Concerns raised 3
Failure to review medical records during mental health risk assessments View source Over-reliance on referrer-provided information in mental health risk assessments View source Lack of investigation and scrutiny of available background information in mental health risk assessments View source
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
Hywel Dda University LHB
Use comprehensive assessment and referral-support tools to prompt multi-source information gathering, collateral enquiries and documentation of information sources.
View source
Hywel Dda University LHB
Issue a professional practice reminder requiring relevant practitioners to review electronic patient records before assessments and consider historical risks and safeguarding concerns.
View source
Hywel Dda University LHB
Discuss historical-record review and collateral-information requirements in Adult Mental Health Services operational team meetings to reinforce consistent practice.
View source
Hywel Dda University LHB
Continue delivering WARRN training across mental health services on multi-source assessment, professional curiosity, collaborative risk management and safety planning.
View source
Hywel Dda University LHB
Work with police colleagues to strengthen understanding and use of Pembrokeshire police handover processes so relevant information reaches assessing clinicians.
View source
Hywel Dda University LHB
Strengthen duty-practitioner expectations so urgent assessments include seeking necessary collateral information beyond analysing information presented.
View source See 3 more actions
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AI-generated summary
Trevor Anthony Evans · 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
Trevor Anthony Evans was struggling with his mental health and had contact with police, ambulance, mental health professionals and healthcare staff before taking his own life by hanging at home on 27 February 2020. The principal concerns were over-reliance on what he told a mental health nurse, failure to review medical records and insufficient investigation of available background information, resulting in concerns that mental health risk assessments could be incomplete or inadequate.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review medical records during mental health risk assessments
Wider context from the report “In this case, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available.
Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information.
For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer. It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from.
” Source location Trevor Anthony Evans · 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 Over-reliance on referrer-provided information in mental health risk assessments
Wider context from the report “In this case, I found that there was an over reliance on what Trevor told the nurse , a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available.
Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information .
For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer . It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from.
” Source location Trevor Anthony Evans · 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 investigation and scrutiny of available background information in mental health risk assessments
Wider context from the report “In this case, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available .
Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information.
For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer. It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from.
” Source location Trevor Anthony Evans · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use comprehensive assessment and referral-support tools to prompt multi-source information gathering, collateral enquiries and documentation of information sources.
Verbatim wording from the response “1. Introduction of referral and assessment support tools” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a professional practice reminder requiring relevant practitioners to review electronic patient records before assessments and consider historical risks and safeguarding concerns.
Verbatim wording from the response “1. Reinforcement of expectations regarding historical information review” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss historical-record review and collateral-information requirements in Adult Mental Health Services operational team meetings to reinforce consistent practice.
Verbatim wording from the response “2. Team discussions and practice reinforcement” Source location Response from Hywel Dda University Health Board
Open published response
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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 Continue delivering WARRN training across mental health services on multi-source assessment, professional curiosity, collaborative risk management and safety planning.
Verbatim wording from the response “4. Workforce development through WARRN” Source location Response from Hywel Dda University Health Board
Open published response
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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 Work with police colleagues to strengthen understanding and use of Pembrokeshire police handover processes so relevant information reaches assessing clinicians.
Verbatim wording from the response “3. Review of partnership information-sharing arrangements” Source location Response from Hywel Dda University Health Board
Open published response
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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 Strengthen duty-practitioner expectations so urgent assessments include seeking necessary collateral information beyond analysing information presented.
Verbatim wording from the response “4. Strengthening the duty practitioner role” Source location Response from Hywel Dda University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implemented, immediate and ongoing safety work collectively addresses the identified risk-assessment concerns.
