1 Feb 2026 Simon Moss · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to obtain and use family contact details in mental health assessment and discharge risk mitigation View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Support mental health trusts through the Culture of Care programme to strengthen clinical information use and relational approaches to care.
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NHS England
Publish and implement national Staying safe from suicide guidance promoting holistic assessments, family involvement and safety planning.
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NHS England
Ensure next-of-kin details are added to patient information during triage at University Hospital London.
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Simon Moss · 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
Simon Moss was discovered on the roof of his family home on 14 February 2024 after recently developing paranoid thinking, becoming extremely anxious and appearing to be considering suicide. After ambulance attendance and a mental health assessment that did not use detailed information in the ambulance record or contact his wife for collateral information, he was discharged and deliberately fell from a nearby building to his death later that day. The concern was that gaps in training, practice, policy or procedures could result in important risk information and family contact details not being used, undermining the assessment and mitigation of risk to patients presenting with potential risk to self.
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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 obtain and use family contact details in mental health assessment and discharge risk mitigation
Wider context from the report “The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient’s own account could not be relied on.
However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient’s account. That triage note was necessarily brief and so the detail in the EPCR was lost. Furthermore, the Manchester Triage System only provided the option of “suicidal ideation” or “self-harm” whereas there was evidence in the EPCR of planning and intent.
Further, neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services . Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted.
The evidence was that across several experienced mental health nurses present – who had worked across many roles and mental health trusts – none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means . The EPCR was accessible on systems available to the mental health nurse however.
While remedied at the relevant trust, given the evidence of broader practice among mental health nurses I am concerned that there remains a gap in training, practice, policy and/or procedural frameworks for mental health assessments leading to an important source of significant information (EPCR narrative and family contact details) not being known of or used , which could otherwise:
(a) inform an accurate evaluation of the risk to self of patients presenting with mental health illness via ambulance services (i.e. this was not an isolated incident of the EPCR not being known of or used by the specific mental health nurse making the assessment) by (i) providing an independent and detailed account of recent patient history and (ii) contact details for family/friends/individuals who can provide further collateral on their recent presentation , and
(b) allow better mitigation of residual risks at the point of discharge (e.g. through engagement with family and ensuring the patient is collected) .
I am concerned that this may undermine the evaluation and mitigation of risk in patients presenting with potential risk-to-self and so represents a risk of future deaths.
” Source location Simon Moss · 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 Support mental health trusts through the Culture of Care programme to strengthen clinical information use and relational approaches to care.
Verbatim wording from the response “Through the Culture of Care national programme, NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings. This includes supporting mental health staff to know the person, understand their history, and engage with family, friends and carers to better recognise and respond to risk. Trusts are beginning to apply these principles more broadly across community services.” Source location 2026-0052 - Response from NHS England
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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 implement national Staying safe from suicide guidance promoting holistic assessments, family involvement and safety planning.
Verbatim wording from the response “The recently launched NHS England Staying safe from suicide guidance was co-produced by mental health nurses and published by NHS England in June 2025. Its aim is to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing the safety. It highlights the importance of bringing in families/carers in gaining an overall understanding and need for safety planning.” Source location 2026-0052 - Response from NHS England
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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 Ensure next-of-kin details are added to patient information during triage at University Hospital London.
Verbatim wording from the response “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.” Source location 2026-0052 - Response from NHS England
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18 Sep 2024 Helen Jane Kerr · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to appropriately assess declining mental health information and provide timely mental health referrals View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Surrey and Borders Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Surrey and Borders Partnership NHS Foundation Trust
Require senior oversight of Single Point of Access triage and recording of referrer collateral information.
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Surrey and Borders Partnership NHS Foundation Trust
Use revised SBAR documentation to include carer and family views in decision-making.
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Surrey and Borders Partnership NHS Foundation Trust
Test new Single Point of Access procedures and apply quality-control review to assess consistent implementation and identify service improvements.
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Surrey and Borders Partnership NHS Foundation Trust
Deliver training across i-access services on recognising psychosis and making timely mental-health referrals.
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Helen Jane Kerr · Prevention of Future Deaths report
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Report summary
Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.
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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 appropriately assess declining mental health information and provide timely mental health referrals
Wider context from the report “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment.
Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced.
” Source location Helen Jane Kerr · 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 Require senior oversight of Single Point of Access triage and recording of referrer collateral information.
