closely whilst in the ED. There should be continuous observation, and this should be documented in the mental health presentation engagement record (Appendix 1); c. Whereas the EDP states at page 7 under the heading: “Summary of levels of risk and suggested action”, the following: “Low: No special observations required Medium: Consider 15-minute special observation”; d. Emphasis has been added above to paragraphs (b) and (c) in bold text; e. My concern is that the inconsistency between these two documents creates a risk that mental health patients admitted at medium risk of self-harm awaiting assessment for their mental health condition in the Emergency Department may not be subjected to an appropriate level of observation. ”

    Source location

    Mr Paz Ogbe-Millar · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Refine mental-health assessment tools and replace the previous proforma with an electronic assessment aligned with the current observation-level SOP.

    Verbatim wording from the response

    “We have collaborated with the Royal Free London NHS Foundation Trust to refine our assessment tools for patients with mental health needs, ensuring accurate identification of the appropriate level of observation. Consequently, the previously used proforma has been replaced by an electronic assessment which aligns with the current SOP, eliminating any inconsistencies between the two documents.”

    Source location

    Response from West Hertfordshire Teaching Hospital
    Page 1 · response
    Published 14 February 2024

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Andrew BOWLES · 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 BOWLES was found face down in a canal on 16 May 2023 after leaving Birmingham City Hospital, where he had been assessed following concerns about his mental health. The medical cause of death was drowning. The principal concern was that the mental health liaison nurse did not have direct access to City Hospital records containing information about command hallucinations and thoughts of self-harm, which may have affected the assessment and potential referral for psychiatric admission.

    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 access to essential patient records before mental health liaison assessment and treatment

    Wider context from the report

    “3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records, but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system, as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission. 4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment. I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment. The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department. ”

    Source location

    Andrew BOWLES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Allocate hospital-record access to bank staff regularly working within the Psychiatric Liaison Team.

    Verbatim wording from the response

    “In the past any “bank staff” (temporary staff) who were on shift would ask a member of the permanent team to access the records, so that they could review them prior to seeing a patient and would also ask permanent staff to update the records, following their review. Following the PFD, a joint meeting has taken place between the two trusts, and we have been able to identify that a number of the bank staff are regularly working bank shifts within the PLT. Therefore these staff will now be allocated access to hospital records. This will improve matters considerably in this area.”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 1 · response
    Published 6 November 2023

    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

    Advise agency staff during local induction how to access, review and update hospital records through permanent team members.

    Verbatim wording from the response

    “There are a small number of staff who may be called in from agencies when there are no other staff available. As these staff may be new to the team and/or to both trusts and only working one shift, it is unlikely that an account is set up immediately for them with the Hospital. In these exceptional circumstance, when the local induction takes place, they will be advised of the processes in place for them to speak with other permanent team members to access the City Hospital notes. They will review them prior to speaking with the patient and also update the records with their assessment after. Now that BSMHFT bank staff also have access to the”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 1 · response
    Published 6 November 2023

    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

    Generic logins for agency staff cannot be provided because they would lack traceability, accountability and lawful information processing.

    Verbatim wording from the response

    “Please be assured, we did explore all possible options including providing a generic log on for agency only staff who may be carrying out one shift. However from an information governance perspective it would not be possible to ascertain who had inputted the information and therefore there would be no traceability or accountability in place, if any problem arose. This is contra to the lawful processing of confidential information. Therefore the only option available was to strengthen the number of PLT staff who have access to the City Hospital records to address any concerns going forward and ensure smooth working.”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 2 · response
    Published 6 November 2023

    Open published response

  5. Blackburn, Hyndburn and Ribble Valley

    AI-generated summary

    Jacqueline Williams · 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

    On 26 January 2015, Jacqueline Williams was taken to Royal Blackburn Hospital and assessed as being at moderate risk of self-harm, but a referral to the Mental Health Liaison Team was not accepted because of a communication breakdown. She subsequently hanged herself in an emergency department cubicle; concerns related to referral errors and systems that did not make missed or unaccepted referrals readily identifiable and rectifiable.

    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 emergency department visibility of referral acceptance and assessment timing

    Wider context from the report

    “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment. ”

    Source location

    Jacqueline Williams · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of the Mental Health Liaison Team to identify patients believed to be referred and awaiting assessment

    Wider context from the report

    “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment. ”

    Source location

    Jacqueline Williams · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Explore developing an email referral system providing receipt confirmation and an approximate assessment time.

    Verbatim wording from the response

    “A further option we are exploring is the development of a system whereby East Lancashire Hospital NHS Trust staff email the Mental Health Liaison Team with the patient's details and a brief reason for referral. The Mental Health Liaison Team would then acknowledge receipt of the email and also give approximate time of assessment. The referral information is already recorded within the Mental Health Liaison referral log book, however this approach we are looking to implement will ensure that positive confirmation is provided to Emergency Department staff.”

