28 May 2025 Julie Sheila Beasley · Prevention of Future Deaths report Essex
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Concerns raised 2
Failure to communicate accurate assessment and appointment information View source Failure of effective communication within and across mental health services View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Julie Sheila Beasley · 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
Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate accurate assessment and appointment information
Wider context from the report “(4) Mrs Beasley had been requesting an urgent appoint and responded immediately to a letter from the Trust informing her she needed an urgent psychiatric appointment. When Mrs Beasley contacted the crisis team, she was again informed incorrectly that she had recently had a V4 psychiatric assessment and did not require an urgent appointment . The crisis team were not communicating effectively either with Mrs Beasley, her GP or internally within their own team.
” Source location Julie Sheila Beasley · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of effective communication within and across mental health services
Wider context from the report “(4) Mrs Beasley had been requesting an urgent appoint and responded immediately to a letter from the Trust informing her she needed an urgent psychiatric appointment. When Mrs Beasley contacted the crisis team, she was again informed incorrectly that she had recently had a V4 psychiatric assessment and did not require an urgent appointment. The crisis team were not communicating effectively either with Mrs Beasley, her GP or internally within their own team .
” Source location Julie Sheila Beasley · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide reflective supervision to the staff member involved in the missed communication.
Verbatim wording from the response “By way of further assurance, reflective supervision is being undertaken with the individual staff member who did not speak with Mrs Beasley.” Source location Response from Essex Partnership University 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 Send patient contact details and highlighted actions to GPs through administrative support.
Verbatim wording from the response “By way of evidence provided to the Court, the team have clear processes for GPs to be emailed following any patient contact. Clinical staff are supported by the Team administrative personnel who are tasked with sending assessment details to GP’s, which includes highlighted actions.” Source location Response from Essex Partnership University 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 Route crisis-team communications and psychiatrist review requests to multidisciplinary team mailboxes.
Verbatim wording from the response “A process has also been initiated whereby communication is not sent to an individual, but will be sent to the MDT. This ensures there are no delays in communication / actions requiring attention.” Source location Response from Essex Partnership University NHS Trust
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13 Nov 2023 Igor Kacper SZALAPSKI · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to re-contact the crisis team after a concerning change in a resident’s condition 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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Igor Kacper SZALAPSKI · 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
Igor hanged himself in his room at a hostel for homeless young people on 30 April 2023. Concerns included failures to re-contact the crisis team after staff found him drowsy and incoherent, insufficient meaningful staff contact and welfare checks, inadequate engagement with partner agencies and family contact, a lack of self-harm and suicide awareness training, and a chaotic hostel culture.
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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 re-contact the crisis team after a concerning change in a resident’s condition
Wider context from the report “1. On 14 April 2023, staff found Igor outside, drowsy and incoherent, cold and wet, but did not re-contact the crisis team .
2. Igor was a vulnerable young man, recently homeless, but the last time that any member of staff had a meaningful conversation with him was on 20 April 2023, ten days before he died.
3. The Depaul executive director of services recognised at inquest that there should have been more staff conversation with Igor throughout his time at the London Youth Hub.
4. She also acknowledged that greater attempts should have been made by staff to engage with partner agencies regarding Igor’s care and welfare.
5. Igor was only 18 years old and his father did visit him, but the hostel did not have any contact details for his family.
” Source location Igor Kacper SZALAPSKI · Prevention of Future Deaths report
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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 DePaul disputes that it failed to identify behavioural deterioration or raise concerns, citing referrals to mental-health services and safeguarding teams.
Verbatim wording from the response “6.9 Though DePaul have reflected following this incident and put in place the above measures and action plan, as discussed at 3.2.1, DePaul raised issues of a deterioration in mental health with the Crisis Team and were told that it was a substance use issue not a mental health issue. This is after he had expressed an intention to take his own life through electrocution in the shower. The GP refused to prescribe his medication given that he had taken 4 weeks supply in 14 days (as detailed at paragraph 3.2.1). DePaul did identify changes in behaviour and raised those concerns with the appropriate mental health services and safeguarding.” Source location Response from DePaul
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25 Jan 2023 Andrew Mark Largin · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of clarity about neighbourhood team referral back to the crisis team View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Andrew Mark Largin · 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 Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.
