12 Jan 2026 STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to update and document risk assessments View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Essex Partnership University NHS Foundation Trust HCRG Care Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
HCRG Care Group
Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.
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HCRG Care Group
Provide structured reception-nurse supervision, coaching, documentation audits, case-based feedback, and governance reporting to improve recording and escalation of mental-health risks.
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HCRG Care Group
Deliver targeted mental-health awareness training and support reception nurses to identify suicide, self-harm, acute distress, and appropriate ACCT observation levels.
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Essex Partnership University NHS Foundation Trust
Standardise sample-based community mental health caseload audits across localities.
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Essex Partnership University NHS Foundation Trust
Review existing EPR capability for consolidated personalised-care and safety-planning records and update standard operating procedures.
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Essex Partnership University NHS Foundation Trust
Monitor clinical-documentation timeliness and quality through supervision, monthly performance reporting, and targeted follow-up.
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Essex Partnership University NHS Foundation Trust
Reissue mandatory escalation guidance and introduce MDT agendas and case-presentation templates for changing risk or uncertainty.
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STUART CHRISTOPHER JAMES BERRY · 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
STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.
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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 update and document risk assessments
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy .
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” Source location STUART CHRISTOPHER JAMES BERRY · 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 Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.
Verbatim wording from the response “We are focusing on strengthening the interfaces between healthcare and custodial services, retraining reception nurses, and introducing a dedicated Early Days in Custody (EDiC) Nurse role.” Source location Response from HCRG
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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 structured reception-nurse supervision, coaching, documentation audits, case-based feedback, and governance reporting to improve recording and escalation of mental-health risks.
Verbatim wording from the response “In addition, the EDiC Nurse role provides structured supervision and coaching to reception nurses, including regular review of SystmOne entries, case-based feedback, and support to improve clinical reasoning and documentation. This approach provides ongoing assurance that mental health risks are clearly recorded, appropriately escalated, and visible to all relevant professionals.” Source location Response from HCRG
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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 targeted mental-health awareness training and support reception nurses to identify suicide, self-harm, acute distress, and appropriate ACCT observation levels.
Verbatim wording from the response “• Strengthening Mental Health Awareness and Screening at Reception
Targeted 1-1 training was introduced on 27 January 2026 to enhance staff understanding of suicide and self-harm risk factors, acute mental distress, and the impact of early custody on mental wellbeing. The newly established EDiC Nurse role provides clinical leadership and quality assurance through supervision, coaching, and review of reception assessments, supporting nurses to move beyond checklist-based screening and to apply professional judgement when identifying and escalating mental health risk. This approach supports earlier identification of risk and timely referral for mental health assessment. The EDiC Nurse also supports and supervises staff in identifying the appropriate ACCT observation levels and carries out reviews of ongoing ACCT observation levels to check their appropriateness.” Source location Response from HCRG
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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 Standardise sample-based community mental health caseload audits across localities.
Verbatim wording from the response “(a) Performance of the CMHT and the allocated Care Coordinator (under CPA/EPUT policy)
EPUT maintains a governance framework that includes regular clinical supervision, weekly MDT forums, escalation procedures, and case auditing to identify and address gaps. We recognise the expectation that staff practise in line with Trust policy.
Trust-wide audit requirements were reviewed in January 2026. While the final Trust standard is being confirmed through the Community First Project, our interim approach combines:” Source location 2026-0015 - Response from Essex Partnership University 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 Review existing EPR capability for consolidated personalised-care and safety-planning records and update standard operating procedures.
Verbatim wording from the response “Until NOVA is fully operational, EPUT continues to maintain robust interim monitoring arrangements to support safe and timely documentation. Alongside this, the Trust is currently reviewing the requirements for personalised care planning and safety planning documentation, with the aim of determining whether the existing EPR can accommodate a single, consolidated place for recording and update associated standard operating procedures. This work is intended to reduce the burden associated with navigating multiple tabs and scattered documentation fields, making it easier for clinicians to record care consistently and for teams to access essential information quickly.” Source location 2026-0015 - Response from Essex Partnership University 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 Monitor clinical-documentation timeliness and quality through supervision, monthly performance reporting, and targeted follow-up.