Verbatim wording from the response “We believe the actions already implemented, the immediate actions undertaken following receipt of this report, and our ongoing participation in national safety and risk improvement work collectively address the issues identified and support the cultural shift towards collaborative, information-seeking, formulation-based assessment practice described by the Coroner.” Source location Response from Hywel Dda University Health Board
Open published response
5 Mar 2026 Caroline Adeyelu · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Lack of information gathering from wider family members View source
This report raised 8 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
Caroline Adeyelu · 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
Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of information gathering from wider family members
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members ; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” Source location Caroline Adeyelu · Prevention of Future Deaths report
Open source report
6 Feb 2026 Michaela FINCH · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to communicate family concerns to assessing clinicians View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Michaela FINCH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate family concerns to assessing clinicians
Wider context from the report “4. The evidence established that at least two family members had brought to the attention of a member of the Mental Health Team their profound concerns, their recent lived experiences with the deceased that underpinned these concerns, their views that the deceased was paranoid, at greater risk to herself - but none of these concerns were brought to the specific attention of the assessing clinician - the communication between the Mental Health Team and family members being sub-optimal .
” Source location Michaela FINCH · Prevention of Future Deaths report
Open source 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 Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.
Verbatim wording from the response “The Trust Standard Operating Procedure (SOP) for Mental Health Liaison Service (MHLS) was updated in August 2025 and clearly outlines the expected standards of engagement with carers by the teams. The SOP includes communicating with carers during an assessment to obtain their views, either with the person being assessed or alone with the practitioner, keeping them up to date during their stay in the Emergency Department and feeding back the outcome of any assessment and plan.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
1 Feb 2026 Simon Moss · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2
Failure to use EPCR narrative in mental health risk assessments View source Failure to obtain and use family contact details in mental health assessment and discharge risk mitigation View source
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
NHS England
Support mental health trusts through the Culture of Care programme to strengthen clinical information use and relational approaches to care.
View source
NHS England
Publish and implement national Staying safe from suicide guidance promoting holistic assessments, family involvement and safety planning.
View source
NHS England
Ensure London Ambulance Service information is added to the Emergency Department iCare system.
View source
NHS England
Introduce an induction form for new bank and locum staff covering access to electronic patient and London care record systems.
View source
NHS England
Ensure next-of-kin details are added to patient information during triage at University Hospital London.
View source See 2 more actions
×
AI-generated summary
Simon Moss · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Simon Moss was discovered on the roof of his family home on 14 February 2024 after recently developing paranoid thinking, becoming extremely anxious and appearing to be considering suicide. After ambulance attendance and a mental health assessment that did not use detailed information in the ambulance record or contact his wife for collateral information, he was discharged and deliberately fell from a nearby building to his death later that day. The concern was that gaps in training, practice, policy or procedures could result in important risk information and family contact details not being used, undermining the assessment and mitigation of risk to patients presenting with potential risk to self.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to use EPCR narrative in mental health risk assessments
Wider context from the report “The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient’s own account could not be relied on.
However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient’s account . That triage note was necessarily brief and so the detail in the EPCR was lost . Furthermore, the Manchester Triage System only provided the option of “suicidal ideation” or “self-harm” whereas there was evidence in the EPCR of planning and intent.
Further, neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services. Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted.
The evidence was that across several experienced mental health nurses present – who had worked across many roles and mental health trusts – none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means. The EPCR was accessible on systems available to the mental health nurse however.
While remedied at the relevant trust, given the evidence of broader practice among mental health nurses I am concerned that there remains a gap in training, practice, policy and/or procedural frameworks for mental health assessments leading to an important source of significant information (EPCR narrative and family contact details) not being known of or used , which could otherwise:
(a) inform an accurate evaluation of the risk to self of patients presenting with mental health illness via ambulance services (i.e. this was not an isolated incident of the EPCR not being known of or used by the specific mental health nurse making the assessment) by (i) providing an independent and detailed account of recent patient history and (ii) contact details for family/friends/individuals who can provide further collateral on their recent presentation, and
(b) allow better mitigation of residual risks at the point of discharge (e.g. through engagement with family and ensuring the patient is collected).
I am concerned that this may undermine the evaluation and mitigation of risk in patients presenting with potential risk-to-self and so represents a risk of future deaths.
” Source location Simon Moss · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain and use family contact details in mental health assessment and discharge risk mitigation
Wider context from the report “The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient’s own account could not be relied on.
