Recurring concern

Unsafe coordination and continuity during mental health service transfers

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First reported 17 Dec 2013•Latest report 6 May 2026

Definition

What this concern includes

Includes transfers between Trusts, areas or mental-health teams where planning, ownership, information exchange or continuity is deficient.

Not included

Ordinary clinical handover with no transfer of mental-health service responsibility
Discharge from mental-health care with no receiving service
Referral failures before a transfer is accepted

Reports: 26
Individual concerns: 33
Date range: 2013–2026
Stated actions: 39

Reports 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.

Department of Health and Social Care4

Greater Manchester Mental Health NHS Foundation Trust3

Lancashire & South Cumbria NHS Foundation Trust3

NHS England3

Herefordshire and Worcestershire Health and Care NHS Trust2

North East London NHS Foundation Trust2

Pennine Care NHS Foundation Trust2

Arts University Bournemouth1

Avon and Wiltshire Mental Health Partnership NHS Trust1

Betsi Cadwaladr University LHB1

Birmingham Women'S and Children'S NHS Foundation Trust1

Blackpool Teaching Hospitals NHS Foundation Trust1

Cheshire and Wirral Partnership NHS Foundation Trust1

Countess of Chester Hospital NHS Foundation Trust1

Coventry and Warwickshire 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.

6 May2026
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Lack of clear escalation procedures during complex case transfers
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sunny Elise EYMOND · 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

Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.

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 clear escalation procedures during complex case transfers
Wider context from the report
“4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for: a) Senior management oversight of the transfer b) Risk assessments at the time of transfer c) Clear escalation procedures if concerns are raised during the transfer and d) Training on any such national guidance ”
Source location
Sunny Elise EYMOND · Prevention of Future Deaths report
Page 5 · concerns
Open source report
14 Nov2025
Surrey
Concerns raised3
1. Lack of universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
2. Lack of safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
3. Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Draft and share the Personalised Care Framework with systems to support early adoption of safer mental-health care transitions.
  Stated by NHS EnglandStated completed
AI-generated summary

Suzanne Julia ELLERBY · 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

Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.

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 universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
Wider context from the report
“Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”
Source location
Suzanne Julia ELLERBY · 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 safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
Wider context from the report
“Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”
Source location
Suzanne Julia ELLERBY · 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 of secondary mental health services to ensure primary care follow-up has been undertaken after transfer
Wider context from the report
“Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”
Source location
Suzanne Julia ELLERBY · 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
Draft and share the Personalised Care Framework with systems to support early adoption of safer mental-health care transitions.

Verbatim wording from the response
“NHS England continues to support systems to improve care for people with mental health problems needing help from secondary mental health services. NHS England has drafted guidance called the Personalised Care Framework (PCF), that sets out the core aspects of care for people who require help from secondary or integrated primary health services, the Voluntary Community and Social Enterprise (VCSE) and secondary care mental health services. It has been shared as a draft with systems to facilitate early adoption.”

Source location
Response from NHS England
Page 1 · response
Published 18 November 2025
Open published response
31 Jan2025
Dorset
Concerns raised1
1. Failure among CMHT staff to recognise direct transfer of patient care between CMHT trusts without prior GP registration
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Maintain an agreed standard operating procedure for transferring patients between community mental health services, including patients without a registered GP.
  Stated by Devon Partnership NHS TrustStated completed
2. Action
  Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.
  Stated by Dorset Healthcare University NHS Foundation TrustStated in progress
3. Action
  Introduce Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.
  Stated by Dorset Healthcare University NHS Foundation TrustStated completed
1. Action
  Share specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.
  Stated by Dorset Healthcare University NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The existing standard operating procedure addresses transfers without a registered GP and provides for continuity and managed handover.
  Stated by Devon Partnership NHS TrustExisting arrangements considered sufficient
AI-generated summary

Alexander Channing · 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

Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.