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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 clarity about neighbourhood team referral back to the crisis team
Wider context from the report “9. Finally, the operations lead for the neighbourhood team had great difficulty in giving me clear evidence about whether his team would or could refer a patient back to the crisis team if they felt the circumstances warranted . He demonstrated a lack of clarity on the point that I found very concerning.
” Source location Andrew Mark Largin · 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 Resume regular Neighbourhood Team and Crisis Pathway meetings and produce an action plan to communicate shared referral processes and criteria.
Verbatim wording from the response “Additionally, the Deputy Borough Director for City and Hackney has confirmed that the Neighbourhood Teams and Crisis Pathway teams (which includes HTT) are resuming their regular pathways meeting on 7 April 2023. They will produce an action plan around communicating a shared understanding of referral process and criteria.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a six-month rolling training programme for Neighbourhood Teams on clinical risk, referral processes, and risk indicators.
Verbatim wording from the response “Further, the Trust is implementing a training programme for all Neighbourhood Teams to highlight issues of clinical risk when triaging incoming referrals. This programme, due to start on 22 March 2023, will run monthly for 6 months in a rolling fashion. Its aim is to train staff and maintain a constant discussion in how to think about complex issues of risk for patients referred to the Neighbourhood Teams, whether that is from Crisis Pathway Teams (which include HTT), GPs, or elsewhere. It will use didactic teaching, role play with actors, sample cases, discussion, and reflection, and will be facilitated by an experienced Consultant Psychiatrist, as well as the Associate Clinical Director for the Neighbourhood Teams. An important part of this training will be to improve understanding of referrals and risk signifiers from the Crisis Team to the Neighbourhood Team.” Source location Response from East London 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 Existing procedures are considered sufficient for neighbourhood team clinicians to refer service users back to the crisis team when necessary.
Verbatim wording from the response “7. Referral to Crisis Team” Source location Response from East London NHS Foundation Trust
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17 Mar 2021 Benjamin Rajinder O’HARA · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to communicate that a review was not a formal mental health assessment View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Benjamin Rajinder O’HARA · 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
Benjamin Rajinder O’Hara died after jumping from the fourth floor balcony of his home on 2 November 2020, following repeated contacts with mental health services and episodes of suicidal thoughts and psychosis. Concerns included that professionals did not ask permission to contact his family, an outdated hospital-admission alert was not reviewed, a review was not a formal mental health assessment, and he had no care co-ordinator or other community mental health team member overseeing his care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate that a review was not a formal mental health assessment
Wider context from the report “3. The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment. If the crisis team had been aware of this , they might have sought a formal mental health assessment when Mr O’Hara disengaged from their care on 4 October.
” Source location Benjamin Rajinder O’HARA · 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 Improve communication between crisis and other Trust teams by requiring further discussion of concerning decisions.
Verbatim wording from the response “Despite ICRT feeling like the option of MHAA was closed to them, they did not explore this further with the duty team who advised on these matters. The report has made a recommendation to improve communication between the crisis teams and other teams in the Trust, so that in future the crisis team ensure they discuss further any decisions by other teams which are of concern to them. Progress against this action will be reviewed in August 2021.” Source location 2021-0077-Response-from-St-Pancras-Hospital-Redacted
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Concerns raised 1
Ineffectiveness of the pathway for communicating information directly to the crisis team View source
Linked response
Yorkshire Ambulance Service NHS Trust
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Christopher Cyril Kiernan · 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
Christopher Cyril Kiernan, who had a history of depression, alcohol use and cannabis use, made threats to harm himself and had contact with emergency services during the night of 3–4 June 2017. He was later found hanging from a tree in nearby woodland. The principal concern was the ineffectiveness of the pathway for communicating information directly to the RDaSH Crisis Team, with the crisis team not being notified.