Verbatim wording from the response “As set out in our earlier response to the Prevention of Future Deaths report, we continue to monitor adherence to the 95% target for clinical documentation to be completed within 24–48 hours of patient contact. This is overseen through a combination of:” Source location 2026-0015 - Response from Essex Partnership University 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 Reissue mandatory escalation guidance and introduce MDT agendas and case-presentation templates for changing risk or uncertainty.
Verbatim wording from the response “Since the incident, we have introduced measures to support staff in consistently meeting expectations around escalation and collaborative working. We recognise that embedding these behaviours is a gradual process and requires ongoing reinforcement, supervision and oversight, which we will continue to prioritise through:” Source location 2026-0015 - Response from Essex Partnership University Foundation Trust
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15 Oct 2025 Tony Montana Duncan · Prevention of Future Deaths report City of London
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Concerns raised 1
Failure to document risk assessments View source
This report raised 5 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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Tony Montana Duncan · 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
Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.
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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 document risk assessments
Wider context from the report “2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others , both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being completed .
” Source location Tony Montana Duncan · Prevention of Future Deaths report
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17 Mar 2025 DARREN NEIL TURNER · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to appropriately update and document risk assessments 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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DARREN NEIL TURNER · Prevention of Future Deaths report
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Report summary
Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.
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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 update and document risk assessments
Wider context from the report “(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Darren’s risk assessment consistent with Trust policy . Relevant passive and active risk factors were not formally reflected in his documented risk assessments . Evidence from his Responsible Consultant Psychiatrist and the discharging Psychiatrist confirmed that, had they been aware of a disclosure made by Darren to his key worker/nurse prior to discharge, the Section 2 detention would not have been rescinded, he would not have been discharged on the 17th October and, accordingly, it is likely that he would not have taken his own life the following day.
” Source location DARREN NEIL TURNER · 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 the unified NOVA electronic patient record to integrate systems and carry forward risk information.
Verbatim wording from the response “Essex Partnership University Trust and Mid and South Essex NHS Foundation Trust (MSEFT) are working together to implement ‘NOVA’, a new and single Electronic Patient Record (EPR) system across our services, which will pull through risk information which will negate need to repeat information.” Source location Response from Essex Partnership University 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 Provide ward-wide digital clinical dashboards displaying quality, performance and risk-assessment information.
Verbatim wording from the response “The Trust has developed new digital clinical dashboards available in all wards which displays a range of ‘at a glance’ quality/performance information. This includes monitoring of risk assessments. All staff have access to this dashboard.” Source location Response from Essex Partnership University NHS Foundation Trust
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10 Jan 2025 Jan Michael RACIBORSKI · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure to properly record risk assessment details View source
Linked response
Oxford Health 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. 6
Oxford Health NHS Foundation Trust
Attend supervision training to refresh risk-assessment and documentation skills.
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Oxford Health NHS Foundation Trust
Extend supervision training to all South Oxfordshire teams.
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Oxford Health NHS Foundation Trust
Discuss risk assessment and documentation during CPA discharge discussions.
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Oxford Health NHS Foundation Trust
Complete spot checks of clinical notes focused on the reported recording concerns.
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Oxford Health NHS Foundation Trust
Use a clinical audit tool to assess records against risk-assessment and risk-management documentation standards.
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Oxford Health NHS Foundation Trust
Ask the CRAM policy owner to consider whether an earlier policy review is required.
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Jan Michael RACIBORSKI · Prevention of Future Deaths report
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Report summary
Jan Michael Raciborski, who had longstanding mental health issues and a brain injury, died at home on 5 February 2024 after hanging himself. The principal concern was that records of contacts with the Adult Mental Health Team contained no written risk assessments, creating risks of inadequate information sharing, misleading records, and difficulties investigating whether risks to life had been identified.
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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 properly record risk assessment details
Wider context from the report “None of the records of contact with Mr Raciborski completed by the AMHT in the period from August 2023 to the date of Mr Raciborski’s death contained any written record of a risk assessment. I found that in Mr Raciborski’s case this absence did not impact his treatment and was not causative factor.