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 among CMHT staff to recognise direct transfer of patient care between CMHT trusts without prior GP registration
Wider context from the report
“ii. There appears to be a failure amongst staff at the Exeter CMHT to appreciate that there can be a direct transfer of a patient’s care to another CMHT trust without the need for a patient to have to first register with a GP surgery ”
Source location
Alexander Channing · 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
Maintain an agreed standard operating procedure for transferring patients between community mental health services, including patients without a registered GP.

Verbatim wording from the response
“Patient transfers to out of area services remain a challenge for all NHS providers. We have an agreed standard operating procedure that articulates the process to collaboratively transition a person between community mental health services from Devon Partnership Trust to another Trust. At times the referring team may still experience local challenges in relation to an out of area transfer, as the policy relates to DPT’s processes only. Details on referring a person to another Trust where they do not yet have a GP can be found on page 6 point 6.6, this is the specific detail,”

Source location
Response from Devon Partnership NHS Trust
Page 1 · response
Published 31 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
Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.

Verbatim wording from the response
“Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.”

Source location
Response from Dorset Healthcare NHS
Page 1 · response
Published 31 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 Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.

Verbatim wording from the response
“Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.”

Source location
Response from Dorset Healthcare NHS
Page 2 · response
Published 31 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
Share specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.

Verbatim wording from the response
“Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.”

Source location
Response from Dorset Healthcare NHS
Page 2 · response
Published 31 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 existing standard operating procedure addresses transfers without a registered GP and provides for continuity and managed handover.

Verbatim wording from the response
“Patient transfers to out of area services remain a challenge for all NHS providers. We have an agreed standard operating procedure that articulates the process to collaboratively transition a person between community mental health services from Devon Partnership Trust to another Trust. At times the referring team may still experience local challenges in relation to an out of area transfer, as the policy relates to DPT’s processes only. Details on referring a person to another Trust where they do not yet have a GP can be found on page 6 point 6.6, this is the specific detail,”

Source location
Response from Devon Partnership NHS Trust
Page 1 · response
Published 31 January 2025
Open published response
14 Oct2024
Herefordshire
Concerns raised1
1. Failure to return patients to Neighbourhood Mental Health Team care and discontinue Mind worker involvement when requested
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Co-produce and ratify a Standard Operating Procedure defining the Community Mental Health Link Worker role and safe support arrangements.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progress
2. Action
  Provide Link Workers with established access to Neighbourhood Mental Health duty staff, team managers, clinical leads and weekly multidisciplinary meetings for care and risk concerns.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completed
AI-generated summary

Caroline Ann STAITE · 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 Ann STAITE was recovered from the River Wye near the Canary Bridge, Hereford, after being reported in the river on 8 March 2024, and was pronounced deceased at 0241 hours on 9 March 2024. The concerns related to the robustness of procedures for considering patients for Mind, and to transparent arrangements for returning patients from Mind to the care of the Neighbourhood Mental Health Team.

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 patients to Neighbourhood Mental Health Team care and discontinue Mind worker involvement when requested
Wider context from the report
“(3) If so requested by the Mind worker the patient should be returned to the care of the Neighbourhood Mental Health Team and the involvement of the Mind worker discontinued. ”
Source location
Caroline Ann STAITE · 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
Co-produce and ratify a Standard Operating Procedure defining the Community Mental Health Link Worker role and safe support arrangements.

Verbatim wording from the response
“Action: Since this time our Community Service Manager, Diane Topham, who oversees our Neighbourhood Mental Health Team has worked closely with the Herefordshire MIND service to co-produce a Standard Operating Procedure (SOP) for the community Mental Health Link Worker Service in Herefordshire.”

Source location
2024-0548 - Response from Herefordshire & Worcestershire NHS
Page 1 · response
Published 14 October 2024
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
Provide Link Workers with established access to Neighbourhood Mental Health duty staff, team managers, clinical leads and weekly multidisciplinary meetings for care and risk concerns.

Verbatim wording from the response
“Action: The MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’ (registered professional) or Team Manager/ Clinical Lead, where they can identify any areas of concern with care and treatment plans.”

