Recipient

All family members

First report 25 Mar 2021•Latest report 25 Mar 2021

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from All family members linked to the concerns in each report. Select any concern, action or position to view the source wording.

25 Mar2021
Nottinghamshire
Concerns raised7
1. Failure to account for autistic presentation when understanding mental health needs
2. Failure to establish informed agreement before withdrawing mental health services
3. Failure to proactively engage with family members and receive their concerns when services withdraw
1. Unavailability of services for patients with dual diagnosis and significant drugs misuse problems
2. Failure to provide access to needed mental health treatment
3. Failure to make secondary mental health care decisions using adequate information and assessment
4. Overriding care plans without assessment by decision-makers and review of the risk assessment
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

Sean Daniel FEGAN · 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

Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.

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 All family members; that does not assign responsibility.
PFD Monitor interpretation
Failure to account for autistic presentation when understanding mental health needs
Wider context from the report
“6. Autism awareness – I was concerned that Mr Fegan’s presentation acted as a barrier to a proper understanding of his mental health needs. In line with his autism diagnosis, he did not present in a socially typical way of expressing his feelings and emotions in a demonstrative manner, but rather ‘jumped’ to his view about what treatment he required, namely prescriptions. This was misunderstood by professionals on more than one occasion. ”
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 All family members; that does not assign responsibility.
PFD Monitor interpretation
Failure to establish informed agreement before withdrawing mental health services
Wider context from the report
“5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required. ”
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 All family members; that does not assign responsibility.
PFD Monitor interpretation
Failure to proactively engage with family members and receive their concerns when services withdraw
Wider context from the report
“4. Liaison with family members – there was no evidence of proactive attempts to engage with family members, even when services withdrew. When a family member sought to share concerns, these were rebuffed. ”
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 All family members; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of services for patients with dual diagnosis and significant drugs misuse problems
Wider context from the report
“3. Dual diagnosis – it was acknowledged that there was a ‘gap’ within the services in relation to dual diagnosis patients. There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems. ”
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 All family members; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide access to needed mental health treatment
Wider context from the report
“2. Access to mental health treatment – Mr Fegan had complex mental health conditions and experienced very high levels of distress and anxiety as a consequence. He was declined mental health treatment on two occasions by the Trust. Mr Fegan took an overdose due to his frustration at not being able to access mental health services which he needed. Whilst this was not the cause of Mr Fegan’s death, it created a dangerous state of affairs. ”
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 All family members; that does not assign responsibility.
PFD Monitor interpretation
Failure to make secondary mental health care decisions using adequate information and assessment
Wider context from the report
“1. Decision making surrounding the need for secondary mental health care – as set out above, a decision was taken in December 2019 that Mr Fegan did not require mental health treatment at all in the absence of adequate information or assessment and for reasons which appeared incorrect. ”
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 All family members; that does not assign responsibility.
PFD Monitor interpretation
Overriding care plans without assessment by decision-makers and review of the risk assessment
Wider context from the report
“5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised7

Failure to account for autistic presentation when understanding mental health needs

Failure to establish informed agreement before withdrawing mental health services

Failure to proactively engage with family members and receive their concerns when services withdraw

Unavailability of services for patients with dual diagnosis and significant drugs misuse problems

Failure to provide access to needed mental health treatment

Failure to make secondary mental health care decisions using adequate information and assessment

Overriding care plans without assessment by decision-makers and review of the risk assessment