Verbatim wording from the response “In the PFD report, you highlighted that a considerable amount of evidence has been provided by the Trust of the changes around prescribing referrals into our services. In particular, the PFD report notes that referrals into the Single Point of Access (“SPA”) can now be made by voluntary agencies and new protocols require more senior oversight of triaging decisions and recording of collateral information from referrers.” Source location Response from Surrey and Borders Partnership
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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 revised SBAR documentation to include carer and family views in decision-making.
Verbatim wording from the response “In addition to the above improvements, the Trust website was updated to provide detail to external professionals on the different routes for emergency, urgent and routine referrals. There is now greater collaboration with family and referrers, supported by changes to the SBAR (a structured tool for communicating and sharing information which requires recording of the Situation, Background, Assessment and Recommendation) to now include carer/family views which are factored into decision making.” Source location Response from Surrey and Borders Partnership
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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 Test new Single Point of Access procedures and apply quality-control review to assess consistent implementation and identify service improvements.
Verbatim wording from the response “The implementation of the new SPA procedures is currently subject to testing in line with our quality improvement approach. The aim of this is to provide assurance that the new processes are applied consistently and are embedded. We have introduced a quality control process within SPA and the ongoing testing and review will allow us to identify other ways in which the service can be optimised. As part of this work, we are taking additional steps to enhance the out of hours offer.” Source location Response from Surrey and Borders Partnership
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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 training across i-access services on recognising psychosis and making timely mental-health referrals.
Verbatim wording from the response “Further learning is reflected in the production of training which has been developed and rolled out across our i-access services. This focuses on recognising signs and symptoms of psychosis and the importance of a timely referral to mental health services for assessment. To date, 86% of relevant staff have viewed this training and it is planned that the remaining staff (who have been unable to do so due to absence from work) will have viewed this by 15 November 2024.” Source location Response from Surrey and Borders Partnership
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25 Jul 2024 Danny Jay Anderson · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of adequate risk formulation before discharge View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
The Trust
Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
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The Trust
Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
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The Trust
Provide clinical risk-assessment training and apply the clinical risk policy.
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The Trust
Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
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The Trust
Review inpatient and community care plans and risk assessments during staff one-to-one supervision.
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The Trust
Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
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The Trust
Review care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
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The Trust
Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
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AI-generated summary
Danny Jay Anderson · 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
Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of adequate risk formulation before discharge
Wider context from the report “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023.
The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny.
From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy).
There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022).
Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk.
There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed.
” Source location Danny Jay Anderson · 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 discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
Verbatim wording from the response “The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.” Source location Response from Essex Partnership NHS
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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 named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
Verbatim wording from the response “The Trust recognises that there was confusion around responsibilities of the named nurse, which includes risk assessment and formulating risks including plan at point of discharge. The Trust Quality Matron for Fundamentals of Care is leading on an improvement project looking at processes for the named nurse which aims to ensure there is consistent understanding of the named nurse role” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinical risk-assessment training and apply the clinical risk policy.
Verbatim wording from the response “The organisation recognises that the quality of the narrative used in risk assessment is essential for staff to understand risk. This will always be dependent on the staff member completing this. The Trust has clinical risk assessment training in place and a clinical risk policy to guide staff. For ongoing support the Trust has implemented review of risk assessments and documentation completed as part of staff members’ clinical supervision, this enables discussion and immediate learning support for each staff member.” Source location Response from Essex Partnership NHS
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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 Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
Verbatim wording from the response “The Trust has established a new oversight system to enable managers to identify any gaps in risk” Source location Response from Essex Partnership NHS
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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 inpatient and community care plans and risk assessments during staff one-to-one supervision.