However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient’s account. That triage note was necessarily brief and so the detail in the EPCR was lost. Furthermore, the Manchester Triage System only provided the option of “suicidal ideation” or “self-harm” whereas there was evidence in the EPCR of planning and intent.
Further, neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services . Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted.
The evidence was that across several experienced mental health nurses present – who had worked across many roles and mental health trusts – none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means . The EPCR was accessible on systems available to the mental health nurse however.
While remedied at the relevant trust, given the evidence of broader practice among mental health nurses I am concerned that there remains a gap in training, practice, policy and/or procedural frameworks for mental health assessments leading to an important source of significant information (EPCR narrative and family contact details) not being known of or used , which could otherwise:
(a) inform an accurate evaluation of the risk to self of patients presenting with mental health illness via ambulance services (i.e. this was not an isolated incident of the EPCR not being known of or used by the specific mental health nurse making the assessment) by (i) providing an independent and detailed account of recent patient history and (ii) contact details for family/friends/individuals who can provide further collateral on their recent presentation , and
(b) allow better mitigation of residual risks at the point of discharge (e.g. through engagement with family and ensuring the patient is collected) .
I am concerned that this may undermine the evaluation and mitigation of risk in patients presenting with potential risk-to-self and so represents a risk of future deaths.
” Source location Simon Moss · Prevention of Future Deaths report
Open source 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 Support mental health trusts through the Culture of Care programme to strengthen clinical information use and relational approaches to care.
Verbatim wording from the response “Through the Culture of Care national programme, NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings. This includes supporting mental health staff to know the person, understand their history, and engage with family, friends and carers to better recognise and respond to risk. Trusts are beginning to apply these principles more broadly across community services.” Source location 2026-0052 - Response from NHS England
Open published response
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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 Publish and implement national Staying safe from suicide guidance promoting holistic assessments, family involvement and safety planning.
Verbatim wording from the response “The recently launched NHS England Staying safe from suicide guidance was co-produced by mental health nurses and published by NHS England in June 2025. Its aim is to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing the safety. It highlights the importance of bringing in families/carers in gaining an overall understanding and need for safety planning.” Source location 2026-0052 - Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure London Ambulance Service information is added to the Emergency Department iCare system.
Verbatim wording from the response “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.” Source location 2026-0052 - Response from NHS England
Open published response
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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 Introduce an induction form for new bank and locum staff covering access to electronic patient and London care record systems.
Verbatim wording from the response “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.” Source location 2026-0052 - Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure next-of-kin details are added to patient information during triage at University Hospital London.
Verbatim wording from the response “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.” Source location 2026-0052 - Response from NHS England
Open published response
Concerns raised 1
Failure to incorporate family and friends' concerns into onward treatment and clinical assessment View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Introduce the Triangle of Care framework and updated co-produced training across Isle of Wight and legacy Solent teams.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Maintain an organisation-wide ESTHER ambassador network and provide ESTHER coaching courses.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Provide Carers Champions in teams and honorary champions across the Trust.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Implement the Carer Information Plan in the electronic patient record with consent, privacy and family-centred information fields.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Expand carer feedback routes and fund or support carer groups, reporting feedback through governance groups.
View source
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Remedy missing carer data by capturing it on the data-insights visualisation platform.
View source
Department of Health and Social Care
Commission and complete an independent audit of arrangements for involving and listening to families and carers.
View source
Department of Health and Social Care
Improve the Triangle of Care initiative to support family and carer involvement.
View source See 5 more actions
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AI-generated summary
Samantha Kate YOUNG · 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
Samantha Young died at home on 20 November 2023 after intentionally taking her own life by hanging. She had a history of mental health difficulties, previous suicide attempts, and worsening condition amid significant stress. The concerns included insufficient training for agency staff in risk assessments and inadequate contact and communication with patients’ families and friends.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate family and friends' concerns into onward treatment and clinical assessment
Wider context from the report “B. Wider family and friends of the deceased perspective were not contacted.. A patient's family and friends are clearly an invaluable resource for learning more about a patient's mental health and specifically risk to life, the support available to the patient and the potential for synergistic support with the NHS Trust. This PFD is not the first time that the issue has been raised with Southern Health NHS Foundation Trust: in 2023 the Senior Coroner for Hampshire, Portsmouth and Southampton issued a PFD on similar grounds arising out of the inquest into the death of Kirsty Taylor. The Senior Coroner observed in the PFD that "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions ." Moreover, in 2021 a report commissioned by NHS England into Southern Health Foundation Trust similarly reported on shortfall in communication with families.