Source location
2024-0548 - Response from Herefordshire & Worcestershire NHS
Page 2 · response
Published 14 October 2024
Open published response
1 Aug2024
West Sussex, Brighton and Hove
Concerns raised1
1. Failure to transfer and communicate mental health treatment requirements to receiving Trusts
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Lee Spencer PURKIS · 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

Lee Purkis, aged 54, was found in an advanced state of decomposition on the floor of his home on 9 March 2023, having been there for up to two months; the cause of death was unascertainable. Before his death, he was subject to a mental health treatment requirement, but the receiving Trust was not informed of it and discharged him without learning about it. The report identifies a risk that failures to transfer or oversee such requirements could affect their proper administration in other cases.

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 transfer and communicate mental health treatment requirements to receiving Trusts
Wider context from the report
“My concern here is that Lee Purkis had been, in the period leading up to his death, the subject of a mental health treatment requirement (MHTR) imposed by the Crown Court as part of a community order, but the Trust that ended up treating him were not aware of it, and discharged him from its care without learning about it. There is no evidence that it made any difference in this case but that is because of the particular (and unfortunate) circumstances of how long it took to find Mr Purkis and the corresponding absence of evidence about how he died. There is, however, a real risk that it might make a difference in another case. This order was handed down by a sympathetic Crown Court judge, supported by probation in the pre-sentence report, and it seems to have been a potentially creative solution for a complex man. The use of MHTRs is, it seems to me on the evidence, to be encouraged, but that objective will be undermined if they are not understood and administered properly and so people don’t see them working. In Mr Purkis’s case, the particular problem appears to have occurred because the Trust that agreed the order (a requirement of it being imposed in the first place) then transferred the care because the accommodation area changed. That is not unusual, but the relevant Trust then failed to transfer or inform the receiving Trust of the fact of the MHTR and what it required. This means that it was, of course, a Trust error, but I am sending this report to probation because the evidence suggests that it is probation that should have oversight, and it should be ensuring all involved in the administration of the requirement are aware of it. I therefore consider there is a risk associated with these circumstances, and that action should be taken, such as ensuring that probation officers keep an eye on MHTRs when they have them, and ensure the other services do so too. There are not many of them; there probably should be more; but again, that means ensuring the ones that there are get used properly. ”
Source location
Lee Spencer PURKIS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
2 Feb2024
North Wales (East and Central)
Concerns raised1
1. Failure to share relevant clinical information between the Health Board and out-of-area psychiatric facilities
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
  Stated by Betsi Cadwaladr University LHBStated planned
2. Action
  Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
  Stated by Betsi Cadwaladr University LHBStated planned
Respondent positions 3
1. Position
  The concern that Elysium failed to share discharge information is factually incorrect; Betsi was informed by telephone and emailed relevant records.
  Stated by Elysium Healthcare LimitedDisputes the concern
1. Position
  The described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.
  Stated by Elysium Healthcare LimitedDisputes the concern
2. Position
  The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.
  Stated by Elysium Healthcare LimitedExisting arrangements considered sufficient
AI-generated summary

Philip David 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

Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.

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 share relevant clinical information between the Health Board and out-of-area psychiatric facilities
Wider context from the report
“a. The Health Board utilises facilities out of area for acute psychiatric care when there are no available beds in the NHS in North Wales. I was informed that the patients, however, remain the responsibility of the Health Board. During the deceased’s time at Ty Grosvenor it does not appear that any/all relevant information was shared between the two organisations e.g. deceased’s progress, medication, treatment etc, except for few telephone conversations. ”
Source location
Philip David Taylor · 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
Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.

Verbatim wording from the response
“The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 12 February 2024
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
Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.

Verbatim wording from the response
“A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 12 February 2024
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 concern that Elysium failed to share discharge information is factually incorrect; Betsi was informed by telephone and emailed relevant records.