Verbatim wording from the response “As part of all staff one to ones, supervisors work with inpatient named nurses/ community care coordinators reviewing their care plans and risk assessment to check quality of the clinical entries.” Source location Response from Essex Partnership NHS
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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 Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
Verbatim wording from the response “In addition the Trust has clinical audit processes which include a record keeping audit and a ‘matron’s records audit’ which includes review of risk formulation and crisis summary. Audit results are taken back to staff and highlighted through discussed in team meetings. The audit process has been reviewed and the Trust now has a person centred audit undertaken where possible with the names nurse to review an individual’s care and documentation thereafter.” Source location Response from Essex Partnership NHS
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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 care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
Verbatim wording from the response “Work has been undertaken by the Director NE Essex Community Services, Trust Wide Perinatal, Children’s Learning Disability and Allied Health Professionals Operations to review the role and responsibilities of care coordinators and ongoing quality improvement for risk assessment is part of the Trust Disengagement Safety Improvement Programme” Source location Response from Essex Partnership NHS
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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 Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
Verbatim wording from the response “Action is already underway as part of the Safety Action Plan to ensure there are clear documented actions agreed at discharge meetings and that the MDT outcome form is completed for each person clearly stating any actions and an overview of relapse signatures and recorded in the patient record.” Source location Response from Essex Partnership NHS
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31 Oct 2023 Andrew BOWLES · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Lack of access to essential patient records before mental health liaison assessment and treatment View source
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Andrew BOWLES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew BOWLES was found face down in a canal on 16 May 2023 after leaving Birmingham City Hospital, where he had been assessed following concerns about his mental health. The medical cause of death was drowning. The principal concern was that the mental health liaison nurse did not have direct access to City Hospital records containing information about command hallucinations and thoughts of self-harm, which may have affected the assessment and potential referral for psychiatric admission.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of access to essential patient records before mental health liaison assessment and treatment
Wider context from the report “3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records , but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system , as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission.
4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment . I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment . The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department.
” Source location Andrew BOWLES · Prevention of Future Deaths report
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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 Allocate hospital-record access to bank staff regularly working within the Psychiatric Liaison Team.
Verbatim wording from the response “In the past any “bank staff” (temporary staff) who were on shift would ask a member of the permanent team to access the records, so that they could review them prior to seeing a patient and would also ask permanent staff to update the records, following their review. Following the PFD, a joint meeting has taken place between the two trusts, and we have been able to identify that a number of the bank staff are regularly working bank shifts within the PLT. Therefore these staff will now be allocated access to hospital records. This will improve matters considerably in this area.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Advise agency staff during local induction how to access, review and update hospital records through permanent team members.
Verbatim wording from the response “There are a small number of staff who may be called in from agencies when there are no other staff available. As these staff may be new to the team and/or to both trusts and only working one shift, it is unlikely that an account is set up immediately for them with the Hospital. In these exceptional circumstance, when the local induction takes place, they will be advised of the processes in place for them to speak with other permanent team members to access the City Hospital notes. They will review them prior to speaking with the patient and also update the records with their assessment after. Now that BSMHFT bank staff also have access to the” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Generic logins for agency staff cannot be provided because they would lack traceability, accountability and lawful information processing.
Verbatim wording from the response “Please be assured, we did explore all possible options including providing a generic log on for agency only staff who may be carrying out one shift. However from an information governance perspective it would not be possible to ascertain who had inputted the information and therefore there would be no traceability or accountability in place, if any problem arose. This is contra to the lawful processing of confidential information. Therefore the only option available was to strengthen the number of PLT staff who have access to the City Hospital records to address any concerns going forward and ensure smooth working.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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5 Jan 2022 James EMMERSON · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure to provide AMHP assessment before discharge from section 136 detention View source
This report raised 1 other concern. 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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James EMMERSON · 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
James Emmerson, known as Jamie, was detained under section 136 of the Mental Health Act on 1 February 2019 but was discharged without being interviewed by an Approved Mental Health Professional. He was later detained at a police custody suite and died by hanging at home on 3 February 2019. The principal concern was confusion in the Code of Practice, which led to an interpretation that an Approved Mental Health Professional assessment was not required before discharge, exposing patients to significant risk including self-harm or suicide.
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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 provide AMHP assessment before discharge from section 136 detention
Wider context from the report “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”).
The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders.
Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital.
Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”.
“The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment.
“The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.”
Jamie was never examined by an AMPH only by a lone section 12 approved
junior doctor and he was discharged from his s.136.
In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.”
This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises.
I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to.
” Source location James EMMERSON · Prevention of Future Deaths report
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25 Mar 2021 Sean Daniel FEGAN · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to make secondary mental health care decisions using adequate information and assessment View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Nottinghamshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Nottinghamshire Healthcare NHS Foundation Trust
Explore shared learning with clinicians, teams and the family from Mr Fegan’s case.
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Nottinghamshire Healthcare NHS Foundation Trust
Pilot primary-care mental-health referral triage by contacting referrers and patients and providing senior multidisciplinary discussion for complex cases.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Operate the established Neurodevelopmental Specialist Service to provide autism diagnosis, post-diagnostic support, training, assessment advice, care planning and crisis support.
