6 Feb 2026 Michaela FINCH · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to communicate family concerns to assessing clinicians View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Michaela FINCH · 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
Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate family concerns to assessing clinicians
Wider context from the report “4. The evidence established that at least two family members had brought to the attention of a member of the Mental Health Team their profound concerns, their recent lived experiences with the deceased that underpinned these concerns, their views that the deceased was paranoid, at greater risk to herself - but none of these concerns were brought to the specific attention of the assessing clinician - the communication between the Mental Health Team and family members being sub-optimal .
” Source location Michaela FINCH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.
Verbatim wording from the response “The Trust Standard Operating Procedure (SOP) for Mental Health Liaison Service (MHLS) was updated in August 2025 and clearly outlines the expected standards of engagement with carers by the teams. The SOP includes communicating with carers during an assessment to obtain their views, either with the person being assessed or alone with the practitioner, keeping them up to date during their stay in the Emergency Department and feeding back the outcome of any assessment and plan.” Source location 2026-0064 - Response from Greater Manchester Mental Health
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13 May 2025 Rose Annie Harfleet · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Department of Health and Social Care Royal College of Emergency Medicine Royal College of Paediatrics and Child Health Royal Surrey 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. 9
Royal Surrey NHS Foundation Trust
Maintain a Learning Disabilities and Autism policy with emergency admission guidance and requirements for carer involvement.
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Royal Surrey NHS Foundation Trust
Implement Martha’s Rule across adult and paediatric services, addressing its three delivery metrics for patient, family, carer and staff escalation.
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Department of Health and Social Care
Continue rolling out Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce.
View source
Department of Health and Social Care
Create a single patient record through the NHS App, bringing together patient health information, test results, and letters.
View source
Royal College of Paediatrics and Child Health
Support rollout of Martha’s Rule and engage with NHS England as pilot data emerge.
View source
Royal College of Paediatrics and Child Health
Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.
View source
Care Quality Commission
Publish interim guidance on mandatory learning disability and autism training for providers and CQC staff.
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Royal College of Emergency Medicine
Publish and maintain a Learning Disabilities Toolkit with emergency-department guidance on reasonable adjustments, intra-abdominal pathology and aspiration.
View source
Royal College of Emergency Medicine
Participate in developing the emergency-department version of the national paediatric early warning system, including parental or carer concern in escalation responses.
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AI-generated summary
Rose Annie Harfleet · 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
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.
” Source location Rose Annie Harfleet · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a Learning Disabilities and Autism policy with emergency admission guidance and requirements for carer involvement.
Verbatim wording from the response “The Trust has a Learning Disabilities and/or Autism Policy to Support Children and Adults with Learning Disability and/or Autism. This has been developed in accordance with other national and local guidelines, including the Mental Capacity Act 2005, Learning from lives and deaths – People with a learning disability and autistic people (LeDeR) policy (2021), NICE NG93 mental capacity, reasonable adjustments and quiet areas, NG11 restraint, Autism Spectrum Disorder in Adults; Diagnosis and Management – Clinical Guide CG142 (NICE 2016), NHS LD&A Programme 2025 Digital flagging and hospital passports and the Equality Act (2010). Specifically the Trust policy includes an emergency admission flow chart and information about supporting carers and engaging with them in decision making including care and interventions.” Source location Response from Royal Surrey County Hospital NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Martha’s Rule across adult and paediatric services, addressing its three delivery metrics for patient, family, carer and staff escalation.
Verbatim wording from the response “The Trust is not however aware of any specific national guidance on consultation with the parents and carers of children with profound disabilities although the Trust recognises that this is an essential part of good clinical practice. Whilst not specifically related to children with profound disabilities, the Trust is aware of Martha’s Rule, and have been selected to be part of Phase 2 for implementing this. Work has commenced to address the three metrics for delivery for adults and children.” Source location Response from Royal Surrey County Hospital NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce.
Verbatim wording from the response “To improve awareness of learning disability and autism within the health and social care system, under the Health and Care Act 2022, from 1 July 2022 Care Quality Commission (CQC) registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role. This will help to ensure that staff have the right knowledge and skills to provide safe and informed care. To support providers to meet the statutory training requirement, we have been rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce: this specifically highlights the difference that listening to parents can make.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a single patient record through the NHS App, bringing together patient health information, test results, and letters.