However my concern is that the failure to properly record the details of a risk assessment can lead to inadequate information sharing and the possibility of someone who relies upon the records gaining the wrong impression . In addition it does not allow the adequacy of the risk assessments to be properly investigated and could hinder investigations into deaths; which mean that a matter giving rise to a risk to life may not be identified in future investigations .
” Source location Jan Michael RACIBORSKI · 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 Attend supervision training to refresh risk-assessment and documentation skills.
Verbatim wording from the response “The team manager of the South Oxon Adult Mental Health Team also attended court on the first day of Mr Raciborski’s inquest and has subsequently listened to the audio recording of your summing up and findings of fact on the second day. The team manager’s attendance at the inquest in order to listen to the evidence provided further valuable insight into the contacts that the AMHT had with Mr Raciborski. Following the conclusion of the inquest, the team manager has taken local actions in relation to your concerns including (a) all supervisors in” Source location Response from Oxford 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 Extend supervision training to all South Oxfordshire teams.
Verbatim wording from the response “the Wallingford, Henley and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire and (b) a meeting in relation to CPA discharge discussions, within which the team discussed risk and how to document assessments of risk. The team manager will also complete spot checks of clinical notes with a focus on the concerns that you identified.” Source location Response from Oxford 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 Discuss risk assessment and documentation during CPA discharge discussions.
Verbatim wording from the response “The team manager of the South Oxon Adult Mental Health Team also attended court on the first day of Mr Raciborski’s inquest and has subsequently listened to the audio recording of your summing up and findings of fact on the second day. The team manager’s attendance at the inquest in order to listen to the evidence provided further valuable insight into the contacts that the AMHT had with Mr Raciborski. Following the conclusion of the inquest, the team manager has taken local actions in relation to your concerns including (a) all supervisors in” Source location Response from Oxford 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 Complete spot checks of clinical notes focused on the reported recording concerns.
Verbatim wording from the response “the Wallingford, Henley and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire and (b) a meeting in relation to CPA discharge discussions, within which the team discussed risk and how to document assessments of risk. The team manager will also complete spot checks of clinical notes with a focus on the concerns that you identified.” Source location Response from Oxford 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 Use a clinical audit tool to assess records against risk-assessment and risk-management documentation standards.
Verbatim wording from the response “The Trust Core Clinical Standards in Mental Health and Learning Disability Care Policy gives colleagues guidance and direction as to the requirements and recording of risk assessment and information for both inpatient and community settings. We developed a clinical audit tool in the autumn of 2024 in order to check patient records against the policy and the standards to which we aspire. The tool reviews the following areas relating to the recording of risk information:” Source location Response from Oxford 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 Ask the CRAM policy owner to consider whether an earlier policy review is required.
Verbatim wording from the response “The Trust’s Clinical Risk Assessment and Management (CRAM) Policy sets out the standards for assessment, formulation and recording of risk assessment. The policy was most recently updated in February 2023 and is due for next review in February 2026. I have asked the CRAM policy owner to consider if an earlier review is required, given your concerns.” Source location Response from Oxford Health NHS Foundation Trust
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1 Aug 2024 Kieran Lavin · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to record transport risk formulations View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Kieran Lavin · 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
Kieran Lavin, who had experienced worsening depression and suicidal thoughts, died after leaving a mental health unit with his wife for transport to another facility. Shortly afterwards, on the M5 motorway, he exited the vehicle and was struck by vehicles. The principal concerns were that critical suicide-risk information was not recorded or recorded promptly, and that the transport risk assessment and guidance for family transport were inadequate.
