Recurring concern

Failure to provide families with information needed to support people receiving mental health care

First to latest report 17 Jul 2014 — 5 Jun 2025

Reports that mention this concern
12
Times this concern has been raised
15
Stated actions linked to this concern
18

What this concern includes

Includes failures by mental-health services to provide families or household supporters with clear, actionable information about how to support a person receiving care, access support for themselves, or contact, reopen or reinstate relevant mental-health support.

What is not included
  • Excludes failures to involve families in clinical decisions, discharge planning or risk management where the specific deficiency is participation rather than provision of support-access information.
  • Excludes clinical assessment, treatment, referral or crisis-response failures where family-facing information was not the deficient control.
  • Excludes generic communication failures and information about unrelated services or administrative matters.
  • Excludes information provided directly to patients or professionals unless the assertion also concerns information needed by families to support mental-health care.

Reports and published responses 12 reports

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

  1. Oxfordshire

    AI-generated summary

    Cain Alex River Donald · 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

    Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

    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

    Insufficient communication with family members about discharge risks and support needs

    Wider context from the report

    “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community. (1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself. (2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process. My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed. ”

    Source location

    Cain Alex River Donald · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement family and carer engagement changes using the triangle of care model in the Psychiatric Intensive Care Unit.

    Verbatim wording from the response

    “More broadly, the Psychiatric Intensive Care Unit has implemented changes since Mr Donald’s death in relation to how they engage with carers and family using the triangle of care model. Our Associate Director of Nursing provided some evidence to you on this work.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 17 June 2025

    Open published response

  2. Somerset

    AI-generated summary

    Jacqueline Anne Potter · 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

    Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide families with codified risk and safety planning information for first overnight leave

    Wider context from the report

    “(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles. Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained. This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community. ”

    Source location

    Jacqueline Anne Potter · 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

    Finalize, consult on, approve and produce supportive Section 17 leave guidance for families, carers and people who matter.

    Verbatim wording from the response

    “Following the concerns raised by the family and the coroner in Mrs Potter’s inquest, the Mental Health and Learning Disability Service group have developed supportive guidance for families and people who matter when a patient is on Section 17 Leave from an inpatient unit. This is currently out for feedback from teams and will be shared at the operational meeting next month for approval prior to production via the patient information team. We will also be sharing the draft document with service users and carers to ensure it covers the information that they feel is necessary to support them.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 1 · response
    Published 25 April 2025

    Open published response

  3. West Sussex, Brighton and Hove

    AI-generated summary

    Harry Benjamin SOUTHERN · 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

    Harry Southern had a history of mental illness, previous suicide attempt and traumatic events in the final year of his life. He died after tying a ligature around his neck with the intention of ending his life. The report raised concerns that young people and their families may not receive accessible, reliable information or timely contact with mental health and suicide-prevention services, and that funding reductions could further reduce available support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide young people and their families with information about available suicide prevention services

    Wider context from the report

    “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

    Source location

    Harry Benjamin SOUTHERN · 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

    Launch multi-agency Neighbourhood Mental Health teams to coordinate access to NHS and voluntary-sector support.

    Verbatim wording from the response

    “In relation to alternative support, I am pleased to say that the Trust has now launched the New Neighbourhood Mental Health teams that you also heard about during the Inquest. As they are multi-agency teams they enable improved access to the breadth of services, be that NHS or voluntary sector services, to provide the best and most accessible support for those experiencing mental ill-health. I know that the importance of working collaboratively was heard throughout Harry's Inquest as he was also receiving support from his GP, a private counsellor and had third sector input too. The new Neighbourhood teams support a co-ordinated approach to ensure all system agency partners are aware of exactly what is available across, what is recognised as being a complex mix of primary and secondary healthcare as well as vital voluntary sectors.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 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

    Develop and launch consistent online mental-health signposting information, categorised by how people may be feeling.

    Verbatim wording from the response

    “I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 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

    Promote online mental-health signposting information through NHS, primary-care, local-authority and voluntary-sector partners.

    Verbatim wording from the response

    “I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 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

    Promote the 24/7 Text SUSSEX to 85258 mental-health support service through the Trust and partner organisations.