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Nottinghamshire Healthcare NHS Foundation Trust
Develop an audit providing ongoing assurance about crisis-team step-down decision making.
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Nottinghamshire Healthcare NHS Foundation Trust
Operate the established Neurodevelopmental Case Discussion Forum for clinicians to present complex cases and obtain advice.
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Sean Daniel FEGAN · 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
Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.
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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 make secondary mental health care decisions using adequate information and assessment
Wider context from the report “1. Decision making surrounding the need for secondary mental health care – as set out above, a decision was taken in December 2019 that Mr Fegan did not require mental health treatment at all in the absence of adequate information or assessment and for reasons which appeared incorrect .
” Source location Sean Daniel FEGAN · 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 Explore shared learning with clinicians, teams and the family from Mr Fegan’s case.
Verbatim wording from the response “Nevertheless we acknowledge that at this point in time he had had a previous admission of some length and more information could have been obtained from his GP about his current mental health, and more consideration could have been given to the details pertaining to his previous admission into B2. The team have reflected over this, and consider that undertaking an assessment at this point would have enabled a clearer formulation to be developed with him, with a rounded consideration of the interplay between Mr Fegan’s ASD, substance misuse and any underlying mental illness, to inform a plan for him. The Clinical Director will explore opportunities for shared learning with other clinicians and teams from Mr Fegan’s story. This will also be explored in discussion with his family.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-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 Pilot primary-care mental-health referral triage by contacting referrers and patients and providing senior multidisciplinary discussion for complex cases.
Verbatim wording from the response “with the Local Mental Health Teams. This will ensure much better oversight, closer working relationships and better communication. As part of the Trust’s Transformation Project, we are now working more closely with primary care. There is a pilot scheme due to start in May 2021, involving band 6 mental health nurses, triaging referrals by contacting both the referrer and the patient. There will be access to a senior MDT panel for discussion in complex cases.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-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 Operate the established Neurodevelopmental Specialist Service to provide autism diagnosis, post-diagnostic support, training, assessment advice, care planning and crisis support.
Verbatim wording from the response “A Neurodevelopmental Specialist Service (NeSS) is now established, from 1st April 2021, to offer diagnosis and post-diagnostic support for autistic people. NeSS will provide training and development of competence in mental health services to support assessment, care planning, advice, and crisis support for autistic people with mental health conditions in the community. Advice can be sought in relation to complex referral decision making involving individuals with autism as a diagnosis.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-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 Develop an audit providing ongoing assurance about crisis-team step-down decision making.
Verbatim wording from the response “We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure accurate decision making when stepping down from crisis team care, and an audit will be developed to provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the Trust’s regular Quality & Risk Meetings.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-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 Operate the established Neurodevelopmental Case Discussion Forum for clinicians to present complex cases and obtain advice.
Verbatim wording from the response “Also established is the Neurodevelopmental Case Discussion Forum, facilitated by an experienced clinician in the NeSS service, where clinicians can bring complex cases to present and discuss, and obtain advice.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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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 referral decision was jointly and carefully considered using available information, although additional GP information could have improved the assessment.
Verbatim wording from the response “At the time the decision was made, it was made in joint approach with the commissioned service for drug and alcohol support, Change, Grow, Live (CGL), who were present at the time, and with the benefit of his substance misuse notes. The prescriber and the consultant were also there and considered the referral carefully. Whilst the patient own clozapine and melatonin to be considered it is felt unlikely that these particular drugs would have been prescribed given his risks, particularly given the addictive potential of clonazepam. Melatonin is not licensed for use in adults, it is a grey drug on the Area Prescribing Committee, as the evidence for benefit is too limited.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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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 Discharge from crisis care was based on immediate needs, an open mental health referral, and the option to re-refer if circumstances changed.
Verbatim wording from the response “The CHRT Teams provide services for those with immediate needs and aim to prevent admissions to hospital. If there are no immediate risks, the patient can be discharged from the CRHT caseload, with the option to self-refer if risks were to increase.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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21 Feb 2020 Billy James Jenkins · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to obtain sufficient assessment information before multidisciplinary mental health review and decision-making View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Billy James Jenkins · 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
Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.
