Recurring concern

Unreliable interim mental health support during care transitions

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First reported 15 Apr 2014•Latest report 5 Sep 2025

Definition

What this concern includes

Includes failures of the mental health care transition or interim-support process that leave patients without appropriate support while awaiting, moving between or remaining pending mental health services, including absent monitoring, unclear responsibility, delayed referral, discharge-dependent access and reliance on patient-led contact.

Not included

  • Excludes generic staffing, documentation or communication deficiencies unless they are directly tied to an identified gap in interim mental health support during a care transition.
  • Excludes failures concerning non-mental-health services, hazards or clinical processes without an interim mental-health-support component.
  • Excludes deficiencies occurring within established ongoing treatment that do not concern a delay or transition between mental health services.
Reports
21

Distinct published reports

Individual concerns
24

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England3
Birmingham Women'S and Children'S NHS Foundation Trust2
NHS Birmingham and Solihull Integrated Care Board2
South West London and St George'S Mental Health NHS Trust2
Betsi Cadwaladr University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Brighton and Hove City Council1
Cambridgeshire and Peterborough NHS Foundation Trust1
CAMHS East – Cross Street Clinic1
Cheshire and Wirral Partnership NHS Foundation Trust1
College of Policing1
Cumbria Constabulary1
Department of Health and Social Care1
Devon Partnership NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. North Yorkshire and York

    AI-generated summary

    Victoria Anne TAYLOR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Victoria Anne Taylor’s mental health deteriorated between May and October 2024, involving suicidal ideation, self-harm and binge drinking. She was reported missing on 1 October 2024, and her body was recovered from the River Derwent on 22 October 2024. The principal concerns were that mental health services did not offer a treatment pathway addressing reported childhood trauma, provided limited safety planning, and did not suggest or convene a multi-agency approach despite knowing that several agencies were involved.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide an effective alternative when a referred provider does not respond

    Wider context from the report

    “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor. ”

    Source location

    Victoria Anne TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Cumbria

    AI-generated summary

    Matthew Brierley · 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

    Matthew Brierley died in the car park of Buttermere Court Hotel on 24 April 2024, after being arrested, bailed and placed under conditions that prevented him from living at home or having unsupervised contact with his children and stepdaughter. The inquest concluded that his death was suicide. Concerns included the potentially prolonged period before decisions were made about his devices and case, the use of standard bail conditions without an apparent specific risk assessment, and the lack of proactive follow-up support after his release on bail.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide proactive contact and support to men at elevated suicide risk

    Wider context from the report

    “(3) Police acknowledged the increased risk and completed a standard assessment form when Matthew was released - he denied any risk and also declined referral to Liaison and Diversion service. A Family Contact Officer was also appointed but the onus remained on Matthew to seek help and there was no proactive contact which might have been helpful as men in Matthew's situation are less likely to seek help due to feelings of shame and embarrassment. ”

    Source location

    Matthew Brierley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete research reviewing five years of post-custody suicide data to identify commonalities and inform prevention.

    Verbatim wording from the response

    “1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:”

    Source location

    Response from National Police Chief's Council
    Page 1 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce an evidence-led post-release risk assessment process with mandatory referrals to partner support agencies for identified high-risk individuals.

    Verbatim wording from the response

    “1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:”

    Source location

    Response from National Police Chief's Council
    Page 1 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Home Office has no authority to intervene in operational policing matters or comment on police officers’ operational decisions.

    Verbatim wording from the response

    “How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Operational decisions about following custody guidance are the responsibility of individual police forces and their chief officers.

    Verbatim wording from the response

    “How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Current police guidance readily available to forces clearly sets out actions to support detainees and prevent custody and post-custody suicides.

    Verbatim wording from the response

    “The Detention and Custody Authorised Professional Practice (APP) produced by the College of Policing (henceforth ‘the College’) sets the standards for police engagement with detainees after their arrest, including any offers of support. This includes operational advice on managing the risk of suicide for persons under investigation, such as Matthew. The College is independent of government; its role is to set high professional standards for policing; sharing what works best; acting as the national voice of policing; and ensuring police training and ethics is of the highest possible quality.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing policing guidance, custody risk assessment and partnership arrangements are considered sufficient to address suicide and post-release support risks.

    Verbatim wording from the response

    “increased risk of suicide (such as those matching Mr Brierley’s demographics). We have produced comprehensive practitioner advice for officers and staff that outlines a series of measures to mitigate against this risk and have also added the latest guidance document from the Faculty of Forensic and Legal Medicine on how to care for suspects of sexual assault in police custody. (Please find further details here).”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 13 January 2025

    Open published response

  3. Inner North London

    AI-generated summary

    Michael Joseph HINDES · 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

    Michael Hindes died by suicide after calling 999 because he felt suicidal and being taken to St George’s Hospital for a half-hour mental health assessment before discharge. The principal concerns were that he was not referred to the crisis team despite a likely minimum one-week wait for community mental health follow-up, and that the assessing nurse did not try to persuade him to involve his family, who were unaware of his mental ill health until after his death.