Verbatim wording from the response “As part of the government’s 10-year plan and transforming the NHS from analogue to digital, the government will create a more modern NHS by bringing together a single patient record, summarising patient health information, test results, and letters in one place, through the NHS App. It will put patients and their advocates in control of their own medical history, meaning they do not have to repeat it at every appointment, and that staff have the full picture of patients’ health.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support rollout of Martha’s Rule and engage with NHS England as pilot data emerge.
Verbatim wording from the response “RCPCH are actively supporting the role out of Martha’s Rule. Martha’s Rule is a patient safety initiative currently being piloted in England which aims to empower all staff, patients and their families to seek an independent medical review if they feel their concerns about a patient’s care are not being adequately addressed. The rule is designed to give families the ability to directly request an expert review by a senior clinician not within the immediate care team, potentially identifying critical issues before they result in harm.” Source location Response from Royal College of Paediatrics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.
Verbatim wording from the response “In addition, RCPCH are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.” Source location Response from Royal College of Paediatrics
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish interim guidance on mandatory learning disability and autism training for providers and CQC staff.
Verbatim wording from the response “Speaking with and respecting patients’ families is a key aspect of the mandatory learning disability and autism training (aka the Oliver McGowan training) so all clinicians involved should be aware of this. A difficulty with regard to the implementation and regulation of providing this training has been the delay to the publication of the Code of Practice. This will give providers and CQC staff clearer guidance on the requirements of the training and for CQC to regulate. Interim guidance is available on our website.” Source location Response from Care Quality Commission
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and maintain a Learning Disabilities Toolkit with emergency-department guidance on reasonable adjustments, intra-abdominal pathology and aspiration.
Verbatim wording from the response “1. The management of children with profound disabilities within a hospital setting
In September 2024, the Royal College of Emergency Medicine (RCEM) published a Learning Disabilities Toolkit [1]. This resource includes information about how best to approach the management of people with a learning disability and suggestions on how to make reasonable adjustments in an ED setting. The toolkit also makes specific mention of intra-abdominal pathology and aspiration. The RCEM also provide additional online educational resources related to Learning Disabilities [2]. The RCEM feel it would not be appropriate to comment about the care delivered in the in-patient setting.” Source location Response from Royal College of Emergency Medicine
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in developing the emergency-department version of the national paediatric early warning system, including parental or carer concern in escalation responses.
Verbatim wording from the response “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
The RCEM Learning Disability Toolkit [1] emphasises the importance of listening to family and carers of people with a learning disability in the ED. The RCEM are represented in the group developing the ED version of the national paediatric early warning system (nPEWS) with NHS England. A key component of the nPEWS (and the current draft of the emergency department specific nPEWS score - EDnPEWS) is parental/carer concern [3]. The response from the parent/carer is built into the escalation response. The RCEM is also supportive of the work just commencing via NHS England’s Patient Safety Collaborative, which is looking to test the use of Martha’s Rule in the ED setting. We would also note” Source location Response from Royal College of Emergency Medicine
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Concerns raised 1
Failure to share relevant presentation information with family View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sally Poynton · 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
Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to share relevant presentation information with family
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented , notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Source location Sally Poynton · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish statutory guidance for discharge from mental health and learning disability and autism inpatient settings, including patient, carer and family involvement in discharge planning.
Verbatim wording from the response “From a national perspective, we recognise how vital it is that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital, and that people and their chosen carers are fully involved in the process. On 26 January 2024, new statutory guidance for discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults was published. The guidance provides clarity in relation to how health and care systems can work together to support discharge from all mental health inpatient settings and ensure the right support is in place in the community. The guidance also includes best practice on how patients, carers and family members should be involved in discharge planning.” Source location 2024-0267 Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Integrated Care Board is expected to respond to concerns about the specific care provided.
Verbatim wording from the response “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.” Source location 2024-0267 Response from Department of Health and Social Care
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16 Feb 2024 Mr Roberto Bottello · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure of psychiatric liaison clinicians to consider diagnoses made by other doctors View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Roberto Bottello · 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
Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of psychiatric liaison clinicians to consider diagnoses made by other doctors
Wider context from the report “6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this case.