” Source location Samantha Kate YOUNG · Prevention of Future Deaths report
Open source 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 Introduce the Triangle of Care framework and updated co-produced training across Isle of Wight and legacy Solent teams.
Verbatim wording from the response “support recovery, and sustain the wellbeing of both the service user and their carer. Having rolled out the programme to legacy Southern Health staff over a number of years, we are now introducing the Triangle of Care framework to our staff in Isle of Wight and Legacy Solent teams (who merged with Southern Health last year to become Hampshire and Isle of Wight Healthcare). Much of this training is co-delivered with carers, carers leads and a former service user with their carer. The training has recently been updated in coproduction with carers.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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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 Maintain an organisation-wide ESTHER ambassador network and provide ESTHER coaching courses.
Verbatim wording from the response “The introduction of Esther coaching has further enhanced and reinforced the Triangle of Care principles. Esther Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous improvement to ensure person-centred care. User involvement is integral to the model, building a network around the patient including family, friends, and key staff.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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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 Carers Champions in teams and honorary champions across the Trust.
Verbatim wording from the response “Carers Champions (Carers Leads)” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Carer Information Plan in the electronic patient record with consent, privacy and family-centred information fields.
Verbatim wording from the response “Our new Carer Information Plan officially launched in May 2025, and is available for all services, replacing the previous Carer Communication Plan. Carers were involved in the development of our new plans and the response has been overwhelmingly positive.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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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 Expand carer feedback routes and fund or support carer groups, reporting feedback through governance groups.
Verbatim wording from the response “The Trust has increased the number of ways that people can give feedback and opportunities to share their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We have a number of carers groups across the Trust, as well as supporting external groups. Most recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton and continue to fund an adult mental health carers group from diverse communities. Feedback and issues highlighted from these different platforms is reported to the services involved, the Carers, Family and Friends group and the Patient Experience and Caring group as part of our business-as-usual reporting. As we develop our new Trust, an overarching Experience of Care group will be established and an unpaid carers group will report into the Experience of Care group.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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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 Remedy missing carer data by capturing it on the data-insights visualisation platform.
Verbatim wording from the response “The audit report goes on to find: ‘The control effectiveness is Moderate as the Trust has been monitoring the Carers Plan and improvement initiatives properly with sufficient evidence available to prove their delivery progress. However, while the Trust uses OpenRio to record patient and carer information, it does not currently capture all essential data, which could limit its ability to monitor carers identification and support provided. Moreover, new roles and responsibilities of the Carers team are still being defined post-merger.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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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 Commission and complete an independent audit of arrangements for involving and listening to families and carers.
Verbatim wording from the response “In recognition of the importance of engagement with families and carers, the Trust last year commissioned an independent audit of this area. Specifically, the purpose of the audit was to review the adequacy of the Trust’s arrangements for involving and listening to families and carers so that the Trust learns from their feedback and experiences. The findings of the audit underline the Trust’s commitment to ensuring” Source location Response from Department for Health and Social Care
Open published response
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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 the Triangle of Care initiative to support family and carer involvement.
Verbatim wording from the response “that patients’ families feel heard, respected, and involved in the care of their loved ones. The findings also outline the programmes of work that are in place as the Trust seeks to embed a culture of compassionate, inclusive care across all of its services, which include improved collaboration with partners and other organisations; improvements to its Triangle of Care initiative; and upskilling staff coaches supporting the development of colleagues to create a culture of continuous improvement and ensure person-centred care.” Source location Response from Department for Health and Social Care
Open published response
10 Jun 2025 Andrew James CONNOLLY · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of a mechanism for family input into mental health clinical assessments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andrew James CONNOLLY · 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 James Connolly died after being struck by a train having entered the track at a railway station on 26 November 2024. Concerns included telephone GP appointments despite his mental health not improving, no opportunity for family input into his clinical assessment, and a lack of guidance or mechanism for these arrangements; the inquest heard that his risk was not recognised.