    Verbatim wording from the response

    “An additional service which is now regularly promoted by both the Trust and partner organisations, including campaigns which are targeted specifically at students, is 'Text SUSSEX to 85258'. It is a digital means for people to access help with their mental health. The service, which is delivered through the national text messaging service Shout, is free and is available 24 hours a day, seven days a week.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 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

    Transform Staying Well into an open-access out-of-hours crisis service, rebrand and promote it, and increase its availability.

    Verbatim wording from the response

    “Over the last 18 months, the Staying Well service, which you heard some detail about during Harry's Inquest, has also been transformed into an open access service to provide support to people who are experiencing a self-defined mental health crisis, as an alternative to attending A&E. It is an out-of-hours crisis support service which is co-delivered by voluntary, community and social enterprise (VCSE) providers and the Trust has worked with those VCSE partners to rebrand and promote Staying Well, and increase the hours it is available, resulting in a substantial increase in the number of people attending in person.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

  4. Cornwall and Isles of Scilly

    AI-generated summary

    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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to advise Nearest Relatives of statutory rights to request MHA assessment

    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
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The 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
    Page 1 · response
    Published 20 May 2024

    Open published response

  5. South Yorkshire (Western)

    AI-generated summary

    Rachel Louise MORTIMER · 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

    Rachel Louise Mortimer took her own life on 25 June 2023 by hanging, following previous overdoses and a recent episode involving overdose and an attempt to hang herself. The report identified concerns that family and paramedics were not given advice about available support or emergency options, and that no alternative service was arranged after a planned risk-mitigation referral was unavailable.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide families with advice on available options when concerned for a family member's safety

    Wider context from the report

    “1. Following concerned calls by family no advice was provided on what options were available to them if they were concerned for their family members safety and no provision of services that could be called to discuss her mental state. ”

    Source location

    Rachel Louise MORTIMER · 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

    Provide Barnsley IHBT practitioners with access to comprehensive, up-to-date information about local mental health support services.

    Verbatim wording from the response

    “Practitioners in the Barnsley Intensive Home-Based Treatment Team (IHBT) have access to a resource pack with comprehensive and up to date information regarding local mental health support services for people in psychological distress, which may not require a secondary care mental health response.”

    Source location

    Response from South West Yorkshire Partnership NHS Foundation Trust
    Page 1 · response
    Published 25 January 2024

    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

    Share the concern with Barnsley IHBT practitioners and reinforce routine use of the resource pack when advising families about safety and wellbeing support.

    Verbatim wording from the response

    “Your concern will be shared with all practitioners in Barnsley IHBT through team meetings and email communication. This will include an emphasis on the importance of practitioners always referring to the resource pack, to ensure the most appropriate advice is provided to service users and their families about how to access support at all times should they have concerns about their loved one’s safety and wellbeing.”

    Source location

    Response from South West Yorkshire Partnership NHS Foundation Trust
    Page 1 · response
    Published 25 January 2024

    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

    Require Barnsley IHBT to reconsider advice and review treatment plans for further risk mitigations when BSARC declines an onward referral, embedding this practice and communicating it to practitioners.

    Verbatim wording from the response

    “Following receipt of your concern, it has been agreed that where the Barnsley IHBT are informed that an onward referral has been declined by Barnsley Sexual Abuse and Rape Crisis Service (BSARC), the service will reconsider the suitability of the advice they have given to service users and families and review any proposed treatment plans to consider whether further risk mitigations or interventions are required to support the service user. This requirement will be embedded into team practice and communicated to all practitioners through team meetings and email communication.”

    Source location

    Response from South West Yorkshire Partnership NHS Foundation Trust
    Page 2 · response
    Published 25 January 2024

    Open published response

  6. Hampshire, Portsmouth and Southampton

    AI-generated summary

    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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to brief families on neurodivergent and mental health diagnoses and their potential difficulties

    Wider context from the report

    “4. Finally, I am concerned that more needs to be done to inform and assist families, particularly in cases of patients with neurodiversity. In this particular case, the evidence found, for example, that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present as a result of their daughter’s joint diagnoses. Being unaware as to what they were to expect, they were consequently often at a loss to know how to interact with or to help her. Neither they nor their daughter received advice on possible medication withdrawal symptoms. ”

    Source location

    Kirsty Clare TAYLOR · 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

    Develop post-diagnostic support options for neurodiverse people and families.