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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 obtain sufficient assessment information before multidisciplinary mental health review and decision-making
Wider context from the report “(1) The findings of the internal investigation by Oxleas NHS were that the assessment undertaken by the Community Mental Health Nurse did not illicit sufficient information to enable the multidisciplinary team to properly review Mr Jenkins’ mental health . Despite this the multi-disciplinary team proceeded with a review and decided that he did not have a mental health condition, without seeking a further assessment
” Source location Billy James Jenkins · 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 community mental-health assessment oversight, including further face-to-face assessment where diagnoses differ and monthly quality audits.
Verbatim wording from the response “Following this incident we have taken further measures to ensure the assessment of patients within the community mental health team are robustly managed in order to ensure that the MDT has sufficient information to review an assessment and to ensure that where there is any disparity in diagnosis that a further face to face assessment is conducted. The operational team manager is monitoring this practice through discussions in Team meetings, supervisions and MDT case discussions.” Source location 2020-0068-Response-from-Oxleas-NHS-Foundation-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 Conduct reflective-practice sessions focused on assessment, risk documentation, record keeping and formulation, with impact monitoring.
Verbatim wording from the response “As a result of the incident the community mental team core induction tool was sent to all CMHT managers to go through with all the new starters and other established colleagues to reinforce the expectations of their roles and the assessment process. This was shared with all staff in supervision and an email has also been sent to all members of staff. Reflective practice sessions have also been conducted focusing on documentation and record keeping, particularly assessment (needs and risk) and formulation. The impact of this is being monitored in Team meetings and in reflective practice meetings. This will be reviewed again after the current unusual working practices in relation to Covid 19.” Source location 2020-0068-Response-from-Oxleas-NHS-Foundation-Redacted
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10 Sep 2019 Gurdeep Singh Dundhal · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to obtain and have available key information and documentation for mental health assessments View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham Women'S and Children'S NHS Foundation Trust Priory Group Walsall Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Birmingham Women'S and Children'S NHS Foundation Trust
Redistribute safer inter-agency information-sharing guidance within the urgent care team and through local governance meetings.
View source
Walsall Borough Council
Develop a procedure for staff to request information promptly from other authorities and NHS services when Walsall assessment may be required.
View source
Walsall Borough Council
Require staff to seek records at the earliest opportunity and use any assessment postponement to obtain them.
View source
Walsall Borough Council
Continue discussions with a neighbouring authority to improve access to relevant records.
View source See 1 more action
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Gurdeep Singh Dundhal · 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
Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.
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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 obtain and have available key information and documentation for mental health assessments
Wider context from the report “2. Evidence at the inquest from the approved Mental health practitioner confirmed that key information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19. I was unable to confirm which at the inquest. This meant the true nature of Mr Dundhal’s long term condition was not known and the assessors were unable to see the “bigger picture”. The delay in arranging the assessment contributed to the lack of available information.
” Source location Gurdeep Singh Dundhal · 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 Redistribute safer inter-agency information-sharing guidance within the urgent care team and through local governance meetings.
Verbatim wording from the response “I would like to reassure you, however, that FTB records are held electronically and these are easily available to be shared where appropriate. Although we are unable to establish the precise circumstances of this call, as a direct result of your report, we have redistributed the safer inter agency information sharing guidance within the urgent care team and at the local governance meetings to ensure that any lessons to be learnt are implemented.” Source location 2019-0294-Response-by-Birmingham-Womens-and-Childrens-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 Develop a procedure for staff to request information promptly from other authorities and NHS services when Walsall assessment may be required.
Verbatim wording from the response “A procedure is also being developed to ensure that whenever another authority agrees to undertake an assessment of a patient in Walsall that the progress of the assessment is notified to Walsall Council and that Walsall Council’s staff will take action in any case in which it appears that there may be a delay in the carrying out of an assessment. In addition to that a procedure is being developed for Walsall Council’s staff to request information from other authorities and other parts of the NHS whenever it appears that a patient may need to be assessed by Walsall Council. This is to avoid delays which may be occasioned by the need to wait for information.” Source location 2019-0294-Response-by-Walsall-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to seek records at the earliest opportunity and use any assessment postponement to obtain them.