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× 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 a mechanism for family input into mental health clinical assessments
Wider context from the report “The inquest heard evidence that whilst initial appointments with his GP were face to face they became telephone appointments even when he indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in relation to his mental health . The evidence given by his family at the inquest was that they could have provided valuable information into the clinical assessment but did not feel they had the opportunity to provide this information.
The consequence of these two factors was that his risk was not recognised.
On the evidence before the inquest there is no guidance for the use of telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations .
” Source location Andrew James CONNOLLY · 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 Produce and distribute a briefing for Greater Manchester GPs on appointment-mode appropriateness, contextual mental-health risk, family involvement, confidentiality, and Zero Suicide Alliance guidance.
Verbatim wording from the response “Having reflected on the contents of your report, I do think it is important for our GP practices to ensure that the best options for appointments are provided for patients recognising both their preferences but also an individual’s clinical assessment of their condition and needs. In response to this report, I will ensure that NHS GM produces an advice briefing for our GPs and practices to be distributed through our primary care networks, that:” Source location 2025-0290 - Response from Greater Manchester ICB
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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 need for a Greater Manchester decision-making tree or flowchart to guide practitioners on sharing information with families, using Zero Suicide Alliance guidance.
Verbatim wording from the response “- Reviews the need for a decision-making tree / tool to guide practitioners across our GM system using the Zero Suicide Alliance guidance and condensing it into a “decision making tree” flowchart.” Source location 2025-0290 - Response from Greater Manchester ICB
Open published response
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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 Individual GPs decide whether family involvement or other information is needed, balancing professional assessment, confidentiality, consent and safeguarding duties.
Verbatim wording from the response “GPs along with all health professionals are bound by the duty of confidentiality between them and their patients, and this is always balanced with their duty of care and responsibilities to safeguard the health and welfare of their patients. Whilst due consideration will always be given to consent, confidentiality and whether there is an agreement in place for family involvement, it will be the individual GP who makes an assessment in their professional opinion in any given consultation that will inform any decision to provide care and treatment and whether other information or opinions are required. A GP will always consider past history, knowledge of previous risks, any treatment and interventions as well as partner agencies that may already be involved. This is balance of professional responsibility and, in some circumstances, this can be difficult” Source location 2025-0290 - Response from Greater Manchester ICB
Open published response
11 Oct 2024 Oliver Davies · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Failure to incorporate self-harm risk referrals into mental-health care prioritisation View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Oliver Davies · 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
Oliver Davies died by suicide by hanging in his cell at HMP Hewell on 31 December 2022. The concerns included delayed and incomplete mental health assessment, failures to share relevant information about his self-harm and suicide risk, inadequate prioritisation and follow-up by the mental health care coordinator, and failures to keep him informed about healthcare and appointments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate self-harm risk referrals into mental-health care prioritisation
Wider context from the report “2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s assessment. An appointment was fixed for Oliver to meet the care coordinator for the first time on 14.12.22. Due to workload pressures, the care coordinator was unable to fulfil that appointment before he went on leave from 16-28.12.22. Shortly before he went on leave, the care coordinator conducted a “RAG rating” exercise to determine whether he should prioritise seeing Oliver, and determined that Oliver’s case merited the lowest priority RAG rating ( green ). When conducting that RAG rating exercise, the care coordinator did not take into account:
(a) The prison officer’s urgent TAG mental health referral of 30.11.22 ( above ); and
(b) A further TAG mental health referral made by a prison paramedic which cited “mild concerns” about deliberate and unintentional self-harm on Oliver’s part, the details of which had been entered onto Oliver’s SystmOne medical record.
In addition, the care coordinator did not raise in the mental health team’s daily forum.the fact that he was unlikely to have time to see Oliver before he went on leave.