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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 Ineffectiveness of the pathway for communicating information directly to the crisis team
Wider context from the report “The ineffectiveness of the pathway for communicating information direct to the RDaSH Crisis Team .
” Source location Christopher Cyril Kiernan · Prevention of Future Deaths report
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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 Existing signposting and consent-based referral during the 999 call provide the available pathway to crisis services.
Verbatim wording from the response “Addressing your concern as to “the ineffectiveness of the pathway for communicating information direct to the RDaSH Crisis Team”, I can state that there is a facility to:” Source location 2017-0304-Response-Yorkshire-Ambulance-Service-NHS-Trust
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5 Sep 2016 John Gerard JONES · Prevention of Future Deaths report Avon
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Concerns raised 2
Delays in notifying GPs of Crisis Team discharge View source Lack of clear Crisis Team training, structural or protocol provision for discharge communication View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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John Gerard JONES · 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
John Gerard JONES had been receiving support because of a perceived risk of suicide, and admission to hospital was recommended but not undertaken. He later took his own life by drowning in the River Avon on or around 1 February 2016. The principal concern was that his GP was not notified of his discharge from the Crisis Team for approximately a week, leaving uncertainty about community support during that period.
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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 Delays in notifying GPs of Crisis Team discharge
Wider context from the report “(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.
” Source location John Gerard JONES · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear Crisis Team training, structural or protocol provision for discharge communication
Wider context from the report “(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.
” Source location John Gerard JONES · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to provide immediate written discharge and high-risk notification to the crisis team View source
This report raised 3 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
Anthony John Preston · 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
Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.
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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 immediate written discharge and high-risk notification to the crisis team
Wider context from the report “(3) There was no immediate follow up by email or fax to the Crisis Team to notify the discharge, and the fact that Mr Preston was at high risk because of the anxiety created when he was living at home.
” Source location Anthony John Preston · Prevention of Future Deaths report
Open source report
1 Jun 2015 Mark Patrick DANIELS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure of communication within the crisis team and with crisis houses View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mark Patrick DANIELS · 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
Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of communication within the crisis team and with crisis houses
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses ;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” Source location Mark Patrick DANIELS · 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 measures across all Crisis Teams and Crisis Houses to address the identified concerns.
Verbatim wording from the response “████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several” Source location 2015-0208-Response-by-Camden-and-Islington-NHS-Trust
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12 Feb 2015 Andrew Elliot FROST · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Insufficient information captured by the crisis team pager messaging service 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
Andrew Elliot FROST · 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 Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.
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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 Insufficient information captured by the crisis team pager messaging service
Wider context from the report “3. The pager messaging service used by the crisis team simply takes the name of the patient and a telephone number to call, nothing more.
This means that valuable time was wasted by the crisis team, trying to track down the police officer who had rung to find out more detail, most especially Mr Frost’s address.
This is time that could be used treating patients.
” Source location Andrew Elliot FROST · Prevention of Future Deaths report
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19 May 2014 Peter Franklin · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2
Confusion and lack of clarity in terminology for out-of-hours CRISIS team calls View source Failure of the CRISIS team to provide relevant information or advice to referring parties View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Kent and Medway Mental Health NHS Trust Maidstone and Tunbridge Wells NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Kent and Medway Mental Health NHS Trust
Use and monitor a referral flow chart clarifying whether urgent referrals require advice or assessment.
View source
Kent and Medway Mental Health NHS Trust
Review and update the Liaison Psychiatry out-of-hours roles and responsibilities protocol to improve staff guidance.
View source
Maidstone and Tunbridge Wells NHS Trust
Implement the SMART Tool in the Emergency Department, finalise its design, incorporate it into the Junior Doctor Handbook, and use it with the Mental Health Trust.