Verbatim wording from the response
“Not sharing information except a few telephone calls That is not a fair reflection of the factual position. The reality is:-”

Source location
Response from Elysium Healthcare
Page 2 · response
Published 12 February 2024
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 described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.

Verbatim wording from the response
“5. This is, therefore, as far as Elysium is concerned, not a case where the facts suggest a risk of future deaths in relation to the role of Elysium. Mr Taylor was an informal patient and was assessed as low risk. His details were already well known to Betsi who had summarised his position when referring him to Elysium in the first place. They had been informed by”

Source location
Response from Elysium Healthcare
Page 2 · response
Published 12 February 2024
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 framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.

Verbatim wording from the response
“The Elysium internal policy is to ensure the relevant information is given to home teams so that they can follow up within 72 hours (as was done here). In case it is of assistance to put the issue in context, the contract we have with Surrey requires that information only within 5 days of discharge.”

Source location
Response from Elysium Healthcare
Page 3 · response
Published 12 February 2024
Open published response
26 May2023
East London
Concerns raised1
1. Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Update and ratify the CADAT discharge policy to require liaison, joint risk planning, and communication with skin clinics about aesthetic treatment.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
2. Action
  Develop a joint working protocol between CADAT and NELFT step-down services covering risk information sharing, joint risk management and discharge planning.
  Stated by North East London NHS Foundation TrustStated planned
3. Action
  Share the joint working protocol with staff and discuss it in team business meetings.
  Stated by North East London NHS Foundation TrustStated planned
1. Action
  Deliver a learning event on completing and updating risk assessments, including relevant assessment parameters.
  Stated by North East London NHS Foundation TrustStated planned
2. Action
  Undertake a quality improvement project to identify and address structural, process and cultural gaps in risk assessment and risk management.
  Stated by North East London NHS Foundation TrustStated planned
3. Action
  Develop risk formulation to support robust risk assessment and risk management processes and improve patient safety.
  Stated by North East London NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  SLAM and NELFT are responsible for addressing liaison, communication, information sharing and staff training concerning Conrad’s care.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Conrad Richard James Colson · 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

Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.

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 share risk information and coordinate risk management planning between specialist and stepdown services at discharge
Wider context from the report
“1. A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT. There was a lack of full information sharing around risk and risk assessment/risk management planning on discharge. ”
Source location
Conrad Richard James Colson · 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
Update and ratify the CADAT discharge policy to require liaison, joint risk planning, and communication with skin clinics about aesthetic treatment.

Verbatim wording from the response
“The Centre for Anxiety Disorders and Trauma (‘CADAT’) has updated its discharge policy (enclosed with this letter), to explicitly state the expectations of liaison between local teams and CADAT. The updates to this policy confront the issues faced in Conrad’s case. The updated policy was circulated to all team members at CADAT and was discussed in the clinic’s team meeting on 1 June 2023. This”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 1 · response
Published 2 June 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
Develop a joint working protocol between CADAT and NELFT step-down services covering risk information sharing, joint risk management and discharge planning.

Verbatim wording from the response
“1) Improve working relationship between the highly specialised services of the CADAT team and the stepdown services provided by NELFT. This should include the need for full information sharing around risk and joint risk/management planning and discharge.”

Source location
Response from NELFT
Page 2 · response
Published 2 June 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
Share the joint working protocol with staff and discuss it in team business meetings.

Verbatim wording from the response
“• Joint working protocol to be developed between the CADAT team and the stepdown services provided by NELFT. This should highlight the need for full information sharing around risk and joint risk/management planning and discharge.”

Source location
Response from NELFT
Page 2 · response
Published 2 June 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
Deliver a learning event on completing and updating risk assessments, including relevant assessment parameters.

Verbatim wording from the response
“• Learning event on completing risk assessments arranged for 05/07/2023. This learning event will cover updating risk, the parameters to consider when completing a risk assessment and when to update a risk assessment.”

Source location
Response from NELFT
Page 3 · response
Published 2 June 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
Undertake a quality improvement project to identify and address structural, process and cultural gaps in risk assessment and risk management.