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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 record transport risk formulations
Wider context from the report “1. Critical suicide risk information was not recorded at all or not recorded in a timely manner. On 10/12/23, the experienced nurse did not record at all in the 'suicide' box on the 'level 1 – risk screening' the first report of suicidal ideation via road traffic collision. She described this omission as an error and the likely explanation was that she was the only nurse working on a very busy shift. On 11/12/23, the experienced nurse did not in a timely manner record in the ‘suicide’ box on the ‘level 1 – risk screening’ the second report of suicidal ideation via road traffic collision received by 11am. She said the likely explanation for not updating the ‘suicide’ box until 8:51pm (and after the nurse-in-charge made his transport risk formulation) was that she was the only nurse working on a very busy shift. The experienced Nurse-in-Charge did not record at all the transport risk formulation saying that was not his usual practice. The Patient Safety Manager said long standing trust policy required clinicians to record key information as soon as possible. I am not persuaded this long standing policy is sufficient by itself to remove the risk in the future of critical suicide risk information not being recorded at all or in a timely manner given three experienced nurses within 24 hours failed to follow the policy.
” Source location Kieran Lavin · 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 Review and revise Psychiatric Decisions Unit handover standards to require urgent information to be documented and communicated before transport, discharge and other significant decisions.
Verbatim wording from the response “The quality and standards of the handover process in the PDU will be reviewed, with particular attention to ensuring that critical information is documented and communicated before key decisions, such as patient transport, are made. The handover process will also be revised to establish clear standards that require the documentation and communication of urgent information prior to any significant decisions, including patient discharge.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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23 May 2024 Jada Monoja · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to clearly date and signpost revisions within compound risk assessments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Jada Monoja · 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
Jada Monoja, who had a history of chronic paranoid and delusional thinking, disclosed suicidal thoughts on 15 November 2020 and was assessed by mental health services before being accepted by the Home Treatment Team. In the early hours of 17 November 2020, he was found unresponsive after leaving home and could not be resuscitated; the inquest concluded that he died by suicide, likely while experiencing delusional and paranoid thoughts. The principal concerns relate to the use of the online risk assessment tool, including assessments being incomplete, insufficiently dated or signposted, and difficult to identify within chronological records.
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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 clearly date and signpost revisions within compound risk assessments
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.
” Source location Jada Monoja · Prevention of Future Deaths report
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15 Jan 2024 Nadia Wyatt · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to record risk assessment completion and outcomes View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University 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
Essex Partnership University NHS Foundation Trust
Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.
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Essex Partnership University NHS Foundation Trust
Remind Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.
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Essex Partnership University NHS Foundation Trust
Audit Home Treatment Team assessments regularly and share findings with the team to improve assessment documentation.
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Essex Partnership University NHS Foundation Trust
Randomly audit patient records monthly for discrepancies in RAG-rated risk assessments and take action where discrepancies are found.
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Nadia Wyatt · Prevention of Future Deaths report
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Report summary
Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.
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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 record risk assessment completion and outcomes
Wider context from the report “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer.
(2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale.
(3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history.
(4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan.
(5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was.
(6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists.
(7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission.
(8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well.
” Source location Nadia Wyatt · 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 Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.
Verbatim wording from the response “Response:
The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.” 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 Remind Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.
Verbatim wording from the response “Response:
The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.” 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 Audit Home Treatment Team assessments regularly and share findings with the team to improve assessment documentation.
Verbatim wording from the response “In order to ensure the assessments undertaken by the Home Treatment Team are comprehensive and the findings (including the rationale for the decisions made) are clearly documented, regular audits on Home Treatment Team assessments will be undertaken and the findings shared with the team to continuously improve practice.” 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 Randomly audit patient records monthly for discrepancies in RAG-rated risk assessments and take action where discrepancies are found.
Verbatim wording from the response “The Trust also randomly audits patients’ records on a monthly basis to identify any concerns with RAG rating of risk assessments in order for actions to be taken where discrepancies are found.” Source location Response from Essex Partnership NHS
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27 Nov 2023 Luke Mervyn WHITELAW · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to clearly document risk discussions and assessments 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
Oxleas 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
Oxleas NHS Foundation Trust
Train clinicians to document medication and medical-review discussions, decisions, participants, timings and outcomes.
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Oxleas NHS Foundation Trust
Implement and monitor an improvement plan addressing clinical-care, risk-assessment, documentation and reflective-practice gaps.