Verbatim wording from the response “Walsall Council has no direct access to any records held by other parties. In view of the need for confidentiality and the data protection legislation it is unlikely that third parties would be in a position to allow Walsall Council direct access to their records. At present the only steps which can be taken by Walsall Council to ensure that records are available is to see that they are requested at the earliest opportunity. In this case it would have been better if the AMHP on duty on the evening of Saturday 13 April 2019 had, instead of merely requesting the following day’s duty AMHP to carry out the assessment, himself made the requests for the records to be provided.” Source location 2019-0294-Response-by-Walsall-Council
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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 discussions with a neighbouring authority to improve access to relevant records.
Verbatim wording from the response “Instructions have therefore been given that not only should records be sought at the earliest opportunity, but whenever an assessment is postponed the period of postponement is used for the purpose of requesting records to be made available. Walsall Council proposes to keep this matter under review. Despite this, Walsall Council has opened discussions with a neighbouring authority to see whether records can be more readily available.” Source location 2019-0294-Response-by-Walsall-Council
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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 Relevant clinical information was made available to the assessing team, and no IT outage prevented access to electronic notes.
Verbatim wording from the response “In respect of point 2 and the concern in relation to key information being unavailable or not asked for, please note that clinical staff at Lakeside View have considerable experience in liaising with professionals undertaking Mental Health Act assessments and have advised that relevant information relating to Mr Dundhal was made readily available to the assessing team. Additionally, Mr Dundhal’s responsible clinical ████████ made himself available on the day of the assessment and in fact was contacted by ward staff who asked him to speak to the assessing doctor, ████████.” Source location 2019-0294-Response-by-The-Priory
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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 Trust could not fully investigate the records request because it could not identify the telephone number used by the Approved Mental Health Practitioner.
Verbatim wording from the response “In preparing this response, we have obtained the call logs from 14 April 2019, providing the telephone numbers which called in to the Access Centre on that day. We were concerned to hear at the inquest that the request for Mr Dundhal’s records was made and not complied with. Unfortunately, we have not been able to establish the telephone number which the Approved Mental Health Practitioner called from and as such we are limited in our investigations on this point.” Source location 2019-0294-Response-by-Birmingham-Womens-and-Childrens-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Walsall Council cannot directly access records held by other parties because confidentiality and data protection requirements restrict access.
Verbatim wording from the response “Walsall Council has no direct access to any records held by other parties. In view of the need for confidentiality and the data protection legislation it is unlikely that third parties would be in a position to allow Walsall Council direct access to their records. At present the only steps which can be taken by Walsall Council to ensure that records are available is to see that they are requested at the earliest opportunity. In this case it would have been better if the AMHP on duty on the evening of Saturday 13 April 2019 had, instead of merely requesting the following day’s duty AMHP to carry out the assessment, himself made the requests for the records to be provided.” Source location 2019-0294-Response-by-Walsall-Council
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1 Jul 2019 Mr Peter Lawrence (PL) · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1
Failure to coordinate multidisciplinary review and mental health act assessment when considering hospital admission View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Peter Lawrence (PL) · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.
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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 coordinate multidisciplinary review and mental health act assessment when considering hospital admission
Wider context from the report “4. A decision to admit to hospital under the mental health act following concerns being raised about self-care and disengagement could potentially have followed a coordinated MDT review and mental health act assessment and prevented deterioration in his mental health.
” Source location Mr Peter Lawrence (PL) · Prevention of Future Deaths report
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1 Nov 2018 Colette Denise Vivienne Jean DUNN · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure to complete a full Mental Health Act assessment by a psychiatrist before discharge View source
This report raised 2 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
Colette Denise Vivienne Jean DUNN · 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
Colette Denise Vivienne Jean Dunn was taken to hospital by ambulance with police officers after threatening to kill herself, but was discharged without a formal Mental Health Act assessment. Later that day, she doused herself with petrol and set fire to herself, sustaining severe burns, and died the following morning. Concerns included the absence of a full mental health assessment before discharge, lack of a clear discharge protocol between relevant agencies, and inadequate facilities in Milton Keynes for people experiencing a mental health crisis.
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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 complete a full Mental Health Act assessment by a psychiatrist before discharge
Wider context from the report “1. During the course of the evidence it was clear that prior to discharge from the hospital a full Mental Health Act assessment by a psychiatrist should have been carried out before the decision was taken to discharge Ms Dunn , particularly as the police officers were expressing their concerns to the staff that Ms Dunn had indicated that once she had left the hospital it was her intention to kill herself and indicated that she would tell the staff what they wanted to hear in order to secure her discharge.
” Source location Colette Denise Vivienne Jean DUNN · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.