Verbatim wording from the response
“• The Trust is planning to undertake a Quality Improvement Project on understanding why there are gaps in risk assessment and risk management processes (a couple of examples of reoccurring themes), particularly when there are poor outcomes associated with care provided. The project will focus on working with users of service, clinical and operational teams, as well as senior leadership and other identified key stakeholders to understand the structural, process and cultural factors which contribute to poor outcomes and use improvement methodology and frameworks to address the areas which can result in process changes to improve outcomes. It may be that a break through series collaborative methodology could be used across various teams at NELFT.”

Source location
Response from NELFT
Page 3 · response
Published 2 June 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
Develop risk formulation to support robust risk assessment and risk management processes and improve patient safety.

Verbatim wording from the response
“This approach could potentially standardise variation through testing a change package which includes evidence based approaches to ensure care provision meets those standards and teams have a realistic chance of providing the care that is required to avoid future untoward outcomes. There is also a workstream which is leading on the development of risk formulation to ensure the implementation of robust risk assessment and risk management process to improve patient safety and move away from the current risk stratification model.”

Source location
Response from NELFT
Page 3 · response
Published 2 June 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
SLAM and NELFT are responsible for addressing liaison, communication, information sharing and staff training concerning Conrad’s care.

Verbatim wording from the response
“In terms of the matters of concern specific to Conrad, NHS England are unable to comment on the absence of liaison between the Centre for Anxiety Disorders and Trauma (CADAT) team at SLAM and the stepdown services provided by North East London NHS Foundation Trust (NELFT), nor the adequacy of communication, information sharing between the two Trusts or the training of staff employed by NELFT, who are the appropriate organisations to respond to your concerns. NHS England has however been sighted on NELFT’s Serious Incident Report into the matters surrounding Conrad’s death and note that there have been learnings and recommendations made, including improvements to information sharing. We have also asked to be sighted on the response to you Report from both NELFT and SLAM and will consider these carefully.”

Source location
Response from NHS England
Page 3 · response
Published 2 June 2023
Open published response
6 Mar2023
East London
Concerns raised1
1. Failure to establish a jointly agreed risk management plan during transition between mental health teams
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Evelina Vilkiene · 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

Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.

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 establish a jointly agreed risk management plan during transition between mental health teams
Wider context from the report
“1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan. ”
Source location
Evelina Vilkiene · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Jun2022
Blackpool and the Fylde
Concerns raised1
1. Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Review the format of the overview document to improve how risk information is presented.
  Stated by Lancashire County CouncilStated in progress
2. Action
  Meet and continue working with the relevant NHS Trusts to improve discharge information and systems.
  Stated by Lancashire County CouncilStated in progress
3. Action
  Attend a cross-organisational meeting to consider alignment of communication and information-sharing expectations with LSCFT.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
1. Action
  Hold a further meeting with LSCFT and LCC to consider continuity and safety of communication and information sharing.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
2. Action
  Collaborate with LSCFT and LCC to examine the transfer policy and its interface with acute trusts and local authorities.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
3. Action
  Cascade respective organisational expectations to matrons, ward managers and consultant groups, including requirements for communicating suicide-risk information.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
Respondent positions 4
1. Position
  Existing assessment, risk management, information sharing and placement arrangements were considered adequate, requiring no specific corrective action.
  Stated by Lancashire County CouncilExisting arrangements considered sufficient
1. Position
  System or process changes for identifying suicide risk should originate with LSCFT and be cascaded to acute trusts and local authorities.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustRedirects responsibility
2. Position
  BTHFT proposes no change to its internal processes because existing inter-hospital transfer practice requires sharing key medical and mental health information.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficient
3. Position
  Local authorities and the Clinical Commissioning Group have primary responsibility for Mental Health Act section 117 aftercare arrangements.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustRedirects responsibility
AI-generated summary

Margaret Florence Joyce Stringer · 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

Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between 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 maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers
Wider context from the report
“3) (Addressed to Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited (the latter referred to collectively as ‘Nightingales’)) The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs Stringer’s risk of suicide. They included the following: i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review; ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge to Nightingales and for the family to have been invited, to ensure that everyone was aware of the plan, that the family was aware of Mrs Stringer’s legal status and to discuss next steps in terms of liaison with other services; iii. There should have been greater professional curiosity and better communication at the time of transfer; iv. The Harbour mental health hospital’s RNNA should have been reviewed to determine whether it needed to be updated and it should have been updated if there was any different clinical information. Further self harm or suicidal ideation, if seen to be significant, should have given rise to a further RNNA; v. There had, in fact, been further indications of self harm and suicidal ideation and, in any event, of a wish to die, on 30th June 2020, in August 2020 and on 3rd September 2020 which were significant and should have been addressed in the information provided to Nightingales and had not been; vi. Mrs Stringer was discharged from The Harbour mental health hospital without an up-to-date Care Act Assessment and, in any event, taking into account the need for Mrs Stringer to be transferred to the acute hospital (which had been necessary), an up-to-date Care Act Assessment had not been completed during the period of her admission to the latter hospital; vii. The risk assessment should have been completed and provided to Nightingales; viii. A positive behaviour support plan should have been completed and provided to Nightingales; ix. A care plan, compliant with CPA Policy and Procedures Key Standard 10, which should have identified a suitable environment in which to manage Mrs Stringer’s risk, her needs and mental health and crisis and contingency planning, to cater for the event of a significant relapse in her mental health, should have been completed and provided to Nightingales; x. Risk behaviour should have been identified to Nightingales and context given, whereas that had not been the case in respect of certain behaviour, including the incident on 30th June 2020; xi. The care coordinator should have been better informed at the points of transfer and discharge; xii. There should have been more robust follow up by the care coordinator whilst Mrs Stringer was at the acute hospital; xiii. There had been no mental health service involvement between the 7-day follow up and 28th September 2020 or, if there had, it had not been recorded; xiv. During the COVID-19 pandemic, it was not possible for a manager to carry out a face-to-face assessment in the mental health hospital but no equivalent measure had been implemented; xv) Whereas it would have been helpful for Nightingales to have received the Continuing Healthcare Checklist, it had not been provided; xvi) Nightingales would have wished to see the risk of suicide referred to in the “Risks to the Service User” section of the FACE Overview Assessment; xvii) The court appointed expert had concerns about the accessibility of key information in the FACE Overview Assessment given the format of that document. Whereas the court heard evidence concerning subsequent, significant, purposeful, developments in practice, the matters listed above can be condensed into a single concern that there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned. ”
Source location
Margaret Florence Joyce Stringer · 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
Review the format of the overview document to improve how risk information is presented.

Verbatim wording from the response
“xvii - the format of this document will be reviewed, but it has a clear heading “risk” with a subdivision re self-harm/injury described as “serious apparent risk” and details of risk setting out mental health deterioration and attempts to kill herself (A1253). The review is taking place in line with the adoption of a strength based approach framework which has started and is planned to be rolled out across all Adult Social Care teams within the next 18 months. The Local Authority would question the proportionality of using Reg 28 in respect of a detail such as the format of a particular document.”

Source location
Response from Adult Community Social Care
Page 3 · response
Published 21 September 2022
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
Meet and continue working with the relevant NHS Trusts to improve discharge information and systems.

Verbatim wording from the response
“Hospitals NHS Foundation Trust in ensuring that their provision of information and systems at discharge are as effective as possible, LCC have agreed to meet with and will continue to work with the Trusts in the future.”

Source location
Response from Adult Community Social Care
Page 4 · response
Published 21 September 2022
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
Attend a cross-organisational meeting to consider alignment of communication and information-sharing expectations with LSCFT.