” Source location Mr Roberto Bottello · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen liaison clinicians’ consultation and collaboration with other doctors and use feedback from A&E doctors on diagnoses and interventions.
Verbatim wording from the response “• We appreciate there is a need to ensure that Psychiatric Liaison nurses and Liaison doctors have regard to and consider diagnoses made by other doctors who see a patient repeatedly in A&E. CNWL will ensure that the established channels of communications are strengthened through improved consultation and collaboration of patient care and a feedback mechanism is used where A&E doctors provide input on the effectiveness of psychiatric diagnoses and interventions at the weekly meeting referred to above,” Source location Response from Central and NW London NHS
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29 Dec 2023 Karmchand Gulzar · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to give adequate weight to concerns from carers and family familiar with a patient's presentation View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Karmchand Gulzar · 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
Karmchand Gulzar was taken to Sandwell Hospital on 23 September 2022 with abdominal distension and pain and was diagnosed with acute intestinal obstruction. A CT scan and immediate surgical review were delayed; his condition deteriorated, urgent surgery took place during the evening and early morning, and he died during the operation in the early hours of 24 September 2022. Concerns included failure to follow the surgical registrar referral pathway, failure to undertake an urgent CT scan, and insufficient recognition of deterioration and concerns raised by carers and family about his condition.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to give adequate weight to concerns from carers and family familiar with a patient's presentation
Wider context from the report “(3) The deterioration in Karmchand’s condition was not recognised due to difficulties in communication of pain due to his mental health condition. Concerns raised by his carers and family who knew him best and his presentation were not given adequate weight. A previous SI was reported to have raised this issue, but no action point or plan was provided in the current report to set out how staff could improve the assessment of patients with communication difficulties, by using observations and relying on people who better knew their demeanour and presentation .
” Source location Karmchand Gulzar · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial a Carers Passport and supporting documentation prompting carers to describe patients’ individual needs and pain expressions.
Verbatim wording from the response “In relation to the concerns regarding the recognition of deterioration not being recognised due to Mr Gulzar’s mental health condition and the concerns of his family/carers being ignored; there is considerable work being done by our Patient Experience team to support improvement in this area. Listening to and valuing the expertise that exists within carers and families is crucial to providing personalised care and treatment, and personalisation is a key-cornerstone of the Trust's Fundamentals of Care programme. Through this work a 'Carers Passport' with supporting patient documentation concentrating on the person, is being trialled in selected wards to understand the benefits this will reap for carers across the organisation. This trial will take place in April 2024, and we will then look to roll this out across the Trust.” Source location Response from Sandwell and West Birmingham NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver patient experience and communication education emphasizing carers’ involvement, expertise, and contribution to care and outcomes.
Verbatim wording from the response “Additionally, we have identified training and education in patient experience and communication as Trust priorities. Every session delivered in the last year stresses the value of carer involvement, their specific expertise and knowledge and the benefits in experience and outcomes that these bring.” Source location Response from Sandwell and West Birmingham NHS Trust
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Concerns raised 1
Culture preventing medics from taking account of parents' or nursing staff's views in assessing patients' overall presentation View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffield Children'S 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. 5
Sheffield Children'S NHS Foundation Trust
Implement processes for clinical Care Groups to review complaints and Freedom to Speak Up themes involving unheard families or colleagues.
View source
Sheffield Children'S NHS Foundation Trust
Embed the In It Together culture framework within the People Plan through leadership events and line-management training.
View source
Sheffield Children'S NHS Foundation Trust
Implement the Parent and Carer Escalation process across all inpatient areas, with prominent posters and continuing promotion and monitoring.
View source
Sheffield Children'S NHS Foundation Trust
Update nurse escalation policies and support them with training.
View source
Sheffield Children'S NHS Foundation Trust
Launch the Quality Promise quality strategy across the Trust to embed safe, kind and outstanding care.