Had the care coordinator taken into account the referrals at (a)-(b) above, and raised at the daily forum his difficulty in being able to see Oliver, it may well have been that Oliver’s case would have merited a more urgent response from the care coordinator or someone else in his stead.
Having heard evidence at the inquest from your Trust’s Clinical Director, ████████, I was not satisfied that the Trust has fully recognised the above shortcomings, and taken action to ensure that they are not repeated for other mental health patients in custody at HMP Hewell.
” Source location Oliver Davies · 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 Ensure TAG referrals and healthcare applications are added to and visible in SystmOne.
Verbatim wording from the response “There is also now, a clear process for the management of TAG referrals and Healthcare applications ensuring that they are added to and visible in SystmOne.” Source location Response from Midlands Partnership 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 Reinforce reviewing recent electronic patient-record activity before assessment or intervention through incident-meeting messages, governance dissemination, management reminders and supervision.
Verbatim wording from the response “The importance of staff familiarising themselves with recent clinical activity from the electronic patient record has been highlighted to all Inclusion staff as part of the key messages that arise from our monthly Health in Justice Serious Incident Meeting.” Source location Response from Midlands Partnership NHS Foundation Trust
Open published response
Concerns raised 1
Difficulty obtaining collateral mental health information from other services View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Miles Ethan Hurley · 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
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.
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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 Difficulty obtaining collateral mental health information from other services
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Source location Miles Ethan Hurley · 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 Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.
Verbatim wording from the response “f) NHS Trust information sharing has also been raised as a concern by the NPCC in that the inability or refusal to share clinical records between criminal justice pathways adds risk to a detainees welfare.” Source location Response from NPCC
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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 Sussex Partnership Trust’s Mental Health Helpline is best placed to respond about family information not being shared with the commissioned Liaison and Diversion service.
Verbatim wording from the response “7. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services.” Source location Response from NHS England
Open published response
Concerns raised 2
Failure to gather sufficient collateral information for MHA 83 assessments View source Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Swansea Bay University Local Health Board Swansea Council Welsh Government
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Swansea Council
Complete a senior-management review and formulate recommendations and an improvement action plan for AMHP practice.
View source
Swansea Council
Discuss with Swansea University's AMHP training committee whether collateral-information competencies require greater emphasis in course delivery.
View source
Swansea Council
Deliver specific refresher training to AMHPs on gathering, weighting and recording collateral information through external training agencies.
View source
Swansea Council
Direct AMHPs to document referral, contact, Nearest Relative, collateral-information, decision-making, medical-discussion and assessment-stage details on assessment forms.
View source
Swansea Council
Amend the AMHP assessment form to capture consultation views, reasons for non-consultation, earlier analysis, and doctors' individual views and detention-criteria conclusions.
View source
Swansea Council
Conduct quarterly audits of AMHP referrals and assessments for 12 months, followed by twice-yearly audits subject to initial findings.
View source
Swansea Bay University Local Health Board
Provide all SBUHB-employed Section 12 doctors with read access to WCCIS for Mental Health Act assessments.
View source
Swansea Bay University Local Health Board
Remind AMHPs and Section 12 doctors to discuss patient history and collateral information before Mental Health Act assessments.
View source
Swansea Council
Continue working with the Health Board through joint forums to secure appropriate WCCIS access for mental-health professionals requiring it.
View source See 6 more actions
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AI-generated summary
Nicholas Kim Harrison · 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
Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to gather sufficient collateral information for MHA 83 assessments
Wider context from the report “I am concerned that an inadequate understanding within the CCOS AMPH service of the duty to gather sufficient collateral information in the context of any assessment under the MHA 83 and / or inadequate systems being employed within CCOS in relation to this issue creates a risk that information may not be captured and / or may be lost in relation to mentally unwell individuals in the community where they may pose a risk to their own lives and / or the lives of others and that this creates a risk that other deaths will occur.
” Source location Nicholas Kim Harrison · 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 Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments
Wider context from the report “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83 . I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur.
” Source location Nicholas Kim Harrison · Prevention of Future Deaths report
Open source 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 Complete a senior-management review and formulate recommendations and an improvement action plan for AMHP practice.