    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 refer patients to the crisis team during delays in community mental health follow-up

    Wider context from the report

    “He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen. In the meantime, it was not thought necessary to refer him to the crisis team. Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this. The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services. Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt. ”

    Source location

    Michael Joseph HINDES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Clinical assessment found low self-harm risk, so discharge with routine CMHT referral rather than crisis services was considered appropriate.

    Verbatim wording from the response

    “As you are aware through the Inquest, the clinical risk assessment undertaken at the time by the assessing nurse in the Psychiatric Liaison Team deemed the patient to be of low risk of self-harm and that he was suitable to be discharged home. In addition, with a routine referral to the Community Mental Health Team (CMHT) for ongoing diagnosis/further assessment, as crisis services were not required at that time.”

    Source location

    Response from South West London and St George's Mental Health
    Page 2 · response
    Published 19 December 2023

    Open published response

  4. West Yorkshire (Western)

    AI-generated summary

    Ben Alan SHIPLEY · 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

    Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.

    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

    Reliance on untrained A&E staff and family for mental health support while detention is pending

    Wider context from the report

    “Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed. Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night. This means Ben cannot be legally detained as the section 2 is not complete until there is a bed. He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). ████████ ████████ ”

    Source location

    Ben Alan SHIPLEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. North West Wales

    AI-generated summary

    Mr Twm Bryn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Twm Bryn died on 4 October 2021 in a shipping container near his home after suspending himself by the neck with a ligature. He had experienced mental health difficulties and was awaiting counselling after an assessment that identified a mild risk of suicide. The report raises concerns about delays and lengthy waiting lists for primary mental health support, and the lack of interim contact, monitoring or support for low-risk patients who are waiting for counselling.

    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

    Interim support for mild or low-risk patients requiring self-referral

    Wider context from the report

    “(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services). ”

    Source location

    Mr Twm Bryn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to offer or arrange interim contact or monitoring for patients awaiting counselling

    Wider context from the report

    “(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services). ”

    Source location

    Mr Twm Bryn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a standardised LPMHSS referral process for low-risk patients’ interim support

    Wider context from the report

    “(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services). ”

    Source location

    Mr Twm Bryn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Have 111+2 staff contact patients fortnightly to review needs and offer support while improvements are developed.

    Verbatim wording from the response

    “We recognise many of these improvements will take some time to develop and embed, and in many cases are reliant on the recruitment of staff. In the short term, 111+2 staff will contact patients on a fortnightly basis to review needs and offer any support as required.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 4 · response
    Published 27 February 2023

    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

    Progress the unallocated-patient waiting-list protocol through consultation, approval, distribution and team launch.

    Verbatim wording from the response

    “Due to the variation in practice across the teams in terms of managing patients on a waiting list, an Unallocated Patient Waiting List Protocol has been developed. This draft protocol ensures that service users referred to the Health Board Community Mental Health Teams and Local Primary Mental Health Support Services are managed efficiently, equitably and consistently. The draft protocol will now progress through consultation, approval and distribution.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 27 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Unfilled vacancies and recruitment difficulties limit the ability to reduce waiting lists, caseloads and delays in access to care.

    Verbatim wording from the response

    “Any patients currently on waiting lists are supported by the duty teams whilst awaiting allocation. The waiting lists are due to currently unfilled vacancies that have been placed into recruitment but unfortunately not all have attracted candidates and have remained unfilled despite being advertised a number of times.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 27 February 2023

    Open published response

  6. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Kieran Joseph Kevan CRIMMINS · 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 Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.

    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 a route back into the Mental Health Service after CRHT discharge

    Wider context from the report

    “(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies. My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy. ”

    Source location

    Kieran Joseph Kevan CRIMMINS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. South Yorkshire (Western)

    AI-generated summary

    Joshua Adey Rennard · 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

    Joshua Adey Rennard died by hanging at his parents’ home on 29 September 2021. The principal concern was an eight-day delay in actioning a professional view that he should be assessed for detention under section 2 of the Mental Health Act, with concern that similar delays could place people at risk of harm or death.

    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 protect people with mental illness while awaiting section assessment

    Wider context from the report

    “5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later. The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future. 5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death. ”

    Source location

    Joshua Adey Rennard · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Liverpool and the Wirral

    AI-generated summary

    Uyapo Theodore Hayunga-Macha · 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

    Uyapo Theodore Hayunga-Macha went missing from Arrowe Park Hospital on 4 December 2020 before he could be assessed for his mental health. He was found drowned on 9 March 2021, and it remained unclear how he ended up in the water. Concerns were raised about why he was not looked after and why he was left alone while waiting for assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide care and supervision while awaiting assessment

    Wider context from the report

    “On 3 December 2020 Merseyside Police were called to Theo where it was apparent that he was suffering from poor mental health. An ambulance was called and Theo agreed to be taken to Arrowe Park Hospital. It is reported that whilst waiting for Triage that he left without being seen. Why was he not being looked after? And why was he left alone when waiting for assessment? ”

    Source location

    Uyapo Theodore Hayunga-Macha · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete online mental-health training for clinical support workers caring for patients in the Mental Health Unit.