    Verbatim wording from the response

    “In addition to the re-commissioning of the assessment and prescribing pathways, a HIOW All Age ASC and ADHD Improvement Group is now operational and responsible for overseeing the transformation of the whole neurodiversity pathway, including:”

    Source location

    Response from Hampshire and Isle of Wight
    Page 2 · response
    Published 11 December 2023

    Open published response

  7. East London

    AI-generated summary

    Thiago Araujo · 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

    Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.

    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 support or education for families and carers managing emotionally unstable personality disorder

    Wider context from the report

    “3. Family and carers of patients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diagnosis from Camden and Islington NHS Trust, unless the patient has been received for treatment by the personality disorder service. ”

    Source location

    Thiago Araujo · Prevention of Future Deaths report
    Page 3 · 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 to inform families about the facility for reopening crisis team support

    Wider context from the report

    “2. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis team was not permanent, and had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support. Mr Araujo’s family were unaware of this facility. ”

    Source location

    Thiago Araujo · 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

    Conduct six-monthly community-team audits of carer assessments, support plans, information, and psychoeducation, with plans to address identified gaps.

    Verbatim wording from the response

    “The Trust recognised that a key theme in the report was that carers had lost confidence in the teams working with the deceased and did not feel that their views were taken on board. As a result of this feedback the Trust has revised the action plan with an additional recommendation relevant to carers involvement. To provide assurance that this is consistently happening, the strengthened action plan includes a requirement for community teams to carry out 6 monthly audits, checking that carers are routinely offered an assessment and support plan, and that information, support and psychoeducation are available. Plans will be developed to address any gaps identified as a result of these audits which are now underway within the teams.”

    Source location

    2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
    Page 2 · response
    Published 4 May 2021

    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

    Remind crisis team staff to provide self-referral information and relevant contact details on discharge.

    Verbatim wording from the response

    “On discharge it is the crisis team’s standard practice to advise service users that they may re-refer themselves, or be re-referred, should the need arise. We can only sincerely apologise to Mr Araujo’s family if this was not made clear to them in this case. All crisis team staff have been reminded of the need to ensure that this information plus relevant contact details is passed on. This is also covered by the recommendation at point 1, where the updating of crisis and contingency plans is required.”

    Source location

    2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
    Page 2 · response
    Published 4 May 2021

    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

    When the Personality Disorder Service is not involved, carers are directed to Local Authority services for assessment and support.

    Verbatim wording from the response

    “The Trust has a duty to assess carers need for support as part of its responsibilities under the Section 75 Agreement with the Local Authority. When the Personality Disorder Service identify a carer who may be in need of support, either at the point of referral, assessment or during the treatment of a patient, a Carers Assessment at the service is offered. A Carers Lead is employed to fulfil this role. When the Personality Disorder Service is not directly involved carers are directed to Local Authority services - Support for carers | Camden & Islington Carers Hub | Supporting unpaid carers in Islington. Carers assessments are also carried out by other community teams within the Trust, including the community rehab team, who can support carers to access appropriate support.”

    Source location

    2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
    Page 2 · response
    Published 4 May 2021

    Open published response

  8. Surrey

    AI-generated summary

    Emmett Alexander Gillah · 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

    Emmett Alexander Gillah had a history of mental illness and was discharged from mental health services at his own request. He later moved onto railway tracks and died after being struck by a train. Concerns included inadequate discharge information and follow-up arrangements, insufficient communication with his family and GP, and failures to refer him to mental health services when his mental health deteriorated.

    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

    Unavailability of publicly accessible information about post-discharge contact arrangements

    Wider context from the report

    “(2) KMPT failed to act in accordance with its policy to maintain telephone contact with discharged patients or their family at least every three months for a period of three years following discharge. This policy also states that within three years from discharge from the EIS, contact may be made by a discharged patient direct with Mental Health Services in order to receive treatment. KMPT procedures were inadequate in communicating this information to either the discharged patient, their family or others who may advocate for a patient’s interests. No information is made publicly available, e.g. by way of leaflet or website, which explains the Trust’s policy in this respect. ”

    Source location

    Emmett Alexander Gillah · Prevention of Future Deaths report
    Page 4 · 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