Verbatim wording from the response “Nevertheless, and in light of His Majesty's Coroner's concerns, senior management have carried out a review with the aim of gaining a fuller understanding of this matter of individual AMHP practice and formulating recommendations and an action plan for improvement. Specific actions, to be taken within the next month, include:” Source location Response from City and County of Swansea
Open published response
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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 with Swansea University's AMHP training committee whether collateral-information competencies require greater emphasis in course delivery.
Verbatim wording from the response “ii. The Principal Officer for Mental Health Services, in his capacity of Chair of Swansea University's AMHP training course committee, will discuss with the committee the key competence area relating to the obtaining of collateral information, and any requirement for the delivery of the course to include greater emphasis on the gathering, weighting and recording of collateral information.” Source location Response from City and County of Swansea
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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 Deliver specific refresher training to AMHPs on gathering, weighting and recording collateral information through external training agencies.
Verbatim wording from the response “iii. The Council will seek to deliver, via its external training agencies, specific refresher training to its AMHP team relating to the gathering, weighting and recording of collateral information.” Source location Response from City and County of Swansea
Open published response
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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 Direct AMHPs to document referral, contact, Nearest Relative, collateral-information, decision-making, medical-discussion and assessment-stage details on assessment forms.
Verbatim wording from the response “iv. AMHPs are to be directed/instructed to record all relevant assessment referral and contact information on the AMHP assessment form.” Source location Response from City and County of Swansea
Open published response
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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 Amend the AMHP assessment form to capture consultation views, reasons for non-consultation, earlier analysis, and doctors' individual views and detention-criteria conclusions.
Verbatim wording from the response “vi. The AMHP assessment form is to be updated to include an additional section for the recording of the views of relevant others or reasons for not consulting with them, and AMHPs are to be directed/instructed to complete this section in as much detail as possible.” Source location Response from City and County of Swansea
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly audits of AMHP referrals and assessments for 12 months, followed by twice-yearly audits subject to initial findings.
Verbatim wording from the response “xii. Audits of AMHP referrals and assessments are to be conducted quarterly for the first 12 months, then bi-annually from then on, depending on the findings of the initial quarterly audits. The audits will be undertaken by the Principal Officer for Mental Health Services with support from managers.” Source location Response from City and County of Swansea
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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 all SBUHB-employed Section 12 doctors with read access to WCCIS for Mental Health Act assessments.
Verbatim wording from the response “Regarding access to WCCIS for MHA Assessments, all S12 Drs employed by SBUHB will be given read access to WCCIS to enable them to access information pertaining to the patient being assessed under the MHA 83. AMHPs also have full access to WCCIS. Both organisations (SBUHB/CCOS) committed to reminding both the AMHP and the S12 Drs to discuss patient history and any collateral information prior to the assessment taking place who recognise the importance of an all Wales digital solution. The Health Board, in the letter sent on 3rd April 2024, (referenced on page of this letter) covered this important area.” Source location Response from Swansea Bay University Health Board 2
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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 Remind AMHPs and Section 12 doctors to discuss patient history and collateral information before Mental Health Act assessments.
Verbatim wording from the response “Regarding access to WCCIS for MHA Assessments, all S12 Drs employed by SBUHB will be given read access to WCCIS to enable them to access information pertaining to the patient being assessed under the MHA 83. AMHPs also have full access to WCCIS. Both organisations (SBUHB/CCOS) committed to reminding both the AMHP and the S12 Drs to discuss patient history and any collateral information prior to the assessment taking place who recognise the importance of an all Wales digital solution. The Health Board, in the letter sent on 3rd April 2024, (referenced on page of this letter) covered this important area.” Source location Response from Swansea Bay University Health Board 2
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the Health Board through joint forums to secure appropriate WCCIS access for mental-health professionals requiring it.
Verbatim wording from the response “The Council will continue to work with SBUHB via the various forums referred to above in order to ensure, as far as is reasonably possible, that the appropriate mental health professionals, deemed by SBUHB as requiring WCCIS access, is granted such access. Discussions have already taken place between SBUHB and the Council with the view to arranging for all patient clinical notes to be available across the relevant systems accessed by both organisations.” Source location Response from City and County of Swansea
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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 Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.