    Verbatim wording from the response

    “2. Further education and training for staff in relation to dealing with Mental Health patients and appropriate use of the Mental Health Unit (MHU). The Clinical support Workers who provide care and support for patients within the MHU have completed an online Mental Health training session”

    Source location

    2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
    Page 1 · response
    Published 23 September 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Take forward further staff education and training on caring for mental-health patients and appropriate use of the Mental Health Unit.

    Verbatim wording from the response

    “2. Further education and training for staff in relation to dealing with Mental Health patients and appropriate use of the Mental Health Unit (MHU). The Clinical support Workers who provide care and support for patients within the MHU have completed an online Mental Health training session”

    Source location

    2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
    Page 1 · response
    Published 23 September 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Triage all ambulance-service arrivals on entry, document fit-to-sit rationales, and require verbal handover to the appropriate assessment or triage nurse.

    Verbatim wording from the response

    “4. Ensure a standardised handover process to alert initial assessment / triage staff when a patient is placed in the waiting room as “fit to sit” by Ambulance Triage Nurse (ATN). All patients who arrive under the care of the North West Ambulance Service are now triaged by the ATN. This is a change in practice; previously, if patients were directed to the waiting room on arrival, as considered “fit to sit”, they would have been booked by the administrative team, at the main reception and would have waited to undergo initial triage assessment. The ATN now completes a triage assessment on arrival for all patients, including those presenting with a mental health concern. If this assessment finds the patient able to sit in the waiting room, the rationale for this decision is documented.”

    Source location

    2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
    Page 2 · response
    Published 23 September 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct monthly audits of 50 ambulance-service patients and share assessment, observation and triage findings with the Patient Safety and Quality Board.

    Verbatim wording from the response

    “The Emergency Department leadership team have arranged for an audit of 50 patients per month to be undertaken to provide ongoing assurance around assessment/observations and triage of patients, who arrive via the ambulance service, the results of which are shared at the Trust’s Patient Safety and Quality Board.”

    Source location

    2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
    Page 2 · response
    Published 23 September 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Escalate full Mental Health Unit capacity to the Tactical Commander and shift leader, with defined overnight senior-doctor and shift-leader decision-making, and communicate the process to staff.

    Verbatim wording from the response

    “Unfortunately there are times when our MHU is full. A process has been developed to ensure that this is escalated to the Tactical Commander (TC) and the Shift leader, who are then responsible for decisions regarding either stepping someone out of MHU to create space, or where to place patients who are just arriving. Overnight if the TC is not on site, the decision is made by the senior Dr and Shift Leader. This process has been communicated to all staff.”

    Source location

    2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
    Page 2 · response
    Published 23 September 2021

    Open published response

  9. Brighton and Hove

    AI-generated summary

    Elena WELLS · 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

    Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a bed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide routine out-of-hours review and support for patients awaiting urgent admission

    Wider context from the report

    “2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team, and no advice offered on the existence of a place of safety at the local Mental Health Hospital. Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so. It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found. ”

    Source location

    Elena WELLS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Finalise the Trust-wide CRHT operational policy, including referral pathways and defined responsibilities for services supporting patients awaiting admission.

    Verbatim wording from the response

    “In response, the Trust is in the process of developing a new Crisis Resolution Home Treatment Team (CRHT) Operational Policy. An interim policy was presented to the Operational Management Board in December 2020 and it was agreed the CRHT teams would work to this whilst the policy is further developed by the newly appointed Trust wide Urgent Care Pathway Lead.”

    Source location

    2020-0248-Responses-from-Sussex-Partnership-Foundation-NHS-Trust-and-Brighton-Hove-City-Council-Redacted..pdf
    Page 2 · response
    Published 29 December 2020

    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

    Run a daily Urgent Demand Oversight meeting to review admission demand, available resources and support packages for patients awaiting hospital care.

    Verbatim wording from the response

    “Locally, the Care Delivery Services [CDS] in Brighton has established an Urgent Demand Oversight meeting that enables the CDS Leads to have daily oversight of our patients requiring admission to hospital. This meeting is informed by the various Operational meetings that take place daily in our Community, Urgent and Acute Care Services and is described in the enclosed Terms of Reference (appendix 1).”

    Source location

    2020-0248-Responses-from-Sussex-Partnership-Foundation-NHS-Trust-and-Brighton-Hove-City-Council-Redacted..pdf
    Page 2 · response
    Published 29 December 2020

    Open published response

  10. North Yorkshire

    AI-generated summary

    ROBIN ANDREW JAMES MCEWAN · 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

    On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient exploration of family support to provide mental health scaffolding during delays in professional help

    Wider context from the report

    “Within the contexts of a) Primary Care and b) acknowledgement that referral access to specialist mental health services is considerably delayed and c) recourse to private therapy was sought in the meantime pending any referral and d) there are resources that can be shared in the ‘waiting’ period then: (1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety; (2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”; (3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis; (4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available ”

    Source location

    ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026