    Inadequate communication of post-discharge treatment access information

    Wider context from the report

    “(2) KMPT failed to act in accordance with its policy to maintain telephone contact with discharged patients or their family at least every three months for a period of three years following discharge. This policy also states that within three years from discharge from the EIS, contact may be made by a discharged patient direct with Mental Health Services in order to receive treatment. KMPT procedures were inadequate in communicating this information to either the discharged patient, their family or others who may advocate for a patient’s interests. No information is made publicly available, e.g. by way of leaflet or website, which explains the Trust’s policy in this respect. ”

    Source location

    Emmett Alexander Gillah · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  9. Plymouth, Torbay and South Devon

    AI-generated summary

    Martin Glyn Baker · 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

    Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to involve and inform families in psychiatric care

    Wider context from the report

    “(1) It was accepted in evidence that there had been a lack of communication with the family. They had not been involved in any psychiatric reviews instead, on one occassion, a consultant was left to rely upon information provided by a junior healthcare assistant. At inquest I expressed my view that where a patient has signed a consent form authorising discussion of relevant events with the family, the default position should be that there will be involvement of the family in the absence of any good reason not to do so, for example, a patient’s subsequent express instruction not to share something with the family. In this case the family were unaware that Mr Baker had been discharged from psychiatric support and were unaware of what to do in the event of deterioration in Mr Baker’s condition. ”

    Source location

    Martin Glyn Baker · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Leicester City and South Leicestershire

    AI-generated summary

    Barry Thraves · 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

    Barry Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and GP.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide accessible information about care roles and contact routes

    Wider context from the report

    “5. Information was not made readily available for either Barry, or the family who were trying to support him, of who was involved in his care, the extent of their role and who to contact to discuss this further or in case of any deterioration or change in presentation. This made the task of the supportive sister considerably more onerous and difficult and introduced unnecessary further delays in obtaining support for Barry at a time when his mental health was deteriorating and he was in need of urgent review. ”

    Source location

    Barry Thraves · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to communicate awaited community support to patients and families

    Wider context from the report

    “2. Community support did not take place as planned, and the family were not even made aware that this was awaited and Barry was on the list. It was not clear what, if any, information Barry had received apart from a very brief letter of discharge that specifically did not mention the community support. ”

    Source location

    Barry Thraves · 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

    Introduce written notifications for people waiting over 14 days for assessment, including contact details, support information and copies for identified carers.

    Verbatim wording from the response

    “In order to ensure an individual, and any relevant persons, are aware of the process following a referral to Adult Social Care a new process has been developed which will be effective from 1 January 2016. The process shall be triggered where Adult Mental Health identifies that someone will need to wait more than 14 days for an assessment from the point the case is transferred to the team. Adult Mental Health Teams will write to them explaining that they have been referred for an assessment, that they will be seen as soon as possible but that they should contact the team if anything changes. Any appropriate leaflets about other support services available will be sent out at this point.”

    Source location

    2015-0443-Response
    Page 2 · response
    Published 26 October 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

    Require staff to include referrals to other agencies in discharge letters and communicate them clearly to patients and carers.

    Verbatim wording from the response

    “Actions taken/planned:”

    Source location

    2015-0443-Response2
    Page 3 · response
    Published 26 October 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

    Review and approve a revised Discharge Policy with detailed electronic discharge-letter requirements.

    Verbatim wording from the response

    “The LPT Discharge Policy is currently under review and the new policy is due to be approved in February 2016.”

    Source location

    2015-0443-Response2
    Page 3 · response
    Published 26 October 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

    Publicize and distribute the developed Trust Carers’ Pack to provide carers with information about processes and services.

    Verbatim wording from the response

    “assist service improvement. The first event in the programme is to be held in January 2016. Additionally a Trust Carers’ Pack has been developed as part of an established CQUIN (Commissioning for Quality and Innovation) to provide information to carers about processes and services. The availability of the same will be widely publicized by the ward, outpatient staff, and service user and carer organisations. Team managers will be asked to cascade to all staff once it is completed and ready for distribution. It is anticipated that this will be completed by March 2016.”

    Source location

    2015-0443-Response2
    Page 5 · response
    Published 26 October 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

    Require relevant information for patients and families to be documented in assessments and care plans.

    Verbatim wording from the response

    “The CMHTs have also been informed in writing that relevant information must be made available for patients and their families, where this is provided it must be documented and made part of each individual’s assessment and care planning.”

    Source location

    2015-0443-Response2
    Page 5 · response
    Published 26 October 2015

    Open published response

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

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Data last updated 7 September 2026