Verbatim wording from the response “It is not within the Council's remit to respond to all of the matters of concern set out by His Majesty's Coroner in the Report, and it is appropriate that the Council responds to the first and second matters of concern. I shall address each in turn:” Source location Response from City and County of Swansea
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.
Verbatim wording from the response “I note the report has been sent to the UHB and the City and County of Swansea for a response and action and I expect them to provide responses within your timescale that address the concerns raised. I am issuing a separate Welsh Government response to ensure lines of accountability are clear. I take the concerns raised in the report very seriously and I would like to set out the actions being taken.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern relates to City and County of Swansea’s AMHP service, not the Health Board’s actions.
Verbatim wording from the response “Whilst this concern relates to the actions of City and County of Swansea (CCOS) and not Swansea Bay University Health Board (SBUHB), the two organisations are working closely together, to ensure that all learning is identified to improve patient safety. A formal meeting has been held between the Service and Head of Adult Services and Tackling Poverty from CCOS, to identify specific actions.” Source location Response from Swansea Bay University Health Board 2
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.
Verbatim wording from the response “This is a matter of concern for SBUHB and NHS Wales to primarily address, but the Council wishes to comment specifically in relation to access to its systems by Section 12 doctors.” Source location Response from City and County of Swansea
Open published response
19 Jan 2024 Tom Sweeting · Prevention of Future Deaths report West London
View report summary
Concerns raised 1
Inappropriate delegation of family collateral information gathering View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
West London NHS Trust
Introduce secondary induction training requiring demonstration, observation and supervised practice for collateral-information gathering.
View source
West London NHS Trust
Provide regular clinical supervision to monitor the quality of clinicians’ work.
View source
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AI-generated summary
Tom Sweeting · 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
Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inappropriate delegation of family collateral information gathering
Wider context from the report “3. It was acknowledged that obtaining collateral information from the family is vital , but in this case was delegated to a very Junior member of the team who was in the early stages of her training . It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care.
” Source location Tom Sweeting · Prevention of Future Deaths report
Open source 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 Introduce secondary induction training requiring demonstration, observation and supervised practice for collateral-information gathering.
Verbatim wording from the response “The Trust has reviewed this practice, and whilst the collating of collateral information will remain an important training task for junior members of staff, that there was a shortfall in supervision in this instance and improvements were required in the expectation of how the task should be undertaken. To aid with this, a secondary induction programme into the service has been introduced for new staff, which sets out how this task will be demonstrated, and observed before carried out independently with supervision. The service has commissioned a piece of co-development work with our Experts by Experience as Carers representatives to improve the practices further.” Source location Response from West London 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 Provide regular clinical supervision to monitor the quality of clinicians’ work.
Verbatim wording from the response “The service governance structures in place to share learning through a Service Line Quality and Performance meeting into the borough team based Clinical Improvement Groups which are documented. A quarterly Mortality and Morbidity meeting has been introduced for liaison psychiatry teams to reflect on and learn from incidents. In addition, learning from our incidents is now fed into an annual team development programme, in the form of a thematic review of serious incidents, teaching and a complex case discussion forum. All clinicians receive regular clinical supervision which monitors the quality of work individual clinicians conduct.” Source location Response from West London NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Delegating aspects of documentation and assessment to trainee doctors remains appropriate where the supervising consultant ensures adequate supervision.
Verbatim wording from the response “The Trust shares your concern about the perceived mismatch between senior practitioners’ work practices and expectations of junior colleagues, and since this incident has confirmed that all members of staff received the same training and are expected to adhere to the same policies. Whilst it is normal practice in most healthcare settings for certain aspects of documentation and assessment to be delegated across the multidisciplinary team, including to trainee doctors, the supervising consultant retains responsibility for ensuring adequate supervision. Learning from this event has been incorporated into the teaching plan for future trainees rotating through LPS settings, and will be reflected upon by the senior practitioners involved in their monthly management meetings and annual appraisal.” Source location Response from West London NHS Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.