Verbatim wording from the response
“I, as BTHFT’s Executive Medical Director, together with the Clinical Lead for Discharge Services and Interim Head of Legal Services, have attended a meeting with LSCFT, to consider whether expectations are aligned for the continuity and safety of communication and information sharing between our organisations. A further meeting is proposed in September, to include LCC.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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
Hold a further meeting with LSCFT and LCC to consider continuity and safety of communication and information sharing.

Verbatim wording from the response
“I, as BTHFT’s Executive Medical Director, together with the Clinical Lead for Discharge Services and Interim Head of Legal Services, have attended a meeting with LSCFT, to consider whether expectations are aligned for the continuity and safety of communication and information sharing between our organisations. A further meeting is proposed in September, to include LCC.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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
Collaborate with LSCFT and LCC to examine the transfer policy and its interface with acute trusts and local authorities.

Verbatim wording from the response
“BTHFT has also been provided with a copy of a policy prepared by LSCFT; the Admission, Discharge and Transfer of Care Policy and Procedure, which provides LSCFT clinical staff with guidance on the admission, discharge, transfer and hand over of patients between wards, teams and services whether they are within LSCFT or other service/private providers.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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
Cascade respective organisational expectations to matrons, ward managers and consultant groups, including requirements for communicating suicide-risk information.

Verbatim wording from the response
“BTHFT will collaborate with LSCFT and LCC to examine this LSCFT policy, and the interface with Acute Trusts and Local Authorities. We will cascade to the Matron, ward manager and consultant groups, what is expected of the respective organisations; to ensure that all relevant information, including suicide risk, is known, managed and communicated.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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 assessment, risk management, information sharing and placement arrangements were considered adequate, requiring no specific corrective action.

Verbatim wording from the response
“vi - an Assessment was available at discharge and this was provided to Nightingale prior to them accepting Mrs Stringer. The social worker was not able to see Mrs Stringer in BVH due to Covid restrictions. The placement at Nightingale was “for assessment” (A1264);”

Source location
Response from Adult Community Social Care
Page 2 · response
Published 21 September 2022
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
System or process changes for identifying suicide risk should originate with LSCFT and be cascaded to acute trusts and local authorities.

Verbatim wording from the response
“BTHFT is one of many acute hospitals across this region which will interface with LSCFT for inter-hospital referrals and transfers. Similarly, it will interface with a number of local authorities who are making s.117 arrangements for patients previously admitted to LSCFT. LSCFT also provides a Mental Health Liaison Team service for BTHFT patients. The Trust respectfully submits that any system or process change for the sufficient identification of suicide risk should originate in LSCFT for their patients, to be cascaded and embedded with Acute Trusts and Local Authorities in the region.”

Source location
Response from Blackpool Teaching Hospitals
Page 1 · response
Published 21 September 2022
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
BTHFT proposes no change to its internal processes because existing inter-hospital transfer practice requires sharing key medical and mental health information.

Verbatim wording from the response
“In relation to BTHFT’s internal process and protocol for the management of patients admitted from a mental health facility, and/or in relation to the Trust’s contribution to the Mental Health Act (MHA) s.117 aftercare arrangements (which are the primary responsibility of the local authority and Clinical Commissioning Group, there is nothing BTH would propose to change at this point. The expectation and standard practice is that in inter-hospital transfers, the transferring hospital should always provide the receiving hospital with key medical and mental health information, together with contact details for the referring clinician, for ongoing communication. The provided mental health information can then be included in the Registered Nursing Needs Assessment, in addition to the medical aspects, to feed into the MHA s.117 aftercare arrangements.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
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
Local authorities and the Clinical Commissioning Group have primary responsibility for Mental Health Act section 117 aftercare arrangements.

Verbatim wording from the response
“In relation to BTHFT’s internal process and protocol for the management of patients admitted from a mental health facility, and/or in relation to the Trust’s contribution to the Mental Health Act (MHA) s.117 aftercare arrangements (which are the primary responsibility of the local authority and Clinical Commissioning Group, there is nothing BTH would propose to change at this point. The expectation and standard practice is that in inter-hospital transfers, the transferring hospital should always provide the receiving hospital with key medical and mental health information, together with contact details for the referring clinician, for ongoing communication. The provided mental health information can then be included in the Registered Nursing Needs Assessment, in addition to the medical aspects, to feed into the MHA s.117 aftercare arrangements.”

