11 Jan 2026 Mark Stuart VIDLER · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure to include the receiving MHT+ team in HTT discharge decisions View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mark Stuart VIDLER · Prevention of Future Deaths report
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Report summary
Mark Vidler had severe depression and was receiving mental health care from Kent and Medway Mental Health NHS Trust. After serious suicide attempts on 30 April and 7 May 2025, he was discharged from the Home Treatment Team and was not reviewed by an out-of-hours clinician on the night of 7 May after a Rapid Response Team referral was declined. He was found dead at home on 8 May 2025, and the inquest concluded that his suicide was contributed to by a failure in care. Concerns included shortcomings in patient-centred care, clinical oversight and referral processes, risk recognition, discharge decision-making, continuity of care, care coordination, and the implementation and recording of suicidality management.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to include the receiving MHT+ team in HTT discharge decisions
Wider context from the report “(5) Both the nurse from MHT+ and the consultant psychiatrist gave evidence that the MHT+ were not included, as the receiving team, in the MDT decision on 6 May 2025. They considered that this could have been useful and is something that can and has happened in the past. I was told that this left Mark 'in limbo' following the his discharge from HTT and I was told that this is something that has not changed since .
” Source location Mark Stuart VIDLER · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold twice-weekly clinical interface meetings with local MHT and MHT+ teams to discuss specific cases and support timely community treatment planning.
Verbatim wording from the response “Following this Inquest outcome, the Home Treatment Team service have implemented a twice weekly clinical MDT interface meeting with local MHT and MHT+ teams to enable and ensure timely discussion of specific cases. Feedback from the clinical teams has been positive as these forums are the opportunity to discuss patients of concern where risk continues to be identified.” Source location Response from Kent and Medway NHS Mental Health Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide senior Rapid Response clinical input to interface forums for clinically considered decisions and agreed safe discharge plans.
Verbatim wording from the response “The Rapid Response Team will have senior clinical input into these interface forums where decisions impacting on patient care can be discussed and decisions made clinically to ensure the person has an agreed discharge plan that promotes clinical safety and is based on senior clinical consideration. The revised Standard Operating Procedure will detail that MHT+ colleagues including medics must be invited to these forums to assist with community treatment planning and will be audited 3 monthly to ensure quality, patient safety and positive patient outcomes agreed across the interface of services.” Source location Response from Kent and Medway NHS Mental Health Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise procedures to require invitations to MHT+ colleagues, including medics, and audit forum participation quarterly for quality and patient safety.
Verbatim wording from the response “The Rapid Response Team will have senior clinical input into these interface forums where decisions impacting on patient care can be discussed and decisions made clinically to ensure the person has an agreed discharge plan that promotes clinical safety and is based on senior clinical consideration. The revised Standard Operating Procedure will detail that MHT+ colleagues including medics must be invited to these forums to assist with community treatment planning and will be audited 3 monthly to ensure quality, patient safety and positive patient outcomes agreed across the interface of services.” Source location Response from Kent and Medway NHS Mental Health Trust
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25 Jul 2024 Danny Jay Anderson · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of adequate risk formulation before discharge View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
The Trust
Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
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The Trust
Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
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The Trust
Provide clinical risk-assessment training and apply the clinical risk policy.
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The Trust
Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
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The Trust
Review inpatient and community care plans and risk assessments during staff one-to-one supervision.
View source
The Trust
Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
View source
The Trust
Review care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
View source
The Trust
Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
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Danny Jay Anderson · 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
Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of adequate risk formulation before discharge
Wider context from the report “There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s discharge from the community mental health team in January 2023.
The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was copied and pasted multiple times throughout the risk assessment template on the 14 December 2022. There was no analysis or formulation of risk for Danny.
From review of the records throughout the admission, I am concerned that there was an over-reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, psychiatric history, history of abuse, social situation – and evidence that this information was used to form a judgement about the likelihood or probability of an adverse or harmful outcome (in accordance with the Trust’s risk policy).
There was no evidence of any consideration of Danny’s historical factors and experiences, more recent problems and existing strengths and resources (in accordance with the NICE guidelines 2022).
Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk assessment process. I am concerned that staff do not fully understand how to assess and manage risk.
There was no safety plan on discharge from hospital, or prior to discharge from the community team, to address the clear risks that Danny posed.
” Source location Danny Jay Anderson · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
Verbatim wording from the response “The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
Verbatim wording from the response “The Trust recognises that there was confusion around responsibilities of the named nurse, which includes risk assessment and formulating risks including plan at point of discharge. The Trust Quality Matron for Fundamentals of Care is leading on an improvement project looking at processes for the named nurse which aims to ensure there is consistent understanding of the named nurse role” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinical risk-assessment training and apply the clinical risk policy.
Verbatim wording from the response “The organisation recognises that the quality of the narrative used in risk assessment is essential for staff to understand risk. This will always be dependent on the staff member completing this. The Trust has clinical risk assessment training in place and a clinical risk policy to guide staff. For ongoing support the Trust has implemented review of risk assessments and documentation completed as part of staff members’ clinical supervision, this enables discussion and immediate learning support for each staff member.” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
Verbatim wording from the response “The Trust has established a new oversight system to enable managers to identify any gaps in risk” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review inpatient and community care plans and risk assessments during staff one-to-one supervision.
Verbatim wording from the response “As part of all staff one to ones, supervisors work with inpatient named nurses/ community care coordinators reviewing their care plans and risk assessment to check quality of the clinical entries.” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
Verbatim wording from the response “In addition the Trust has clinical audit processes which include a record keeping audit and a ‘matron’s records audit’ which includes review of risk formulation and crisis summary. Audit results are taken back to staff and highlighted through discussed in team meetings. The audit process has been reviewed and the Trust now has a person centred audit undertaken where possible with the names nurse to review an individual’s care and documentation thereafter.” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
Verbatim wording from the response “Work has been undertaken by the Director NE Essex Community Services, Trust Wide Perinatal, Children’s Learning Disability and Allied Health Professionals Operations to review the role and responsibilities of care coordinators and ongoing quality improvement for risk assessment is part of the Trust Disengagement Safety Improvement Programme” Source location Response from Essex Partnership NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
Verbatim wording from the response “Action is already underway as part of the Safety Action Plan to ensure there are clear documented actions agreed at discharge meetings and that the MDT outcome form is completed for each person clearly stating any actions and an overview of relapse signatures and recorded in the patient record.” Source location Response from Essex Partnership NHS
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Concerns raised 1
Lack of planned post-discharge support View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leicestershire Partnership NHS Trust
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Christopher Henrik LARSEN · 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
Christopher Henrik Larsen, a 52-year-old man, was found hanging at his home in Leicestershire on 6 January 2023 and died before a planned mental health triage call. Concerns included inadequate documentation and decision-making in multidisciplinary team meetings, inaccurate interpretation of risk information, insufficient risk assessment and discharge planning, and weaknesses in the serious incident investigation and learning process.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of planned post-discharge support
Wider context from the report “3. Discharge
Mr Larsen was discharged from the care of LPT on 3 December 2022, there was no planned support for Mr Larsen post-discharge other than some counselling which was due to start three weeks later.
The Trust’s SI report states that it is “unclear why it was felt the risks had subsided by the time of discharge on 3.12.2022” and that Mr Larsen had the “presence of ample markers for high risk of completed suicide” yet he was discharged back to the care of his GP and into a lacuna of care with no pre-arranged support other than counselling which would not commence for three weeks .
” Source location Christopher Henrik LARSEN · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discharge to primary care is considered appropriate for many patients when supported by a collaboratively formulated crisis and contingency plan with 24-hour access.