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Oxleas NHS Foundation Trust
Introduce a single crisis-assessment form capturing the person’s journey and prior assessment information in the clinical record.
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Oxleas NHS Foundation Trust
Review the Trust electronic-record risk-assessment template to support improved risk assessment, formulation, communication and recording.
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AI-generated summary
Luke Mervyn WHITELAW · 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
Luke Mervyn Whitelaw, who was known to mental health services, died by suicide; his body was recovered from the River Thames on 17 March 2023. Before his death, his mental health deteriorated and a referral for urgent psychiatric review following his disclosure that he would accept informal hospital admission was not acted on. Concerns included insufficient consideration of historic and current risks, inadequate documentation and exploration of deterioration, and a lack of reassurance that identified learning points would be addressed.
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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 clearly document risk discussions and assessments
Wider context from the report “(3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following:
• There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment
• “Discussions and assessments of risk should be clearly documented”
• “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”
• There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”
However, the Serious Incident Investigation Report does include any plan to address the concerns it identified. As such, there insufficient reassurance that there is plan to address the matters in a meaningful way moving forward.
” Source location Luke Mervyn WHITELAW · 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 Train clinicians to document medication and medical-review discussions, decisions, participants, timings and outcomes.
Verbatim wording from the response “We have discussed with the team members of CRHTT the need to precisely document discussions about medication or medical review in future (i.e. to outline date and time of discussion, who was involved in the discussion, and the outcome that was agreed). Since this time, significant discussion and training has taken place with all clinicians in this team to document key discussions and decisions – including when the clinical needs changes to the point that inpatient care is indicated. Training and discussion has also taken place during 2023 and into 2024 with the consultant psychiatrists, managers and clinical staff about meaningful discussion and documentation of same, and consideration of written notes.” Source location Response from Oxleas 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 and monitor an improvement plan addressing clinical-care, risk-assessment, documentation and reflective-practice gaps.
Verbatim wording from the response “In 2023 an improvement plan was put in pace for this clinical team to address gaps which were identified during the investigation and gaps which were identified as a result of day-to-day oversight. This plan is monitored by the service director and the clinical director for the Acute & Crisis Directorate and will continue until such time that we are satisfied that the care provided is to the standard needed, and for at least until July 2024.” Source location Response from Oxleas NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a single crisis-assessment form capturing the person’s journey and prior assessment information in the clinical record.
Verbatim wording from the response “We have also had intensive engagement with clinicians and the transformation team to co- design a single crisis assessment form that allows to capture a person journey /story in one single document on the patient recording system. This would prompt clinicians to add to assessment that was carried out previously which reduce the risks of clinicians not considering the full information on what has been happening in that person care. The form has recently gone live on the Patient clinical record as of 22 January 2024 and is on testing phase for which we are collecting feedback.” Source location Response from Oxleas 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 Review the Trust electronic-record risk-assessment template to support improved risk assessment, formulation, communication and recording.
Verbatim wording from the response “• On a trust wide basis, work is underway to review the Trust Risk assessment template on the electronic patient record. This will support the embedding of the fresh approach to risk assessment, formulation, communication and recording.” Source location Response from Oxleas NHS Foundation Trust
Open published response
2 Oct 2023 Paula LENIHAN · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to complete or update risk assessments adequately View source
Linked response
Birmingham and Solihull Mental Health 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
Birmingham and Solihull Mental Health NHS Foundation Trust
Provide protected dedicated staff time to update risk assessment documentation.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Operate a project group reviewing the risk assessment process, outpatient clinics and documentation for care support patients.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Complete the review of the risk management policy.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Ratify the revised risk management policy.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Monitor risk-assessment completion through monthly local clinical governance committees and the trust-wide performance delivery group.
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AI-generated summary
Paula LENIHAN · 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
Paula Lenihan was found deceased at her home on 6 March 2023. The medical cause of death was ischaemic and hypertensive heart disease, with combined toxicity from drugs in her system. The principal concern was that risk assessments within the Birmingham & Solihull Mental Health NHS Foundation Trust were not being completed or updated satisfactorily, creating a risk from insufficient recording of risk information.