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Kyra Ali Aslam · 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
Kyra Ali Aslam was admitted to Sheffield Children's Hospital for a planned procedure to reverse a stoma, deteriorated over two days after surgery, and died on 13 August 2022. The substantive concerns relate to whether medics adequately considered the views of parents and nursing staff, and whether junior doctors receive sufficient explanation when overruled by a consultant.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Culture preventing medics from taking account of parents' or nursing staff's views in assessing patients' overall presentation
Wider context from the report “1. Whether there is a culture which prevents medics from taking account of the views of parents or nursing staff when considering the overall presentation of the patients
” Source location Kyra Ali Aslam · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement processes for clinical Care Groups to review complaints and Freedom to Speak Up themes involving unheard families or colleagues.
Verbatim wording from the response “The Trust has recognised that the views of parents and nursing staff have not always been listened to, through feedback we triangulate from inquests, serious incidents and complaints. As a result of this, we have undertaken a significant amount of work to consider and improve areas within our culture and the processes that underpin our ways of working. This includes:” Source location Response from Sheffield Children's NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the In It Together culture framework within the People Plan through leadership events and line-management training.
Verbatim wording from the response “• Embedding the Trusts ‘In it Together’ culture framework within our People Plan and supporting this with leadership events and line management training.” Source location Response from Sheffield Children's NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Parent and Carer Escalation process across all inpatient areas, with prominent posters and continuing promotion and monitoring.
Verbatim wording from the response “The Trust has implemented a new process to enable parents and carers to escalate concerns about their child’s clinical condition if they feel they are not being listened to. This new process is called PaCE (Parent and Carer Escalation). It is acknowledged by Sheffield Children’s NHS FT that failure to recognise and treat patients whose condition is deteriorating is a cause of significant harm in healthcare environments. One resource in the early detection of deterioration is the contribution that patients and carers can make.” Source location Response from Sheffield Children's NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update nurse escalation policies and support them with training.
Verbatim wording from the response “The Trust has processes and policies in place for escalation by nurses should they feel that their concerns are not being heard, these policies are being updated and will be supported by training. The new Quality Matron post will play a significant part in enabling this culture change at ward level. All clinical colleagues also have access to the Freedom to Speak Up Guardian who will take concerns and raise these directly with the Executive Team.” Source location Response from Sheffield Children's NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the Quality Promise quality strategy across the Trust to embed safe, kind and outstanding care.
Verbatim wording from the response “The continued work we are doing with our Quality Strategy, known as the Quality Promise, which has just been launched across the Trust, will assist in embedding our culture to provide safe, kind and outstanding care to everyone. In implementing human factors, engagement with leaders and everyone across the Trust highlighting the importance of listening to parents/ carers and other colleagues across the Trust, along with the learning culture that is being implemented through PSIRF (Patient Safety Incident Response Framework).” Source location Response from Sheffield Children's NHS Foundation Trust
Open published response
Concerns raised 1
Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Hampshire and Isle of Wight Healthcare NHS Foundation Trust NHS Hampshire and Isle of Wight Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Progress Triangle of Care accreditation from Star 2 toward Star 3.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
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NHS Hampshire and Isle of Wight Integrated Care Board
Maintain an ongoing focus on improving engagement with families and carers using learning from this case.
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Kirsty Clare TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions .
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically , there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed . In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” Source location Kirsty Clare TAYLOR · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress Triangle of Care accreditation from Star 2 toward Star 3.
Verbatim wording from the response “In June of this year we were delighted to be awarded Triangle of Care Star 2 accreditation and we are now working towards Star 3 to complete the process. In order for a mental health trust to achieve star 2 status, it must not only have completed the self-assessment for inpatient wards and crisis services, but also provision of support within community mental health services.” Source location Response from Southern Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
Verbatim wording from the response “The introduction of Esther coaching this year will further enhance and reinforce the Triangle of Care principles. Esther Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous” Source location Response from Southern Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
Verbatim wording from the response “There are 152 carer leads in teams across the Trust with an additional 63 honorary Carers Leads – influencers and ambassadors. These are members of the team with a responsibility to champion family and carer engagement as part of their wider clinical role. We have also employed 22 staff in the roles of Carer Support Workers across the Trust. These are paid roles exclusively for working with carers.” Source location Response from Southern Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
Verbatim wording from the response “Policies and protocols with regards to information sharing (including the issue of capacity) are also in place. The Trust promotes the importance of both the 7th and 8th principles of the UK Caldicott Guardian Council in recognising the importance of the duty to share information being as important as the duty to protect patient confidentiality. They are included with our Triangle of Care work and information governance (IG) training. IG training is completed annually by every member of staff which will help to embed these principles further.” Source location Response from Southern Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
Verbatim wording from the response “The Trust has increased the number of ways that people can give feedback and opportunities to share their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We have a number of carers groups across the Trust, as well as supporting external groups. Most recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton. Feedback and issues highlighted from these different platforms is reported to the Carers, Family and Friends group and the Patient Experience and Caring group as part of our business-as-usual reporting.” Source location Response from Southern Health NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an ongoing focus on improving engagement with families and carers using learning from this case.
