Recurring concern

Unreliable tracking and transfer of completed mental health-related forms

First to latest report 16 Apr 2015 — 6 Jul 2021

Reports that mention this concern: 3
Times this concern has been raised: 3
Stated actions linked to this concern: 1

What this concern includes

Includes failures of the dedicated process for tracking, transferring, receiving or confirming the disposition of completed mental health-related forms, including mental health proformas and completed Appropriate Adult forms where they support mental-health or custody-related care and safeguarding.

What is not included

Excludes generic clinical record-keeping or information-sharing deficiencies not specifically concerning the tracking or transfer of completed mental health-related forms.
Excludes failures to complete, assess or act on the substantive clinical content of a form when the form's tracking or transfer is not deficient.
Excludes unrelated referral, appointment, investigation or administrative forms without a supported mental-health or custody-related form-control connection.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Care UK1

Crown Prosecution Service1

Department of Health and Social Care1

Durham Prison1

G4S Forensic & Medical Services (UK) Ltd1

GeoAmey PECS Limited1

Greater Manchester Combined Authority1

Greater Manchester Police1

HM Prison and Probation Service1

Home Office1

Lancashire County Council1

Lincolnshire Police1

Medacs Healthcare Limited1

Ministry of Housing, Communities and Local Government1

National Police Chiefs’ Council1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

6 Jul2021
Lincolnshire
Concerns raised1
1. Failure to track the disposition of completed mental health proformas
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Lincolnshire Police
Respondent positions 1
1. Lincolnshire Police
  Officers need not understand the mental-health proforma data workflow because it does not affect care; existing training and administrator checks suffice.
  Existing arrangements considered sufficient
AI-generated summary

Levi Craig Don Pettit · 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

Levi Craig Don Pettit was reported to police as having suicidal ideations on 8 December 2019. Four days later, he died by suicide; concerns included the handling of the police response, including the failure to complete or make required referrals and uncertainty about relevant policy and training.

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 track the disposition of completed mental health proformas
Wider context from the report
“(III) DS ████████ when asked did not know what happened to the mental health proforma when completed ”
Source location
Levi Craig Don Pettit · 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
Officers need not understand the mental-health proforma data workflow because it does not affect care; existing training and administrator checks suffice.

Verbatim wording from the response
“I would not expect DS ████████ to know what happens to the mental health proforma once completed. Officers are trained (see below) to understand that the mental health proforma provides a statistical return that is used by the Home Office and other stakeholders to understand the local data for mental health policing. It is not a referral mechanism. We do have an administrator who checks against our incidents to ensure that mental health proforma have been completed when required. Understanding the mechanics of the workflow of this statistical submission would not contribute to officers’ work “on the ground”.”

Source location
2021-0231-Response-from-Lincolnshire-Police_Published
Page 2 · response
Published 9 July 2021
Open published response
15 Dec2015
County Durham and Darlington
Concerns raised1
1. Lack of a detailed, documented and tracked account of SASH form transmission
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Care UK Limited
GeoAmey PECS Limited
HM Prison and Probation Service
Stated actions 1
1. HM Prison and Probation Service
  Require reception staff to physically check, read, cross-reference and jointly sign prisoner documentation before escort departure, with daily staffing records and routine observation.
Respondent positions 3
1. Care UK Limited
  Unable to address individual staff and local HMP Durham issues because it no longer provides healthcare there.
  Unable to act
1. GeoAmey PECS Limited
  The contractor has no remit over HMP Durham staff compliance with Prison Service Instructions.
  Outside remit
2. GeoAmey PECS Limited
  The Ministry of Justice has final responsibility for policy, procedures and documentation.
  Redirects responsibility
AI-generated summary

Derek Thomas · 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

Derek Thomas died by suicide while in HMP Durham after arriving on remand and undergoing reception and first-night induction. Information suggesting suicidal intent was not adequately communicated or identified because of failures involving the SASH and PER forms across escort, prison reception and healthcare staff. The report raised concerns about procedures failing under demanding but foreseeable conditions, unclear inter-agency responsibilities, inadequate tracking of information, and poor interoperability between agencies.

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 detailed, documented and tracked account of SASH form transmission
Wider context from the report
“(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed. ”
Source location
Derek Thomas · 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
Require reception staff to physically check, read, cross-reference and jointly sign prisoner documentation before escort departure, with daily staffing records and routine observation.

Verbatim wording from the response
“Reception – The Head of Operations at HMP Durham has instructed all staff working in reception that, prior to the escort contractor leaving the reception area, all documentation must be physically checked and read. The PER and all documentation must be cross referenced. It will be signed for by both staff. A daily detail is published which clearly identifies the members of staff who are working in reception on any given day and these are retained. The escort contractor has been informed of the process and is aware that the warrant and the SASH need to be handed to the supervising officer and the PER and property to the officer. All staff working in reception are expected to be competent in all areas of the process, both are situated side by side. A custodial manager and the Head of Operations will routinely observe this process.”

Source location
2015-0502-Response-by-NOMS
Page 2 · response
Published 15 December 2015
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
Unable to address individual staff and local HMP Durham issues because it no longer provides healthcare there.

Verbatim wording from the response
“As you are aware Care UK Clinical Services Limited (“Care UK”) ceased to be the providers of primary healthcare services at HMP Durham and for the North East cluster of prisons on 31st March 2015 and as of 1st April the providers appointed was G4S Medical Services who I note are also copied into your letter.”

Source location
2015-0502-Response-by-Care-UK
Page 1 · response
Published 15 December 2015
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 contractor has no remit over HMP Durham staff compliance with Prison Service Instructions.

Verbatim wording from the response
“The PER and any other available documentation including the SASH Form must be examined and prisoner interviewed in prison reception to assess the risk of self-harm or harm to others as part of the Cell Sharing Risk Assessment (paragraph 2.18). The information is recorded and shared with other departments and agencies (e.g. Healthcare) internally and externally and actions are to be documented (paragraphs 2.19 and 2.20). We have no remit over HMP Durham staff (who are MOJ employees) and their compliance with the PSIs.”

Source location
2015-0502-Response-by-GEOAMEY
Page 2 · response
Published 15 December 2015
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 Ministry of Justice has final responsibility for policy, procedures and documentation.

Verbatim wording from the response
“The final say on policy, procedures and documentation is with the MOJ to whom we are contracted.”

Source location
2015-0502-Response-by-GEOAMEY
Page 3 · response
Published 15 December 2015
Open published response
16 Apr2015
Manchester South
Concerns raised1
1. Failure to return completed Appropriate Adult forms to Social Services
This report raised 27 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.
AI-generated summary

Kesia Lena Mary Leatherbarrow · 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

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

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 return completed Appropriate Adult forms to Social Services
Wider context from the report
“Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases. ”
Source location
Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Page 7 · concerns
Open source report