Verbatim wording from the response “The Crisis Resolution Home Treatment Team is a short-term, needs-based intervention service whose primary role is to mitigate the requirement for inpatient admission to an acute mental health hospital setting. Patients are referred into the service for intensive home treatment from a variety of different settings, including both primary and secondary care. For a substantial number of patients who have received care from the team, a referral into secondary care is not clinically appropriate or indicated. Many patients are subsequently discharged back to primary care following the formulation of a clear crisis and contingency plan which is formulated in collaboration with the patient (and carers where applicable).” Source location Response from Leicestershire Partnership NHS (2)
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30 Apr 2024 Mohamed Ahmed Hany Ellaboudy · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Insufficiently robust care coordination for patients discharged from mental health settings View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mohamed Ahmed Hany Ellaboudy · 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
Mohamed Ahmed Hany Ellaboudy, known as Moh, died after deliberately placing himself in front of a moving train; his mental state and capacity to form intention were unclear. The report raised concerns about care coordination after discharge from mental health services, reliance on telephone rather than face-to-face appointments, the regularity of multidisciplinary discussions, routes for family to report concerns, and correspondence with primary care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficiently robust care coordination for patients discharged from mental health settings
Wider context from the report “1. I am concerned about whether systems are in place for sufficiently robust care coordination for patients who have been discharged from a mental health setting , particularly in the context of detained/recently detained patients .
” Source location Mohamed Ahmed Hany Ellaboudy · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the new community mental-health care coordination and delivery model focused on planned, intervention-based care.
Verbatim wording from the response “Berkshire Healthcare are progressing changes to the way care is coordinated, planned, and delivered for our mental health patients, treated in the community. We have commenced a programme of work to move away from the Care Programme Approach (CPA). This is in line with guidance from NHS England and the national Community Mental Health Framework (which has been co-produced with service users, carers and professionals) and calls for providers to move away from care planning as an intervention in itself and focus on delivering compassionate, meaningful, intervention-based care which has been planned between the service user and their care team. The roll out of this new model has commenced.” Source location Response from Berkshire Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver five-day clinical-skills training covering named-worker responsibilities, targeted interventions, relapse prevention, discharge planning, 72-hour follow-up and evidence-based care.
Verbatim wording from the response “To support staff to deliver within the new model new five-day clinical skills training is now in place, that we are progressing staff through. This includes the responsibilities of the Named Worker such as spending time face to face with the person and those important to them, to collaboratively work out what might be helpful in their situation and to determine the outcomes they want to achieve, what strengths and resources they have to achieve these outcomes and what interventions and support are available. Furthermore, the need to provide targeted interventions, including relapse prevention as well as a focus on robust discharge planning, 72 hour follow up after discharge from an inpatient mental health setting and the provision of evidence-based interventions is also included in this work that commenced on the 12th June 2024.” Source location Response from Berkshire Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the transfer and discharge policy to require appropriate discharge correspondence with GPs and inclusion of 72-hour follow-up in care plans.
Verbatim wording from the response “Supervision of individual members of staff following training is embedded into the model, with audit and peer review processes to ensure new standards are being met. This aspect will commence in October 2024. The Trust’s Transfer and Discharge from Mental Health and Learning Disability In-Patient Care Policy CCOR45b has been updated from June 2024 to reflect the changes.” Source location Response from Berkshire Healthcare NHS Trust
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28 Mar 2024 Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to make adequate discharge decisions after failed engagement with mental health services View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Ellen Ocean WOOLNOUGH · 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
Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make adequate discharge decisions after failed engagement with mental health services
Wider context from the report “1. The adequacy of Norfolk and Suffolk NHS Foundation Trust’s (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred .
” Source location Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
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Concerns raised 1
Insufficient in-person engagement before discharge from the Community Treatment Team View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Odessa Carey · 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
Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient in-person engagement before discharge from the Community Treatment Team
Wider context from the report “4. Discharge from the Community Treatment Team on 6 August 2018
There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning.
A more assertive approach to engagement may have been appropriate.
I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator.
I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature.
I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment.
” Source location Odessa Carey · Prevention of Future Deaths report
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30 Mar 2023 Carol Ann Robinson · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Carol Ann Robinson · 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
Carol Ann Robinson died at Queen's Hospital on 8 May 2022 after taking an overdose of medication and being diagnosed with mixed drug toxicity. The principal concerns were that she was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multidisciplinary discussion, or communication with her domiciliary care agency and family about the withdrawal of support.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge
Wider context from the report “3. There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team . There was no communication with regard to the withdrawal of the Home Treatment Team’s input, with the domiciliary care agency or family of Mrs Robinson.