    Source location

    2015-0421-Response-by-Lancashire-Care-NHS-Trust
    Page 2 · response
    Published 2 November 2015

    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

    Plan to utilise the CRISP board to record referrals to specialist teams.

    Verbatim wording from the response

    “Within the Emergency Department they use the CRISP board to record the referrals made to specialist teams and we are looking to utilise this technology.”

    Source location

    2015-0421-Response-by-Lancashire-Care-NHS-Trust
    Page 2 · response
    Published 2 November 2015

    Open published response

  6. North Wales (East and Central)

    AI-generated summary

    Anthony Gwyn Williams · 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

    On 9 February 2014, Anthony Gwyn Williams, whose mental health was declining, went to Pentwmpath Woods and took his own life with a ligature while his balance of mind was disturbed. Concerns included insufficient guidance on when staff could deviate from the recognised psychiatric assessment pathway, lack of continuous access to patients’ medical records, and the need for greater engagement with families and carers about care and treatment plans.

    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 training or guidance on exceptional deviations from the recognised psychiatric assessment pathway

    Wider context from the report

    “1. Although a memorandum has been issued to staff advising that there may be times when it is appropriate to deviate from the recognised pathway of psychiatric assessment within the Emergency Department, no clear training or guidance has been given to staff as to what may constitute such “exceptional cases”. ”

    Source location

    Anthony Gwyn Williams · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain increased out-of-hours psychiatric nursing presence on the Heddfan Adult Unit.

    Verbatim wording from the response

    “1. Although a memorandum from the Chief of Staff was circulated to all Medical, Inpatient and Psychiatric Liaison staff on 8 September 2014, it did not provide these staff groups with any guidance as to what constitutes ‘exceptional cases’ in terms of where out of hours psychiatric assessments should take place. I am pleased to report that since this incident, we now have a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours and in similar situations in the future, socially anxious patients such as Mr Williams could be assessed at the Unit and would not need to await psychiatric assessment at the Emergency Department. Notwithstanding this, our Business Manager for Safety & Regulation will fully discuss this matter at the next Operational Management meeting to ensure full understanding and compliance across the Mental Health & Learning Disabilities Division.”

    Source location

    2014-0523-Response-by-University-Health-Board
    Page 1 · response
    Published 2 December 2014

    Open published response

  7. Mid Kent and Medway

    AI-generated summary

    Lorna Frances Cullen · 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

    Lorna Frances Cullen died after falling from the upper level of a multi-storey car park on 23 December 2012, following attendance at an emergency department where she left before receiving a mental health assessment. The principal concern was the long-term adequacy of liaison psychiatry nurse staffing in hospital emergency departments, as patients requiring assessment were regularly waiting well beyond the standard two-hour period.

    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

    Inadequate long-term liaison psychiatry nurse staffing levels covering hospital emergency departments

    Wider context from the report

    “It became apparent that if the deceased had waited at the hospital she would not in fact have been seen until at least midnight and possibly later (more than twice the standard time). The reason for this was due to the fact that there was only one nurse on duty during the ‘late’ shift and in view of the fact that a mental health assessment takes between 2-3 hours the demand (the nurse on duty receives referrals from a number of different departments within the hospital) far exceeded the available staffing provision. It was apparent from the evidence of at least three witnesses that at the time of this death in 2012, patients in need of mental health assessment by the on-duty liaison psychiatry nurse were regularly waiting well in excess of 2 hours. The importance of a mental health assessment taking place as soon as possible after such a need has been identified is obvious. A specially trained psychiatry nurse is more likely to pick up on the more subtle indicators as to risk, that means it is more likely that appropriate management of that risk can be put into place thus affording the most effective preventative measures against self-harm and harm to others. During the course of the inquest I heard evidence that as a result of review additional resources had been awarded to facilitate increased staffing levels and to provide a 24 hour service (previously there were no liaison nurses on duty after midnight) thus providing continuation of services before and after midnight. I was advised that the additional levels of funding remain in place until at least the end of September 2014. The effect of these resources has been to significantly decrease the number of patients who require mental health assessments and who have to wait in excess of 2 hours. It has meant that staff can properly research a patient’s history prior to or as part of the assessment which is not only essential so far as assessing the individual patient but is useful in assessing priority as between patients waiting to be seen. The matter of concern therefore relates to the long term (ie post September 2014) liaison psychiatry nurse staffing levels covering hospital emergency departments. ”

    Source location

    Lorna Frances Cullen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026