View source
Kent and Medway Mental Health NHS Trust
Reinforce requirements for staff to provide complete, accurate information to carers and referring agencies.
View source
Kent and Medway Mental Health NHS Trust
Monitor compliance with relevant policies through supervision and audit, managing performance concerns under the Trust’s performance framework.
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Peter Franklin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Franklin, who had longstanding mental health difficulties and increasingly frequent hospital attendances, died after jumping from a motorway bridge following an attempted jump earlier that day. The concerns included unclear communication about whether a referral, advice or assessment was required, relevant information not being passed on, and delays in sharing information with his GP.
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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 Confusion and lack of clarity in terminology for out-of-hours CRISIS team calls
Wider context from the report “(1) There was confusion in the terminology used between nursing staff or doctors and the CRISIS team when out of hours calls were made such that it was not clear between parties whether a referral, advice or assessment was sought .
” Source location Peter Franklin · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the CRISIS team to provide relevant information or advice to referring parties
Wider context from the report “(2) Relevant information/advice was not provided by the CRISIS team to parties who had made referrals
” Source location Peter Franklin · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use and monitor a referral flow chart clarifying whether urgent referrals require advice or assessment.
Verbatim wording from the response “We have developed a clear process outlining the pathway for urgent referrals through a referral flow chart which includes confirmation as to whether advice or assessment is being requested. This is being monitored by the Liaison Psychiatry Service Manager and at the monthly interface meeting between the two Trusts.” Source location 2014-0230-Response-by-Kent-Medway-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 Review and update the Liaison Psychiatry out-of-hours roles and responsibilities protocol to improve staff guidance.
Verbatim wording from the response “In addition we have reviewed and updated the Liaison Psychiatry roles and Responsibilities Out of Hours Protocol. This provides improved guidance to staff.” Source location 2014-0230-Response-by-Kent-Medway-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 Implement the SMART Tool in the Emergency Department, finalise its design, incorporate it into the Junior Doctor Handbook, and use it with the Mental Health Trust.
Verbatim wording from the response “Firstly I would like to address the issue of confusion in terminology 5(1). The use of a SMART Tool was discussed and agreed at the Emergency Directorate Clinical Governance meeting on 1st July 2014. It is being implemented from an Emergency Department perspective by Dr Bell, Consultant in A&E Medicine and Cliff Evans, Consultant Nurse. Once the design is finalised this will be incorporated into the Junior Doctor Handbook. A copy of the format is attached for your information. This will be used in conjunction with the Mental Health Trust.” Source location 2014-0230-Response-by-Tunbridge-Wells-Hospital
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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 Reinforce requirements for staff to provide complete, accurate information to carers and referring agencies.
Verbatim wording from the response “It has been reinforced to the CRISIS Team that we expect our staff to provide full and accurate information to carers and referring agencies. The Clinical Records Policy has been amended to reflect the importance of recording the outcome of urgent patient contact immediately on Rio, the KMPT wide electronic records system. The adherence to relevant KMPT Trust policy is monitored through supervision and audit. If there are concerns about performance this is managed through the Trust’s Performance Management Framework. Steps that can be taken include training, mentoring, working under supervision and where necessary formal capability management.” Source location 2014-0230-Response-by-Kent-Medway-NHS-Trust
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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 Monitor compliance with relevant policies through supervision and audit, managing performance concerns under the Trust’s performance framework.
Verbatim wording from the response “It has been reinforced to the CRISIS Team that we expect our staff to provide full and accurate information to carers and referring agencies. The Clinical Records Policy has been amended to reflect the importance of recording the outcome of urgent patient contact immediately on Rio, the KMPT wide electronic records system. The adherence to relevant KMPT Trust policy is monitored through supervision and audit. If there are concerns about performance this is managed through the Trust’s Performance Management Framework. Steps that can be taken include training, mentoring, working under supervision and where necessary formal capability management.” Source location 2014-0230-Response-by-Kent-Medway-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.