” Source location Carol Ann Robinson · Prevention of Future Deaths report
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26 Oct 2022 Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report Lincolnshire
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Concerns raised 1
Premature closure of the mental health assessment case View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report
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Report summary
Vincenzo Joseph Michael LIPPOLIS, aged 21, died on 1 November 2021 after being found hanging in woodland at Sand Dunes, Mablethorpe. Concerns were raised about why he was not admitted under the Mental Health Act after a recent suicide attempt and why a recommended face-to-face assessment was replaced by a telephone call, after which the case was closed the same day.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Premature closure of the mental health assessment case
Wider context from the report “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation"
the SW replies
"An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future".
The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA.
Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted.
In addition, the recommendation was for a face-to-face meeting with the deceased.
Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day.
” Source location Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report
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15 Feb 2022 Theo Jude BRENNAN-HULME · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to conduct an immediate check or discussion before discharge from the Community Team following assessment View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Theo Jude BRENNAN-HULME · Prevention of Future Deaths report
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Report summary
Theo Brennan Hulme, a university student with Asperger’s Syndrome, a history of deliberate self-harm and suicidal thoughts, was found hanging in his room on 12 March 2019 and declared dead at the scene. The report identified concerns about the adequacy and timeliness of his mental health assessment, failure to make reasonable adjustments or involve his family, lack of follow-up after a missed appointment, a persistent culture within the Crisis Resolution Home Treatment Team, and the absence of an immediate review when a person is discharged after assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct an immediate check or discussion before discharge from the Community Team following assessment
Wider context from the report “2. Following an Assessment, a person is still discharged from the Community Team without any immediate “check” or discussion as to the correctness of this decision . It was heard that following Theo’s death immediate discharge from the Community Team following assessment is relatively rare. In these circumstances, such a discussion would not place an onerous burden on the Team and would enable a review of the discharging decision to be undertaken to ensure it is the correct decision.
” Source location Theo Jude BRENNAN-HULME · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require young people to be seen or contacted before discharge through an implemented triage tool, including contact with referrers and significant others where appropriate.
Verbatim wording from the response “In response to your second concern, I would like to draw your attention to the extensive safety action plan put in place by the Norfolk Youth Teams post the deaths of young people in those teams in 2021, this has been discussed at the subsequent inquests into the deaths of those young people therefore I will not repeat the safety actions here. The salient aspects in respect of Theo’s case being that the Clinical Director for the Norfolk Youth Teams has implemented a triage tool which includes the directive that no young person is discharged without being seen face to face or contacted via phone or virtual contact if face to face not possible, plus the referrer and any significant other where appropriate.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing discharge safeguards require contact, case-by-case decisions, multidisciplinary communication and follow-up to support safe discharge decisions.
Verbatim wording from the response “In response to your second concern, I would like to draw your attention to the extensive safety action plan put in place by the Norfolk Youth Teams post the deaths of young people in those teams in 2021, this has been discussed at the subsequent inquests into the deaths of those young people therefore I will not repeat the safety actions here. The salient aspects in respect of Theo’s case being that the Clinical Director for the Norfolk Youth Teams has implemented a triage tool which includes the directive that no young person is discharged without being seen face to face or contacted via phone or virtual contact if face to face not possible, plus the referrer and any significant other where appropriate.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
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1 Nov 2021 Neil Peter Bastock · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to establish alternative accommodation and transition arrangements before discharge consideration View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leeds and York Partnership NHS Foundation Trust
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Neil Peter Bastock · 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
Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish alternative accommodation and transition arrangements before discharge consideration
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised . In the absence of such transition infrastructure, it was premature to consider him for discharge from the section .
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” Source location Neil Peter Bastock · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Rescinding detention was not premature discharge because the patient agreed to remain in hospital informally; discharge was not imminent.
Verbatim wording from the response “e. Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.