Recurring concern

Unreliable supervisory review of mental-health clinical decisions

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First reported 25 Jan 2023•Latest report 14 Mar 2023

Definition

What this concern includes

Includes failures in dedicated mental-health supervision arrangements to review, challenge, discuss or provide feedback on consequential clinical decisions, including crisis-team decisions and SPA contacts involving mental-health symptoms or suicidality.

Not included

  • Excludes generic clinical supervision or staff-feedback failures without a mental-health clinical decision or assessment context.
  • Excludes failures in mental-health assessment, treatment, referral or crisis response where supervisory review of the decision is not the deficient control.
  • Excludes organisational learning, incident investigation or safety-culture deficiencies that do not directly concern supervisory review or feedback on a mental-health clinical decision.
  • Excludes failures occurring after an appropriately supervised decision when the remaining issue is implementation or clinical disagreement.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2023–2023

First to latest report issue date

Stated actions
1

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.

Central and North West London NHS Foundation Trust1
East London NHS Foundation 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. Inner West London

    AI-generated summary

    Nicola Norman · 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

    Nicola Norman died on 20 January 2020, aged 42, after being found dead hanging at her mother’s address. Before her death, she contacted the Single Point of Access while highly anxious, reported feeling a burden and later reported an overdose and cutting her wrists. The principal concerns were that these contacts were not routinely discussed with a supervising clinician, passed to a suitably qualified clinician for assessment, or notified to her GP and mental health services.

    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 routinely discuss SPA contacts with a supervising clinician when mental health symptoms or suicidality are raised

    Wider context from the report

    “1. That SPA contacts are not routinely discussed with a supervising clinician, ss should have but did not happen in Ms Norman’s case, where mental health symptoms and especially where suicidality is raised by the caller. ”

    Source location

    Nicola Norman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Andrew Mark Largin · Prevention of Future Deaths report

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

    Report summary

    Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.

    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 of ELFT managers to discuss crisis-team decision making with the decision maker

    Wider context from the report

    “7. Thus, nobody from ELFT found out what the decision maker’s thinking had been, or what misconceptions she might have had that other staff members might share. The former crisis team member who made the decision still works for ELFT. As far as I could ascertain, her decision making concerning Mr Largin has never been discussed with her by ELFT managers. ”

    Source location

    Andrew Mark Largin · 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

    Amend the Serious Incident reviewer responsibilities document to require relevant staff to be contacted through Human Resources for review involvement.

    Verbatim wording from the response

    “I was troubled that the Trust’s SI review did not highlight that the relevant crisis team member did not record their rationale explaining why Mr Largin should remain with WWNT. I asked the Trust’s Associate Director of Governance and Risk to explore this further.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 30 January 2023

    Open published response
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Data last updated 7 September 2026