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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 or update risk assessments adequately
Wider context from the report “1. The evidence given on behalf of the Birmingham & Solihull Mental Health NHS Foundation Trust was that in addition to this present case, where the deceased's risk assessment was not updated between November 2021 and her death in March 2023 despite circumstances which I was told ought to have triggered an update, there were a further number of cases within the Trust in which Root Cause Analysis reports had been produced, where it had also been found that risk assessments were not being completed in line with expectations ; further, that it was not clear why this was happening.
2. If risk assessments are not being properly completed or updated , then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk . The fact that risk-relevant information may be recorded in the body of clinical notes is not reassuring, because a risk assessment or risk summary ought to capture the most salient risk information so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure.
3. The evidence given to me was that a 'task and finish group' has been set up to address the issue, which expects to have concluded by early next year, i.e. 2024, and that this group will be addressing matters as they are found rather than waiting until the final stage of its existence early next year. The evidence was that this group is at an early stage, with meetings considering the terms of reference and also, recently, the most appropriate persons to contribute to the group.
4. In the circumstances I am concerned that currently there is an extant issue within the Trust about the completion of risk assessments being, on a number of occasions, unsatisfactory . The task and finish group is at an early stage and I do not know what it is going to do, or when. I therefore cannot be reassured that the issues around risk recording which that group is going to examine have, at this point in time, been addressed . It seems to me that they continue to exist , because there has been no evidence to tell me otherwise.
” Source location Paula LENIHAN · 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 protected dedicated staff time to update risk assessment documentation.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
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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 Operate a project group reviewing the risk assessment process, outpatient clinics and documentation for care support patients.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
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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 Complete the review of the risk management policy.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
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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 Ratify the revised risk management policy.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
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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 risk-assessment completion through monthly local clinical governance committees and the trust-wide performance delivery group.
Verbatim wording from the response “To ensure we continue to support staff in maintaining these levels of completion we will be monitoring via our monthly local CMHT clinical governance committee and trust wide performance delivery group.” Source location Response from Birmingham and Solihull Mental Health
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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 disputes that failing to update risk assessment information already recorded would create a risk of death or meet the PFD threshold.
Verbatim wording from the response “I understand that during evidence presented at the inquest you concluded that the failure to update the risk assessment did not contribute to the death and accepted that the information was recorded within the records for staff to access. Your report sets out your belief that the risk assessment should be updated ‘so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure.’ This aspect of your report is not based on evidence heard at the inquest and the Trust does not accept that failing to update the Risk Assessment section of the medical notes, when the information is already within the records, would result in death. Even in times of pressure, clinicians would review all the necessary pertinent information prior to reviewing a patient.” Source location Response from Birmingham and Solihull Mental Health
Open published response
26 Jul 2022 Archi Johnson · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Failure to clearly record and make relevant previous incidents known to those responsible for care 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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AI-generated summary
Archi Johnson · 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
Archi Johnson, who had a history of depression, self-harm and suicidal ideation, was admitted voluntarily to a hospital ward on 5 November 2019 after reporting intrusive thoughts of taking his own life. He was found hanging on 7 November 2019; concerns were raised that information about a previous similar suicide attempt was not clearly recorded or shared, which may have affected decisions about his risk level, observation level and the removal of potentially dangerous ligature items.
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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 clearly record and make relevant previous incidents known to those responsible for care
Wider context from the report “1.Evidence was heard regarding the manner in which information crucial to the
formulation of risk assessments was recorded and shared:
a)Two types of risk assessments were completed, with no system to ensure that important
information is present on both;
b) The previous incident in which Archi had attempted to take his own life in very similar
circumstances on the ward was not clearly entered on the risk assessments used by staff
and therefore not known to a number of those responsible for his care;
c) Those responsible for his care accepted that the above incident was one of which they
would have wanted to have knowledge;
d) The absence of that information may have affected the subsequent decisions made
regarding the setting of risk level, observation level and removal of potentially
dangerous ligature items.
” Source location Archi Johnson · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.