Verbatim wording from the response “Whilst there is more to be done to ensure that feedback from families and carers is heard and acted on and informs the delivery of care and decision-making for those in receipt of services, the trust has demonstrated its commitment to deliver continuous improvements in this area.” Source location Response from Hampshire and Isle of Wight
Open published response
28 Apr 2023 Winbourne Gregory Charles · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to incorporate available clinical information into self-harm risk assessments View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Winbourne Gregory Charles · 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
Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate available clinical information into self-harm risk assessments
Wider context from the report “1. A failure to adequately assess risk of harm - Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team (“MDT”) ward round on 6ᵗʰ April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion.
” Source location Winbourne Gregory Charles · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
Verbatim wording from the response “1. Risk assessment (lack of appropriate consideration of risks) – the Coroner found that poor | 1. | Handovers and daily run through to take place using live RiO | 1. Matrons, Ward Managers and Consultant Psychiatrists to be made aware that this needs to be in place” Source location NELFT NHS Foundation Trust Action Plan
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with live-record use and risk-assessment processes.
Verbatim wording from the response “2. To be audited to ensure compliance | DON/AMD | June 2023” Source location NELFT NHS Foundation Trust Action Plan
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about care provision and coordination are mainly for the NHS Trust to address.
Verbatim wording from the response “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.” Source location Response from Department of Health and Social Care
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17 May 2021 Stephen Thurm · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to incorporate family information into care plans and risk assessments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Stephen Thurm · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate family information into care plans and risk assessments
Wider context from the report “1. The inquest heard that information regarding the risk of self-harm to Stephen was passed by his family to his treating clinicians and his care coordinator but this was not taken into account as Stephen denied a recent attempt to take his own life. What steps could be taken to ensure family information is taken into account in the relevant care plan and risk assessments .
” Source location Stephen Thurm · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Clinical Risk Assessment Policy to address confidentiality breaches where necessary to manage risks of serious harm.
Verbatim wording from the response “GMMH Trust Clinical Risk Assessment Policy has been updated in March 2021 to include circumstances when staff may be required to breach someone’s confidentiality in respect of risk to self or others.” Source location 2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update Trust-wide clinical risk training to require gathering and corroborating risk information from family, friends and other professionals.
Verbatim wording from the response “Alongside the updated Clinical Risk Policy the Trust wide clinical risk training has also been reviewed and updated in March 2021 to include the need for staff to gather information from other sources and not just the service user when undertaking assessment of risk. The use of professional curiosity is raised within the training and the need not to take things at face value but to corroborate information with other professionals, friends and family. The training makes it clear to staff that you do not require consent from a service user to receive information from others.” Source location 2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an updated Care Programme Approach Position Statement setting expectations for involving and supporting carers in care and support planning.
Verbatim wording from the response “Carers are often vital in supporting people with severe mental health problems in the community. There was existing national CPA guidance which sets clear expectations around carer involvement, however, there was a need to bring this guidance (although helpful) up to date. As part of the newly published Care Programme Approach Position Statement, NHS England and NHS Improvement has set out clear expectations for systems to provide support for carers of people with severe mental health problems and to better involve carers in care and support planning from April 2021. Specifically, to use Long Term Plan funding to develop and implement plans to improve the lives of carers of people with severe mental health problems and also to look at specific inequalities’ carers may face.” Source location 2021-0155-Response-from-NHS-Improvement_Published
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12 Dec 2019 Peter Frosdick · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to exercise professional curiosity and consider GP information View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Peter Frosdick · 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
Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to exercise professional curiosity and consider GP information
Wider context from the report “(3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.
” Source location Peter Frosdick · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.