Source location
Response from Blackpool Teaching Hospitals
Page 2 · response
Published 21 September 2022
Open published response
15 Oct2021
Manchester City
Concerns raised1
1. Inadequate transfer, communication and follow-up from HBTT to CMHT
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Hold daily CMHT multidisciplinary zoning meetings with HBTT participation twice weekly to review crisis support and transfers of care.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Introduce an HBTT discharge coordinator to quality-check discharge plans before service users leave HBTT.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
3. Action
  Use an HBTT discharge checklist, including joint CMHT visits, to support transfers into CMHT.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
1. Action
  Conduct quarterly audits of HBTT discharges to check policy-compliant step-downs and adequate support.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
AI-generated summary

Darren John Lawrence · 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

Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.

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
Inadequate transfer, communication and follow-up from HBTT to CMHT
Wider context from the report
“a.The transfer and communication process from the HBTT to the CMHT in 2019 and 2020 was unsatisfactory with inadequate follow up as required. The court has received evidence about similar problems in other inquests in which GMMH was the treating NHS Trust and is a repeated issue of concern. ”
Source location
Darren John Lawrence · Prevention of Future Deaths report
Page 4 · 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
Hold daily CMHT multidisciplinary zoning meetings with HBTT participation twice weekly to review crisis support and transfers of care.

Verbatim wording from the response
“The Trust has implemented daily multi-disciplinary zoning meetings in CMHT to review individuals who may be in crisis and require additional support. These daily meetings are now attended by staff from HBTT twice per week allowing for better communication between the teams and the ability for both teams to communicate with each other in respect of”

Source location
2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 1 · response
Published 21 October 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
Introduce an HBTT discharge coordinator to quality-check discharge plans before service users leave HBTT.

Verbatim wording from the response
“HBTT has introduced a discharge coordinator who is a Senior Practitioner in the team who as part of their role quality checks all discharge plans before an individual is discharged from HBTT.”

Source location
2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 2 · response
Published 21 October 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
Use an HBTT discharge checklist, including joint CMHT visits, to support transfers into CMHT.

Verbatim wording from the response
“HBTT have also introduced a discharge checklist that includes joint visits with CMHT staff when discharging to CMHT which has had an audit undertaken to ensure this is embedded. Going forward the HBTT Team Manager will carry out a quarterly audit of discharges from HBTT to ensure that individuals are being stepped down from HBTT to CMHT in line with both services operational policies and receiving the support they require. The first one of these will be completed by 31st March 2022.”

Source location
2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 2 · response
Published 21 October 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 quarterly audits of HBTT discharges to check policy-compliant step-downs and adequate support.

Verbatim wording from the response
“HBTT have also introduced a discharge checklist that includes joint visits with CMHT staff when discharging to CMHT which has had an audit undertaken to ensure this is embedded. Going forward the HBTT Team Manager will carry out a quarterly audit of discharges from HBTT to ensure that individuals are being stepped down from HBTT to CMHT in line with both services operational policies and receiving the support they require. The first one of these will be completed by 31st March 2022.”

Source location
2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 2 · response
Published 21 October 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of clear escalation procedures during complex case transfers

Concerns raised3

Lack of universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services

Lack of safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services

Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure among CMHT staff to recognise direct transfer of patient care between CMHT trusts without prior GP registration

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to return patients to Neighbourhood Mental Health Team care and discontinue Mind worker involvement when requested

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to transfer and communicate mental health treatment requirements to receiving Trusts

Concerns raised1

Failure to share relevant clinical information between the Health Board and out-of-area psychiatric facilities

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Actions described in response 4

Respondent positions 1

Actions described in response 2

Actions described in response 2

Respondent positions 3

Actions described in response 6

Respondent positions 1