21 Feb 2020 Billy James Jenkins · Prevention of Future Deaths report South London
View report summary
Concerns raised 8 Over-reliance on alcohol and drug use in assessing suicidal ideation View source Failure to complete assessment sufficient to identify mental health diagnosis requiring treatment View source Unavailability of a proforma of assessment questions View source Failure to identify training or support requirements for the Community Mental Health Nurse View source Failure to establish lessons learned by teams involved in care and treatment View source Failure to obtain sufficient assessment information before multidisciplinary mental health review and decision-making View source Failure to develop robust plans addressing protective factors and harm minimisation View source Failure to document clinical formulation or impression View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Billy James Jenkins · 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
Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.
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. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on alcohol and drug use in assessing suicidal ideation
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation . There appeared to be no proforma of questions to ask.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Failure to complete assessment sufficient to identify mental health diagnosis requiring treatment
Wider context from the report “(3) As a direct consequence of the limited information gathering Billy Jenkins was not properly assessed and it was not known whether he had a mental health diagnosis which required treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a proforma of assessment questions
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Failure to identify training or support requirements for the Community Mental Health Nurse
Wider context from the report “(4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Failure to establish lessons learned by teams involved in care and treatment
Wider context from the report “(4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain sufficient assessment information before multidisciplinary mental health review and decision-making
Wider context from the report “(1) The findings of the internal investigation by Oxleas NHS were that the assessment undertaken by the Community Mental Health Nurse did not illicit sufficient information to enable the multidisciplinary team to properly review Mr Jenkins’ mental health . Despite this the multi-disciplinary team proceeded with a review and decided that he did not have a mental health condition, without seeking a further assessment
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Failure to develop robust plans addressing protective factors and harm minimisation
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ADAPT, Bexley Locality Community Mental Health Team; that does not assign responsibility.
PFD Monitor interpretation Failure to document clinical formulation or impression
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression . The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations