4 Dec 2024 Kayleigh Ann MELHUISH · Prevention of Future Deaths report Avon
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Concerns raised 5 Failure by healthcare staff to check and update ACCT care plan support actions during reviews View source Ligature point where the Residential Unit 3 privacy screen meets the wall View source Failure to complete or review ACCT care plans and support actions at every review View source Lack of understanding of when and how constant supervision can be used View source Lack of mandatory neurodiversity training for prison staff View source See 2 more concerns
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AI-generated summary
Kayleigh Ann MELHUISH · 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
Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by neglect.
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× 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare staff to check and update ACCT care plan support actions during reviews
Wider context from the report “2. Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated ; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ligature point where the Residential Unit 3 privacy screen meets the wall
Wider context from the report “3. To HMP Eastwood: the ligature point in Residential Unit 3 where the privacy screen meets the wall .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or review ACCT care plans and support actions at every review
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews ;
c. Little or no understanding of when constant supervision can be used and how is it used;
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of when and how constant supervision can be used
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used ;
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory neurodiversity training for prison staff
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory ;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used;
” Open source report
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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 Quality Improvement Plan supporting the ACCT procedure and associated monitoring.
Verbatim wording from the response “A Quality Improvement Plan has been developed to support this and is attached.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
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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 Monitor ACCT training, refresher completion, and record-keeping standards through a scheduled audit programme.
Verbatim wording from the response “To ensure adherence with this procedure, the Quality and Standards meeting will monitor completion of ACCT training and refreshers through an audit schedule, which will also include monitoring improvements in standards across record keeping in ACCT and SystmOne.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
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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 Revise and approve the local operating procedure for ACCT attendance.
Verbatim wording from the response “The Trust has reviewed our involvement and input into the ACCT process, and revised the Local Operating Procedure for ACCT attendance (attached). This was discussed and signed off at the service level Quality and Standards meeting on 22nd January 2025.” Source location Response from Avon and Wiltshire Mental Health Partnership Trust
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3 Nov 2022 Ami Louise Mitchell · Prevention of Future Deaths report Avon
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Concerns raised 3 Failure to admit a patient when admission is requested and clinically indicated View source Failure to make a formal diagnosis View source Failure to escalate management View source
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AI-generated summary
Ami Louise Mitchell · 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
Ami Louise Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 and died by hanging on 31 May 2022. The report raises concerns that, despite delusions, hallucinations, intrusive thoughts of killing her partner and children, and requests for admission, no formal diagnosis was made and there was no escalation in management or admission.
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× 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to admit a patient when admission is requested and clinically indicated
Wider context from the report “Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she hung herself on 31st May 2022.
Throughout this period she presented regularly and persistently with
a) delusions;
b) auditory hallucinations (including command);
c) visual hallucinations;
d) intrusive thoughts of killing her partner and children;
e) her and her family requesting admission
Despite this
a) No formal diagnosis was made;
b) No escalation in management or admission took place.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make a formal diagnosis
Wider context from the report “Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she hung herself on 31st May 2022.
Throughout this period she presented regularly and persistently with
a) delusions;
b) auditory hallucinations (including command);
c) visual hallucinations;
d) intrusive thoughts of killing her partner and children;
e) her and her family requesting admission
Despite this
a) No formal diagnosis was made ;
b) No escalation in management or admission took place.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate management
Wider context from the report “Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she hung herself on 31st May 2022.
Throughout this period she presented regularly and persistently with
a) delusions;
b) auditory hallucinations (including command);
c) visual hallucinations;
d) intrusive thoughts of killing her partner and children;
e) her and her family requesting admission
Despite this
a) No formal diagnosis was made;
b) No escalation in management or admission took place.
” Open source report
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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 Ensure crisis care and treatment plans specify management escalation, including possible admission where appropriate.
Verbatim wording from the response “The trust will achieve improvement in this area in part by the previous improvement around diagnosis, which will clearly support the escalation of a pathway. The Clinical lead for South Gloucestershire will also ensure that all care and treatment plans (Crisis Plans) have a clear expectation of management escalation including possible admission if relevant. This might include clarity on escalation to admission if deemed appropriate.” Source location Response from Avon and Wiltshire Mental Health Partnership
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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 Implement a diagnosis and formulation process based on best-practice guidance, recorded clinically and discussed with service users and carers.
Verbatim wording from the response “Our improvement in this area includes the assurance that all service users receive a diagnosis and formulation from which care and treatment is informed by the NICE guidance appropriate for the diagnosis. In order to achieve this the trust must ensure the diagnosis or working diagnosis is clearly recorded in the clinical record, that the diagnosis or working diagnosis is discussed with the Service user and their family where appropriate and that there should be a protocol to adhere to where there is a difference of opinion.” Source location Response from Avon and Wiltshire Mental Health Partnership
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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 Establish a Consultant medical lead for diagnosis in South Gloucestershire.
Verbatim wording from the response “We have ensured that there is now a Consultant medical lead for diagnosis in the area of South Gloucestershire and that this lead with senior support will work with the local team to put in place a diagnosis, which has been discussed informed by best practice guidelines and” Source location Response from Avon and Wiltshire Mental Health Partnership
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8 Jul 2021 Maria STANCLIFFE-COOK · Prevention of Future Deaths report Avon
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Concerns raised 1 Failure to check risk assessments before downgrading a well-known patient’s suicide risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Maria STANCLIFFE-COOK · 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
Maria STANCLIFFE-COOK was found dead on 1 August 2019 after intentionally taking her own life using helium, causing asphyxiation. The principal concern was that her suicide risk was downgraded from high to medium by members of the mental health team who had not previously dealt with her, followed by a brief telephone contact that did not include an assessment or plan to manage her risk.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check risk assessments before downgrading a well-known patient’s suicide risk
Wider context from the report “The trust have themselves admitted the failures reflected in an independent report they commissioned after the death, that report said “we would not expect a patients level of risk to be downgraded from high ... to medium immediately following a suicide attempt ”; In addition I heard evidence in relation to the assessment on the 26th July 2019 when the risk was downgraded from high to medium.
I listened very carefully to the steps that the Trust has taken to make changes following this death and I am pleased that a number of changes have taken place. I raised my concern about the downgrading of risk from high to medium in this case by two members of the team that had no previous dealings with Maria .
Maria was well known to the trust and her own care coordinator said “We were concerned about the ongoing risk of completed suicide given she continued to be in possession of a helium bottle, the risk was not considered to have changed since my first meeting with her when the risk to self was recorded as high”. That was a reference to a multidisciplinary meeting which took place a matter of weeks before her death.
I was told that risk is dynamic and that professionals assess risk at the time and that it can go up and down. I was also told that there are lots of assessments by staff that do not know patients. That said there is a concern that there is a risk of future death - is it right that the risk of a patient, who is well known to the trust, with a care coordinator who knew her well, is downgraded without any check put in place .
” Open source report
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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 face-to-face training package on risk assessment and management, including suicidality, self-injury and complex behaviours.
Verbatim wording from the response “A ‘task and finish group’ has also been formed to specifically develop a new face-to-face training package to address risk assessment and management including suicidality, self-injurious and complex behaviours. Again, this is a co-produced delivery group and to the training is expected to commence in the next couple of months.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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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 learning from the circumstances of the death more widely with colleagues.
Verbatim wording from the response “Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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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 autism, risk-assessment and suicide-prevention guidance for the Clinical Toolkit and RiO Clinical Support.
Verbatim wording from the response “Suicide prevention remains a key area of development and concern. We are particularly focussing on developing guidance for staff regarding autism, risk assessment and suicide prevention. These will form part of a Clinical Toolkit and RiO Clinical Support. Our Library Services have started sending out literature on suicide prevention so that staff are up to date with the latest research and thinking on suicide prevention.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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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 a suicide-prevention workshop featuring specialist autism guidance on supporting people experiencing complex or suicide risk.
Verbatim wording from the response “There is a quarterly Suicide Prevention Workshop held for Bristol services that hosts guest speakers, reviews identified literature and explores challenges in practice through break-out groups. The next workshop is in November 2021 and is hosting the Specialist Autism Team who are providing a presentation for staff on how to support individuals experiencing complex and/or suicide risk.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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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 Use the new care-plan and risk-supervision tool during monthly management supervision to audit records and address identified concerns.
Verbatim wording from the response “A new care plan and risk supervision tool has been introduced as a means to support staff to audit their patient records through management supervision each month. The tool is more comprehensive than the Trust sample audit and is specific to risk assessment, management, crisis and contingency, formulation of care and how individual practitioners are meeting the standards as indicated within the tool.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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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 and implement the action plan supporting consistent application of systems, policies, procedures and guidelines.
Verbatim wording from the response “We have updated and continue to work with the action plan shared during the inquest. We will continue to support staff, patients and carers to ensure that all systems, policy, procedures and guidelines are consistently and robustly implemented in practice.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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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 the procured 4Mental Health training package, including co-produced safety plans, to an initial 60 staff members.
Verbatim wording from the response “Earlier this year, the Trust procured the services of ‘4Mental Health’ to provide AWP staff with a training package to be delivered in September and October 2021. The training package is 3.5 days and will initially be delivered to 60 members of staff. This is anticipated to promote consistency and benchmark standards of competency, linking the research of Dr ████████. It specifically includes the co-production of Safety Plans. This training was identified to provide support to address the quality of risk assessments and care plans. These are areas of practice which have been recognised as thematic learning from investigations.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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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 Complete a full multi-professional review of autonomous working and safe patient care.
Verbatim wording from the response “At the conclusion of the inquest held on 5 July 2021 you shared your concerns with regard to the downgrading of risk status by practitioners who had ‘no previous dealings with Maria’. We acknowledge your concerns alongside the recommendations made within the Niche report. Please be assured, we have completed a full multi-professional review to consider how we can ensure that our staff can continue to work in an autonomous manner whilst maintaining the safe care of patients as indicated within your Regulation 28 report. The implementation of learning from this is our absolute priority.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_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 A policy change is not considered necessary because existing quality-improvement work addresses risk-assessment practice.
Verbatim wording from the response “We will achieve this through; audit, governance and assurance across all levels of the Trust. We do not believe that a change of policy would support the quality improvement work that has commenced and is already being introduced into practice. Instead, the Trust is continuing to support the delivery of these commitments with the actions detailed below, to improve the understanding and application of risk assessment and ensure that practitioners are able to demonstrate a clear and informed decision making process whenever risk is assessed.” Source location 2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
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23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment View source
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.
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AI-generated summary
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
28 Nov 2019 Thomas Wedrychowski · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 2 Failure to share relevant physical healthcare check results between primary and secondary healthcare providers View source Failure to provide more frequent diabetes monitoring for individuals at higher risk View source
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.
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AI-generated summary
Thomas Wedrychowski · 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
Thomas Wedrychowski had paranoid schizophrenia and had been prescribed antipsychotic medication for a number of years. Expert evidence indicated that the medication caused diabetes and contributed to morbid obesity; the medical cause of death was recorded as diabetic ketoacidosis and medication-induced diabetes mellitus. Concerns included whether higher-risk patients should receive more frequent diabetes monitoring and whether physical healthcare findings were adequately shared between primary and secondary care providers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant physical healthcare check results between primary and secondary healthcare providers
Wider context from the report “At both primary and secondary health levels it appeared to have been the view that following initial titration and a period of regular checks, annual monitoring for signs of the development of diabetes should be carried out annually as recommended in NICE guideline CG178. However, expert evidence at the inquest suggested that in cases of individuals with a higher risk of developing diabetes, more regular checks were called for. Further there was evidence to the effect that the results of relevant physical healthcare checks had not been shared between primary and secondary healthcare providers . Thus:
(1) I draw to the attention of the National Institute for Health and Care Excellence their guidance CG178 and specifically clause 1.3.6.4 thereof and ask them to consider whether to the directive for an annual test of inter alia HbA1c, there might be added the words:
“or more frequently in those who have a higher baseline risk for the development of diabetes”.
(2) I draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with reference to their planned review of their document entitled “Medicines Guideline: Monitoring psychotropic medication” my first paragraph addressed to the National Institute for Health and Care Excellence and ask them to consider adding similar wording to their recommendations with regard to annual review appearing at page 4 of the present document.
Secondly, I ask the Trust to consider adding advice in the document to the effect that when a patient is prescribed anti-psychotic medication contact be made with the patient’s GP practice (a) informing them of this fact (b) requesting communication thereafter of any physical health findings that might indicate serious side-effects or potential side-effects of the drugs and (c) communicating any relevant physical health findings to the GP practice as well as mental health findings.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide more frequent diabetes monitoring for individuals at higher risk
Wider context from the report “At both primary and secondary health levels it appeared to have been the view that following initial titration and a period of regular checks, annual monitoring for signs of the development of diabetes should be carried out annually as recommended in NICE guideline CG178. However, expert evidence at the inquest suggested that in cases of individuals with a higher risk of developing diabetes, more regular checks were called for . Further there was evidence to the effect that the results of relevant physical healthcare checks had not been shared between primary and secondary healthcare providers. Thus:
(1) I draw to the attention of the National Institute for Health and Care Excellence their guidance CG178 and specifically clause 1.3.6.4 thereof and ask them to consider whether to the directive for an annual test of inter alia HbA1c, there might be added the words:
“or more frequently in those who have a higher baseline risk for the development of diabetes”.
(2) I draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with reference to their planned review of their document entitled “Medicines Guideline: Monitoring psychotropic medication” my first paragraph addressed to the National Institute for Health and Care Excellence and ask them to consider adding similar wording to their recommendations with regard to annual review appearing at page 4 of the present document.
Secondly, I ask the Trust to consider adding advice in the document to the effect that when a patient is prescribed anti-psychotic medication contact be made with the patient’s GP practice (a) informing them of this fact (b) requesting communication thereafter of any physical health findings that might indicate serious side-effects or potential side-effects of the drugs and (c) communicating any relevant physical health findings to the GP practice as well as mental health findings.
” Open source report
16 May 2019 Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report Avon
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Concerns raised 1 Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years View source
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AI-generated summary
Natasha Elizabeth Victoria Abrahart · 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
Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years
Wider context from the report “The NICE guideline Depression in Adults: Recognition and management (CG90) states in section 1.5.2.7 “A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important ”
In this case Sertraline was prescribed but the NICE guideline was not followed by the mental health trust or the GP practice.
The expert indicated that the review at 1 week is to ensure that the patient is taking the medication, to check for any side effects including suicide risk and to see what has happened ; that review can be done by the G.P. or the mental health team but there needs to be a known appointment.
” Open source 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 medical leads to discuss the prescribing alert with all line reports to reinforce effective communication.
Verbatim wording from the response “We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.” Source location 2019-0504-Response-from-AWP
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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 Distribute a Trust-wide alert requiring adherence to NICE antidepressant-prescribing guidance, documented seven-day review responsibility, and auditable team responses.
Verbatim wording from the response “We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.” Source location 2019-0504-Response-from-AWP
Open published response
10 Jan 2019 Christopher Michael SEAL · Prevention of Future Deaths report Avon
View report summary
Concerns raised 9 Absence of a no-response policy for primary care View source Lack of explicit identification of permissible information-sharing recipients View source Intensive service switchboard inability to call 999 when life protection is required View source Incomplete demographic information on RIO View source Limited care-planned communication options for service-user contact View source Failure to record next-of-kin details on RIO View source Unclear timeliness standard for RIO entries View source RIO records system displaying an older information-sharing form as the most recent View source Absence of a welfare-check policy for primary care View source See 6 more concerns
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AI-generated summary
Christopher Michael SEAL · 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 Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff processes.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a no-response policy for primary care
Wider context from the report “5. I was told that there is no “no response policy” for those in primary care ; that the policy which exists is for secondary or tertiary care and is therefore not applicable to the service users or staff in primary care . This would also raise the question of training
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of explicit identification of permissible information-sharing recipients
Wider context from the report “1. The information sharing form – in this case it was not explicit as to whom information could be shared with hence the family were not informed or contacted; is there an issue with the form itself to make this clearer for clinicians to be more explicit or is there a training issue for the staff involved with completing this form?
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Intensive service switchboard inability to call 999 when life protection is required
Wider context from the report “8. The intensive service switchboard – is there an issue in relation to the training of staff and their ability to react to protecting life? I was told they do not have ability to call 999 but that they advise the service user to make the call , is that appropriate?
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete demographic information on RIO
Wider context from the report “4. The demographics page in RIO – in this case it was incomplete and I was told it often is – is this a training issue for the staff or again a technical matter with the RIO system?
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited care-planned communication options for service-user contact
Wider context from the report “9. Contact with service user – I was told that the preferred method is verbal contact and the only other means is a text message with this being care planned . In this changing world of communication should other care planned options be considered such as email or messaging?
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record next-of-kin details on RIO
Wider context from the report “3. There were no next of kin details recorded on RIO – I was told that you use The National Spine to automatically populate this information however the next of kin details were on the hospital records for the A&E attendance and I was told that they use The National Spine. Is this system being used properly?
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear timeliness standard for RIO entries
Wider context from the report “7. RIO entries generally – I was told that there is an expectation that staff are expected to make their entry onto the RIO system within either 72 hrs. or 24hrs. Is this in line with what professional bodies expect and should it be?
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation RIO records system displaying an older information-sharing form as the most recent
Wider context from the report “2. On the RIO records system I was advised that it put the first information sharing form as the most recent when it wasn’t , in this case there was a more recent form, this misled the staff , although both forms were clearly completed and on the RIO system – is this a technical matter with IT or is this a training matter for the staff using the system?
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a welfare-check policy for primary care
Wider context from the report “6. I was told that there is no “welfare check policy” for those in primary care ; that the policy which exists is for secondary or tertiary care and is therefore not applicable to the service users or staff in primary care . I was told that Avon and Somerset Constabulary are in the process of writing a “welfare check policy” and it may be beneficial for there to be liaison with the police forces in the AWP area to ensure that any new policy that you consider is appropriate is in line with their expectations as to what a police officer can and will do following such a call. This would also raise the question of training.
” Open source report
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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 Request close liaison and joint working with Avon and Somerset Police on welfare checks.
Verbatim wording from the response “AWP have contacted Avon and Somerset Police to request close liaison and joint working regarding their ‘Welfare Check Policy’ to ensure understanding and expectations are aligned. The local representative for the Avon & Somerset Crisis Concordat will maintain close follow” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to record explicit consent specifying information, recipients and contact details.
Verbatim wording from the response “Immediate action has been taken regarding the current ‘Consent to Share’ form in use across the Trust. This has been discussed at local Quality and Standards meeting and the Learning from Experience Forum, where key learning from the untimely death of Mr Seal has been shared and disseminated. It has been agreed that all staff need to record explicit consent, i.e. stating what information can be shared, with whom and what their contact details are. The Trust recognises that the consent to share information form could and should be clearer, as could the staff guidance. In light of the General Data Protection Regulation (GDPR), the Governance Team are now reviewing the Trust’s consent to share information procedures.” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 Ensure staff understand individualised communication options and can discuss communication-method risks with service users.
Verbatim wording from the response “AWP has local procedures for text access for people who are deaf or hard of hearing. It is recognised that some service users, regardless of disability, may prefer forms of communication other than phone calls. Where this is indicated an Individualised approach to communication with the service users will be considered and planned. However, e-mail or texting high risk information is not always suitable as information can be missed or there can be technical risks. The Trust has ensured that all staff are aware of the individualised communication options and that they are suitably able to have appropriate conversations with service users about the risks of various communication methods” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 Improve, align and communicate consent recording, retrieval, clinical processes, guidance and information presentation.
Verbatim wording from the response “Once they have ensured that the framework is compliant with GDPR, we then will proceed with making the recording and retrieval of consent to share is in place and the clinical processes, supporting guidance, recording processes and information presentation will be improved, aligned and communicated by the end of June 2019. We are also working with the Senior Practitioner for Family Interventions to provide staff training regarding involving relatives and carers, including working with service users who might initially be reluctant to allow this but may change their views over time. Furthermore, the Trust is engaged with year long improvement programme with ‘Making Families Count’ initiative, set up by NHS England, collaborating to improve families’ involvement in mental health services and ensure that learning from their experience is used to improve services and reduce avoidable harm.” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 Review consent-to-share information procedures for GDPR compliance.
Verbatim wording from the response “Immediate action has been taken regarding the current ‘Consent to Share’ form in use across the Trust. This has been discussed at local Quality and Standards meeting and the Learning from Experience Forum, where key learning from the untimely death of Mr Seal has been shared and disseminated. It has been agreed that all staff need to record explicit consent, i.e. stating what information can be shared, with whom and what their contact details are. The Trust recognises that the consent to share information form could and should be clearer, as could the staff guidance. In light of the General Data Protection Regulation (GDPR), the Governance Team are now reviewing the Trust’s consent to share information procedures.” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 Reinforce minimum demographic-information requirements and audit patient records monthly.
Verbatim wording from the response “Staff have been reminded what the minimum information requirement is, and that this includes completion of the demographics page. A random selection of patient records are audited monthly and team managers have been made aware that completed demographic information is a requirement for all staff.” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 Amend and disseminate RiO guidance on editing or creating information-sharing forms.
Verbatim wording from the response “The Trust recognises the confusion this caused staff and indeed the Court and we welcome the fact that this has been highlighted for improvement. The training and guidance for staff has consequently been amended. The RiO clinical support now states that it is acceptable to either edit the most recent RiO form, or to create a new form. It is not acceptable to edit forms other than the most recent. This has been disseminated to clinical staff through team meetings and is being circulated to staff via an internal ‘Red Top Alert’.” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 RiO front-screen indicator showing Next of Kin or emergency-contact absence.
Verbatim wording from the response “The Trust is working to find a technical solution to create a work list of records that require synchronisation in order that administrative staff might be able to complete this task and improve compliance (target completion date 31 August 2019). There is a secondary issue that where there is no Next of Kin recorded, the absence of this is not evident. There is presently a development request to place an indicator on the front screen of the record showing the Next of Kin/In Case of Emergency contact, or the absence of that record in red, in order to make this more obvious to the clinician/user (target completion date 31 July 2019).” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 Discuss GP notification expectations for primary-care non-response, based on clinical risk assessment.
Verbatim wording from the response “The ‘No Response’ Policy is applicable to secondary and tertiary care. The policy states that for patients in primary care, the GP is informed of the lack of response to a planned visit. A planned visit is taken to mean planned and agreed between the staff member and the service user. Discussions have been held with the GP Mental Health Lead who has reinforced the expectation that the need to inform that GPs will be based on clinical judgement of staff involved. The expectation is that AWP would assess the risk based on all the available evidence, and alert the GP where appropriate, i.e. when risk or likely risk is increased.” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
Open published response
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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 policy and clinical risk assessment determine when primary-care non-response should be reported to the GP.
Verbatim wording from the response “Lack of “No Response policy” for those in primary care.” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
Open published response
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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 switchboard can call 999 when an emergency requires it, contrary to evidence that it lacked this ability.
Verbatim wording from the response “The intensive service switchboard and their ability to react to protecting life” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
Open published response
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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 communication procedures address accessibility while restricting high-risk messaging and non-secure platforms because of safety and confidentiality risks.
Verbatim wording from the response “AWP has local procedures for text access for people who are deaf or hard of hearing. It is recognised that some service users, regardless of disability, may prefer forms of communication other than phone calls. Where this is indicated an Individualised approach to communication with the service users will be considered and planned. However, e-mail or texting high risk information is not always suitable as information can be missed or there can be technical risks. The Trust has ensured that all staff are aware of the individualised communication options and that they are suitably able to have appropriate conversations with service users about the risks of various communication methods” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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 police are responsible for the welfare-check policy, while the Trust will liaise and work jointly with them.
Verbatim wording from the response “No “welfare check policy” for those in primary care” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
Open published response
14 Sep 2018 Terence Andrew Bennett · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 15 Deficiencies in supervision of unqualified mental health workers View source Inadequate allocation of time for care duties View source Insufficient staff knowledge of accessing, interrogating and using computerised medical records View source Lack of external audit of care plans and medical records View source Gaps in adequacy of staff training and knowledge View source Insufficient multi-disciplinary working for complex mental health needs View source Failure to maintain sufficiently robust and informative care, risk and crisis management plans View source Failure to establish satisfactory ways of working View source Failure to acquire and deploy necessary skills View source Computerised medical records system failing to cater for particular mental health service requirements View source Assignment of unqualified staff where qualified staff are required View source Lack of family involvement in the triangle of care View source On-call rota failing to provide rest and recuperation after 12-hour night duties View source Lack of proper handover between healthcare professionals when care personnel change View source Lack of peer review within mental health teams View source See 12 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
Terence Andrew Bennett · 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
Terence Andrew Bennett, who had schizo-affective disorder and was severely mentally ill, suicidal and threatening harm to his mother, died by suicide after self-inflicting deep wounds to his neck and wrists on 26 October 2016. The inquest found that his death was contributed to by neglect. Concerns included inadequate care and risk-management plans, failures in record use and handover, insufficient family and multidisciplinary involvement, reliance on unqualified staff, and deficiencies in supervision, training and consultant working arrangements.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in supervision of unqualified mental health workers
Wider context from the report “6. There appeared to be deficiencies in the supervision of unqualified mental health workers .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate allocation of time for care duties
Wider context from the report “9. Much of the above implied serious gaps in the adequacy of training / knowledge, the allocation of time , the acquisition and deployment of necessary skills and the establishment of satisfactory ways of working.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff knowledge of accessing, interrogating and using computerised medical records
Wider context from the report “2. Staff had insufficient knowledge of how to access, interrogate and effectively use computerised medical records , in respect of a generic system which itself did not sufficiently cater for the particular requirements of Avon and Wiltshire Mental Health Partnership NHS Trust.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of external audit of care plans and medical records
Wider context from the report “4. There did not appear to be a system of peer review within the mental health teams nor a system of external audit as regards the adequacy of care plans and medical records .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Gaps in adequacy of staff training and knowledge
Wider context from the report “9. Much of the above implied serious gaps in the adequacy of training / knowledge , the allocation of time, the acquisition and deployment of necessary skills and the establishment of satisfactory ways of working.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient multi-disciplinary working for complex mental health needs
Wider context from the report “7. There was little evidence of multi-disciplinary working in relation to an individual with complex mental health needs.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficiently robust and informative care, risk and crisis management plans
Wider context from the report “1. Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish satisfactory ways of working
Wider context from the report “9. Much of the above implied serious gaps in the adequacy of training / knowledge, the allocation of time, the acquisition and deployment of necessary skills and the establishment of satisfactory ways of working .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to acquire and deploy necessary skills
Wider context from the report “9. Much of the above implied serious gaps in the adequacy of training / knowledge, the allocation of time, the acquisition and deployment of necessary skills and the establishment of satisfactory ways of working.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Computerised medical records system failing to cater for particular mental health service requirements
Wider context from the report “2. Staff had insufficient knowledge of how to access, interrogate and effectively use computerised medical records, in respect of a generic system which itself did not sufficiently cater for the particular requirements of Avon and Wiltshire Mental Health Partnership NHS Trust .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Assignment of unqualified staff where qualified staff are required
Wider context from the report “5. Unqualified staff were relied upon in circumstances where qualified staff should have been assigned .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of family involvement in the triangle of care
Wider context from the report “3. There was a lack of involvement of family members and in particular, the concept of a triangle of care which involved family, the patient and the medical team had largely been ignored .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation On-call rota failing to provide rest and recuperation after 12-hour night duties
Wider context from the report “10. The on-call rota for duty consultants meant that consultant psychiatrists on occasions faced a full day of clinical work immediately following the completion of a 12 hour night time duty, without any period of rest and recuperation .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of proper handover between healthcare professionals when care personnel change
Wider context from the report “8. When there was a change in personnel responsible for the care of the patient, there appeared to be a lack of a proper handover between the healthcare professionals .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of peer review within mental health teams
Wider context from the report “4. There did not appear to be a system of peer review within the mental health teams nor a system of external audit as regards the adequacy of care plans and medical records.
” Open source report
13 Dec 2017 Rebecca Jay ROMERO · Prevention of Future Deaths report Avon
View report summary
Concerns raised 6 Lack of training or guidance for staff communicating with young persons by text or social media View source Lack of a clear documented process for in-patient transfers View source Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care View source Lack of guidance for managing children receiving out-of-area psychiatric inpatient care View source Inconsistent terminology and grading in risk assessment View source Failure of care plans to specify dates for meetings and task completion View source See 3 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
Rebecca Jay ROMERO · 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
Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric 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. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training or guidance for staff communicating with young persons by text or social media
Wider context from the report “(4) That consideration should be given to training and/or guidance issued for staff communicating with young persons by text or any means of social media .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear documented process for in-patient transfers
Wider context from the report “(1) In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure . As well as clarifying this process with all providers concerned consideration should be given that a clear documented process is put in place for in-patient transfers so that all those involved understand clearly the situation and the decision made in relation to the patient.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area . Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children receiving out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area. Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology and grading in risk assessment
Wider context from the report “(3) That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach. In this case there were a number of different phrases and grading's used to determine the deceased's risk .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of care plans to specify dates for meetings and task completion
Wider context from the report “(2) Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so agreeing expectations are managed to everyone knows exactly what the plan is and when actions will occur.
” Open source report
7 Jun 2017 Callum Oliver SMITH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment View source Inadequate training of healthcare/mental healthcare staff on the ACCT process View source
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
Callum Oliver SMITH · 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
Callum Oliver SMITH was in the care of HMP Bristol when he was found hanging in his cell and died from hanging. The inquest concluded that his death was caused by suicide while he was suffering extreme anxiety and distress. Concerns included inadequate risk assessment and mental health assessment, poor communication and record-sharing, and repeated failures to open an ACCT due to training and staff-understanding issues.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment
Wider context from the report “1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011.
2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011.
3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide.
4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of healthcare/mental healthcare staff on the ACCT process
Wider context from the report “1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011.
2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011.
3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide.
4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff.
” Open source report
14 Nov 2016 Mr Martyn Watkins · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to identify deficiencies in care on Aspen Ward View source Failure to address deficiencies and outstanding issues in care on Aspen Ward View source
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
Mr Martyn Watkins · 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
Mr Martyn Watkins, who was at high risk of suicide, was admitted to a mental health ward under section 2 of the Mental Health Act on 23 March 2016. He was found hanging from his belt, which had been secured to a fold-up bed in his room, and died in hospital on 1 April 2016. The report identified concerns including the unsafe room environment, inadequate checks for ligature risks, failures in admission procedures, and insufficient communication of specific risks.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify deficiencies in care on Aspen Ward
Wider context from the report “(2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed.
(3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address deficiencies and outstanding issues in care on Aspen Ward
Wider context from the report “(2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed .
(3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity .
” Open source report
5 Sep 2016 John Gerard JONES · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Delays in notifying GPs of Crisis Team discharge View source Lack of clear Crisis Team training, structural or protocol provision for discharge communication View source
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
John Gerard JONES · 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
John Gerard JONES had been receiving support because of a perceived risk of suicide, and admission to hospital was recommended but not undertaken. He later took his own life by drowning in the River Avon on or around 1 February 2016. The principal concern was that his GP was not notified of his discharge from the Crisis Team for approximately a week, leaving uncertainty about community support during that period.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in notifying GPs of Crisis Team discharge
Wider context from the report “(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear Crisis Team training, structural or protocol provision for discharge communication
Wider context from the report “(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.
” Open source report
15 Aug 2016 Oliver Hamlin · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Lack of weekend PCLS cover for next-working-day patient follow-up View source Failure to include risk assessment in telephone triage View source Failure to document post-triage risk assessments in Rio notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Hamlin · 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
Oliver was found dead hanging from a tree at Norton Wood, Clevedon, after expressing paranoid thoughts and being triaged by the Primary Care Liaison Service. The concerns raised were that no risk assessment was carried out during triage, risk assessments should be documented, and weekend cover for the service should be considered.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of weekend PCLS cover for next-working-day patient follow-up
Wider context from the report “3. I am aware that you have considered extending the PCLS service into Saturday. I would ask that you look at cover for the PCLS service over the weekend , so for example any need to follow up a patient the next working day even if it is by a phone is actioned by another team and not left because the triage occurs on a Friday .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include risk assessment in telephone triage
Wider context from the report “1. That there is a further review of the telephone triage process to specifically consider including a risk assessment . I was made aware that the triaging process has been reviewed but was not advised of any review to the risk assessment process itself .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document post-triage risk assessments in Rio notes
Wider context from the report “2. In addition that any risk assessment at all, whether it is formal, informal or indeed based on clinical judgment alone following the triage, is always documented in the Rio notes .
” 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 Use the Access Trigger Tool across telephone triage to require clinicians to assess risk and determine response urgency.
Verbatim wording from the response “1. Following the review, the telephone triage process now includes the access trigger tool which is a trust wide tool that requires every clinician to ask in depth questions about risk. In essence it is a risk assessment which will indicate an immediacy of response.” Source location 2016-0306-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Document the full rationale for Access referral decisions in RIO using collateral information from the Access Trigger Tool and audit the process monthly.
Verbatim wording from the response “2. Following the Access Trigger Tool assessment the clinicians are required to document on RIO a full rationale for decision making based on the collateral information gathered from the Access Trigger Tool. This is being used in all Access referrals.” Source location 2016-0306-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Cover urgent and emergency referrals outside PCLS hours through the 24-hour Intensive Support Team and hand over follow-up actions for out-of-hours completion.
Verbatim wording from the response “3. For all urgent and emergency referrals the PCLS service will be covered by the Intensive Support Team (outside of its normal operating hours which are Monday to Friday 08.00-20:00). The Intensive Support Team operates 24 hours per day 365 days per year.” Source location 2016-0306-Response-by-Avon-and-Wiltshire-NHS-Trust
Open published response
7 Aug 2016 Mr. Rohan Fitzsimons · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment View source Failure to carry out required Mental Health Act Assessments promptly when a bed is unavailable View source
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
Mr. Rohan Fitzsimons · 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
Mr. Rohan Fitzsimons, who had been detained under the Mental Health Act and was receiving inpatient psychiatric care, died after jumping from Clifton Suspension Bridge while on unescorted leave on 25 November 2015. The principal concern was that a necessary Mental Health Act Assessment was delayed for four days because no inpatient bed was available, with evidence that this commonly occurred and that assessments were not carried out until a bed became available.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment
Wider context from the report “(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG) .
(2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred .
(3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available. Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available.
(4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment .
The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required Mental Health Act Assessments promptly when a bed is unavailable
Wider context from the report “(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG).
(2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred.
(3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available . Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available .
(4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment.
The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds .
” Open source report
27 Oct 2015 Charlotte Emily BEVAN and Zaani Bevan Malbrouck · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Failure to hold multi-disciplinary team meetings when pregnant women have known mental health conditions View source Failure to widely circulate care plans to involved professionals View source Failure to draw up appropriate multi-agency care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Emily BEVAN and Zaani Bevan Malbrouck · 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
Charlotte Emily Bevan, who had schizophrenia and an undiagnosed psychotic relapse following childbirth, left hospital with her four-day-old daughter Zaani and went to the Avon Gorge cliff top; both died from injuries. The inquest identified failures including the absence of multidisciplinary care planning, insufficient psychiatric involvement, and failures to diagnose and manage Charlotte’s relapse.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hold multi-disciplinary team meetings when pregnant women have known mental health conditions
Wider context from the report “It was not stated in evidence - that in all cases when a lady with a known mental health condition becomes pregnant that there is a multi-disciplinary team meeting to include all or some of the following professionals: GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate.
It was not stated in evidence - that and an appropriate care plan involving all agencies and professionals is drawn up and then widely circulated to those professionals who are involved with the care and treatment of the patient. That group to include; GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to widely circulate care plans to involved professionals
Wider context from the report “It was not stated in evidence - that in all cases when a lady with a known mental health condition becomes pregnant that there is a multi-disciplinary team meeting to include all or some of the following professionals: GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate.
It was not stated in evidence - that and an appropriate care plan involving all agencies and professionals is drawn up and then widely circulated to those professionals who are involved with the care and treatment of the patient . That group to include; GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to draw up appropriate multi-agency care plans
Wider context from the report “It was not stated in evidence - that in all cases when a lady with a known mental health condition becomes pregnant that there is a multi-disciplinary team meeting to include all or some of the following professionals: GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate.
It was not stated in evidence - that and an appropriate care plan involving all agencies and professionals is drawn up and then widely circulated to those professionals who are involved with the care and treatment of the patient. That group to include; GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services; and any others to be deemed appropriate.
” 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 Produce and prominently issue a reflective training vignette through the internal safety alert system, requiring confirmation of action and monitoring implementation through supervision and appraisal.
Verbatim wording from the response “In addition, although we have not found the need to revise our existing policies, systems and procedures in light of Charlotte’s and Zaanyi’s deaths, we do plan to produce and issue in the New Year a vignette of Charlotte’s care that can be shared with all teams as a valuable reflective training exercise. This will place emphasis on the importance of multi-disciplinary working and care planning. This vignette will be issued with prominence via our internal safety alert system, that requires our positive confirmation that action has been taken. Implementation of change will be monitored via our supervision and appraisal processes.” Source location 2015-0418-Response
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 No revision of existing policies, systems or procedures was considered necessary in light of the deaths.
Verbatim wording from the response “In addition, although we have not found the need to revise our existing policies, systems and procedures in light of Charlotte’s and Zaanyi’s deaths, we do plan to produce and issue in the New Year a vignette of Charlotte’s care that can be shared with all teams as a valuable reflective training exercise. This will place emphasis on the importance of multi-disciplinary working and care planning. This vignette will be issued with prominence via our internal safety alert system, that requires our positive confirmation that action has been taken. Implementation of change will be monitored via our supervision and appraisal processes.” Source location 2015-0418-Response
Open published response
24 Jul 2015 Simon Peter REYNOLDS · Prevention of Future Deaths report Avon
View report summary
Concerns raised 6 Failure to appropriately assess service users' risk of suicide or self-harm View source Failure to record admission information in computerised Rio notes View source Failure to appropriately communicate suicide or self-harm risk to other staff View source Failure to appropriately set patient observation levels at admission View source Failure to appropriately manage suicide or self-harm risk View source Lack of documented risk assessments at admission onto Mason Unit View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Simon Peter REYNOLDS · 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
Simon Peter REYNOLDS was admitted to Mason Unit at Southmead Hospital on 10 November 2014 after being detained under section 136 of the Mental Health Act. While left alone in his room, he forced a fist-sized ball of paper into his throat, causing him to choke; he later died in hospital on 21 November 2014. Concerns included the absence of a documented admission risk assessment, no computerised admission note by the nurse in charge, and the need to consider guidance or training on observation levels, suicide and self-harm risk assessment, risk management, and communication of risk.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately assess service users' risk of suicide or self-harm
Wider context from the report “(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record admission information in computerised Rio notes
Wider context from the report “(2) During the investigation I heard evidence that the nurse in charge made no record on the computerised Rio notes in relation to the admission . I would ask that you look into the appropriateness of this.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately communicate suicide or self-harm risk to other staff
Wider context from the report “(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately set patient observation levels at admission
Wider context from the report “(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit ; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately manage suicide or self-harm risk
Wider context from the report “(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documented risk assessments at admission onto Mason Unit
Wider context from the report “(1) I heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit . I would ask that you review whether this is still appropriate.
” 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 Revise 136 suite admission paperwork to incorporate Royal College of Psychiatrists’ risk headings for clearer detainee risk identification.
Verbatim wording from the response “Documented Risk Assessment
It is our policy and standard to have a risk assessment completed at the time of admission. In Mr Reynolds’s case, a risk assessment had taken place with risk indicators linked from the progress notes to the risk assessment, however, this was not in a clear form. The admission paperwork for the 136 suite has been revised to incorporate the risk headings recommended by the Royal College of Psychiatrists. The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.” Source location 2015-0296-Avon-and-Wiltshire-NHS-Trust
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 Review the Observation Policy against revised NICE guidance on observation levels and reflect the guidance in policy and practice.
Verbatim wording from the response “• Reviewing our Observation Policy to take account of revised guidance from the National Institute for Health and Care Excellence - “NICE NG10 Violence and aggression: short-term management in mental health, health and community settings”. This guidance includes definitions on the levels of observations which need to be reflected in our policy and practice.” Source location 2015-0296-Avon-and-Wiltshire-NHS-Trust
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 Continue implementing Safewards interventions to reduce incidents of harm to self and others.
Verbatim wording from the response “• Continue the implementation of the ‘Safewards’ interventions already underway. Research has demonstrated that incidents of harm to self and others can be reduced through the implementation of the ‘Safewards’ Interventions as observation alone is insufficient and can increase risks.” Source location 2015-0296-Avon-and-Wiltshire-NHS-Trust
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 Review Place of Safety staffing levels through the Safer Staffing initiative to support timely observations and information recording.
Verbatim wording from the response “• Reviewing staffing levels on the Place of Safety suite as part of the wider national Safer Staffing initiative, to ensure optimal staffing levels at all times, which will in turn support timely observations and recording of information.” Source location 2015-0296-Avon-and-Wiltshire-NHS-Trust
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 RIO entry was made shortly after the incident, although documentation was delayed while staff managed the traumatic incident and debrief.
Verbatim wording from the response “Record on Rio
The nurse-in-charge should have made an entry on the RIO record. Staff are encouraged to make their written record in as close a proximity to any assessment or event taking place as possible. Since the inquest, we have examined the audit trail of entries on RIO and determined that the entry was made on RIO at 00:11 hours, which was not long after staff had finished dealing with the incident and participating in the debrief. The day-time nurse in charge did not go off duty until 23.00 hours (one and a half hours beyond the end of her shift) in order to handover all necessary information and support staff.” Source location 2015-0296-Avon-and-Wiltshire-NHS-Trust
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 Observation alone is insufficient and may increase risks; reducing harm also requires Safewards interventions.
Verbatim wording from the response “• Continue the implementation of the ‘Safewards’ interventions already underway. Research has demonstrated that incidents of harm to self and others can be reduced through the implementation of the ‘Safewards’ Interventions as observation alone is insufficient and can increase risks.” Source location 2015-0296-Avon-and-Wiltshire-NHS-Trust
Open published response
17 Jul 2015 Mr. Masoud Ghaderi · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Ward-round planning and preparation relying solely on a brief nursing summary View source Lack of overarching responsibility for reviewing risk assessments View source Inconsistent recording of engagement with service users View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr. Masoud Ghaderi · 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
Mr. Masoud Ghaderi, who had severe depression and was an informal inpatient at Lime Unit, was found hanging by a belt from a bathroom door on 10 April 2014 and died on 12 April 2014 after life support was withdrawn. The report identified concerns about inconsistent records of engagement, the absence of overarching responsibility for reviewing risk assessments, and ward-round reliance on brief nursing summaries that could result in errors or omissions.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ward-round planning and preparation relying solely on a brief nursing summary
Wider context from the report “(3) The Trust has a comprehensive single care record for each service user. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward rounds . The Trust should review its planning and preparation for ward rounds so that reliance is not placed solely on a brief summary with the inherent risk of errors and omissions .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of overarching responsibility for reviewing risk assessments
Wider context from the report “(2) There was no one member of staff with overarching responsibility for reviewing any risk assessments . Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide, could not be identified . The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plan(s) are reviewed and maintained up-to-date.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent recording of engagement with service users
Wider context from the report “(1) There was inconsistence records of engagement with service users . The Engagement and Observation policy of the Trust should be reviewed to consider how the policy operates and how engagements with service users are to be recorded in a consistent manner with appropriate staff training in application of the policy.
” 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 nursing models of care and generate recommendations for a standardised care-delivery model.
Verbatim wording from the response “When undertaking ward rounds, the care team have access to the patients full and comprehensive care record. However, it is accepted that there are occasions when the nursing summary is not as comprehensive as it should be. A full review of nursing models of care is to be undertaken by the Nursing Directorate with recommendations generated for a standardised model of care delivery (i.e. named professional / team nursing structure). This will facilitate a more comprehensive recording of a patients presenting needs state at any given time. Also a review of the existing multi professional weekly review meetings has been undertaken. The findings and recommendations will be taken to the Integrated Governance Group, chaired by the Executive Director of Nursing and Quality in October 2015. The review was completed by the Heads of Quality for each of the six local delivery units.” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Commission an audit of risk-assessment reviews across inpatient units.
Verbatim wording from the response “The Clinical Executive appreciates the Coroners comments re responsibility for reviewing and as a result have commissioned an audit of reviewing risks across inpatient units. The Clinical Executive will take the information from this audit and design a framework of staff responsibilities for all staff to follow.” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Roll out local training on implementing the Engagement and Observation Policy across all Bristol wards.
Verbatim wording from the response “Local training in the implementation of the Trust Engagement and Observation Policy has been rolled out across all wards in Bristol following learning from root cause analysis process.” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
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 monthly spot audits of caseload supervision records and present findings to the Integrated Governance Group from October 2015.
Verbatim wording from the response “The monitoring of engagement and observation recording is through monthly management supervision. This is when the line manager sits with individual clinicians and goes through their caseload on the ward and highlights any issue or remedial actions to take. However, this has not been consistently monitored by the Clinical Executive; our plan is to undertake monthly spot audits of the caseload supervision records to ensure consistent application of the Engagement and Observation Policy. This audit will be taken to the Integrated Governance Group (IGG) meeting for action (attendees include Quality Directors from all localities). These audits will commence from October 2015.” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
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 the risk-review audit findings to design a framework of staff responsibilities.
Verbatim wording from the response “The Clinical Executive appreciates the Coroners comments re responsibility for reviewing and as a result have commissioned an audit of reviewing risks across inpatient units. The Clinical Executive will take the information from this audit and design a framework of staff responsibilities for all staff to follow.” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Engagement and Observation Policy already clearly defines engagement, observation and recording requirements, so policy revision is not indicated.
Verbatim wording from the response “The Trust Engagement and Observation Policy is based on guidance in the recently revised Mental Health Act Code of Practice, (Chapter 26, Safe and Therapeutic Responses to Disturbed Behaviour). The Policy is also informed by the recently published NICE Guidance - Violence and aggression: short-term management in mental health, health and community settings, (NICE 2015).” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
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 processes, including daily risk review and weekly multidisciplinary review, coordinate inpatient risk information without requiring one overarching reviewer.
Verbatim wording from the response “The Trust has in place processes and procedures for the co-ordinating of risk assessment information for inpatients.” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Ward rounds have access to the patient's full comprehensive care record and do not rely solely on the nursing summary.
Verbatim wording from the response “3. The Trust has a comprehensive single care record for each service users. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward round. The Trust should review its planning and preparation for ward rounds so that reliance is not paced solely on a brief summary with the inherent risk of errors and omissions.” Source location 2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
Open published response
19 Jun 2015 Elizabeth Godwin · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Failure to gather information from family and others involved in mental health assessments View source Failure to communicate and acknowledge transfers of patient care between agencies View source Failure to share mental health assessment information with other agencies involved in patient care View source Failure to assess, record and monitor the urgency of mental health assessments View source Failure to assign responsibility for patient care, mental health assessment and resulting treatment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Godwin · 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
Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to gather information from family and others involved in mental health assessments
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment .
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above 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. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and acknowledge transfers of patient care between agencies
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail .
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above 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. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share mental health assessment information with other agencies involved in patient care
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient .
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above 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. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess, record and monitor the urgency of mental health assessments
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored .
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above 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. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for patient care, mental health assessment and resulting treatment
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it .
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above 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 Establish guidance and training requiring staff to involve service users, families and carers in CPA and risk assessments.
Verbatim wording from the response “The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Communicate triage, assessment and referral outcomes to referrers, service users, families, carers and relevant agencies.
Verbatim wording from the response “The Trust CPA and Risk Policy outlines the requirement that referrals not requiring assessment will be returned to the referrer with referral outcome decision and recommendations for further intervention.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Set response-time standards for urgent and routine assessments and record triage outcomes in electronic patient records.
Verbatim wording from the response “The Trust has developed a triage tool to support decision making in PCLS. The response to urgent referrals is addressed in the Trust Access to Mental Health Care Assessment and Treatment General Policy. All urgent assessments should be carried out within 4 hours by the Intensive Support team. Those requiring face to face routine assessment will be seen by PCLS workers within an appropriate time frame indicated by the triage process, with an expected maximum of 4 weeks.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Implement a PCLS referral pathway using a standard operating procedure, telephone triage and a triage decision-support tool.
Verbatim wording from the response “When an individual is referred to our services a triage process is undertaken to establish the urgency with which an assessment is required. The Trust has developed a Standard Operating Procedure for Primary Care Liaison Services, (PCLS), which outlines the process for receiving referrals and carrying out a phone triage system to establish risk and therefore urgency of response. All referrals are now made through the PCLS.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Record referral and assessment times and monitor significant delays in Mental Health Act assessments.
Verbatim wording from the response “In the event of a Mental Health Act Assessment the AMHP would conduct a risk assessment to determine the urgency and proceed to set up the mental health act assessment. The AMHP service record the time of referrals and the time of assessments and monitor any significant delays between the two.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Audit Wiltshire PCLS records for comprehensive triage, assessment and outcome communication documentation.
Verbatim wording from the response “The Trust services in Wiltshire have recently audited the records of the PCLS service recently and have found these to be comprehensive.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
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 policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.
Verbatim wording from the response “The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
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 local authority is responsible for arranging an Approved Mental Health Professional assessment when the referral is not made to Trust services.
Verbatim wording from the response “If a Mental Health Act Assessment is requested and a referral not made to the Trust services, it is the responsibility of the local authority to make arrangements for an approved mental health professional to consider the patient’s case on their behalf. Only once the assessment is completed would it be the responsibility of the Trust to provide treatment arising out of the assessment.” Source location 2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
Open published response
29 May 2015 Alison Jane DRAPER · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to manage and balance hourly checks with 10-minute observations View source Lack of policy for responding when a patient or service user is not found during a 10-minute observation period View source
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
Alison Jane DRAPER · 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
Alison Jane Draper, who had a history of mental health problems and previous attempts to self-harm, was found ligatured in her bedroom while on 10-minute observations at Juniper Ward. She sustained an unsurvivable hypoxic brain injury and died from her injuries. Concerns included the absence of a policy for when a patient is not found during a 10-minute observation and how staff should balance hourly checks for multiple patients with 10-minute observations.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage and balance hourly checks with 10-minute observations
Wider context from the report “2. I would also request that you consider the hourly check as detailed above. It appears in this case that one member of staff was asked to check 19 patients, two of whom were on 10 minute observations . Please consider whether guidance be given as to how to manage and balance the hourly checks with those on 10 minute observations .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for responding when a patient or service user is not found during a 10-minute observation period
Wider context from the report “1. I heard evidence that there is no policy in relation to what staff should do if a patient/service user is not found within the 10 minute observation period . I would ask that you consider whether guidance should be issued as to the steps that staff should take.
” Open source report
20 Apr 2015 Andrew Ralph Mitchell Farrow · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1 Unavailability of hospital beds for patients requiring admission at Green Lane Hospital Devizes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Ralph Mitchell Farrow · 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
Andrew Ralph Mitchell Farrow died at home on 7 July 2014 as a result of self-administered acute codeine and alcohol toxicity. He had expressed a wish to be admitted to hospital for his own safety, and the concern was that no beds would have been available at Green Lane Hospital Devizes if admission had been needed.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of hospital beds for patients requiring admission at Green Lane Hospital Devizes
Wider context from the report “He was known to have suicidal ideation but no actual plan had been formulated. I did not find that he ought to have been admitted. My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services.
” 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 Monitor bed pressures and out-of-area placements.
Verbatim wording from the response “When there is a bed pressure in a locality, clinical staff may take a number of different actions, depending upon the requirements of the individual patient. These actions may include seeking alternatives to admission such as intensive home treatment, seeking an bed in another part of the Trust, making a bed available by seeing if there are patients who need to be discharged, or sending a patient out of the Trust’s area. The decision is always risk based, and takes account as far as is possible the wishes of the patient and their family. When a patient is sent out of area, every effort is made to repatriate them locally as soon as it is possible and in their best interests to do so. The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.” Source location 2015-0147-Response-by-Avon-and-Wiltshire-NHS-Trust
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 Work with commissioners and NHS England to manage bed pressures and out-of-area placements.
Verbatim wording from the response “When there is a bed pressure in a locality, clinical staff may take a number of different actions, depending upon the requirements of the individual patient. These actions may include seeking alternatives to admission such as intensive home treatment, seeking an bed in another part of the Trust, making a bed available by seeing if there are patients who need to be discharged, or sending a patient out of the Trust’s area. The decision is always risk based, and takes account as far as is possible the wishes of the patient and their family. When a patient is sent out of area, every effort is made to repatriate them locally as soon as it is possible and in their best interests to do so. The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.” Source location 2015-0147-Response-by-Avon-and-Wiltshire-NHS-Trust
Open published response
20 Feb 2015 Richard Jeffrey Jones · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to record primary responsibility for patient care during transfers of care View source Failure to share patient information accurately with other agencies involved in care View source Failure to record information obtained from mental health patients, including perceived risk and assessment urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Jeffrey Jones · 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
Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health 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. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record primary responsibility for patient care during transfers of care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share patient information accurately with other agencies involved in care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency .
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record information obtained from mental health patients, including perceived risk and assessment urgency
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment .
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” 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 Conduct a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.
Verbatim wording from the response “Your report was considered by our Critical Incident Review Group, which is chaired by my Medical Director, ████████ on 2 March 2015. It was decided that to best explore the issues you have raised, we should conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces. This will enable staff from the different agencies to collaborate and identify the best solutions to the problems you have raised concerns about, to include a review of any relevant policies and procedures.” Source location 2015-0068-Response-by-Avon-Wiltshire-Mental-Health-NHS-Trust
Open published response
4 Mar 2014 Ms. Kimberley Parsons · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Lack of published evidence supporting assisted self-harming as a treatment approach View source Lack of proper procedures for introducing and using novel treatments View source Failure to discuss proposed treatment with the consultant in charge View source Failure to record proposed treatment discussions View source Failure to address identified patient-safety deficiencies at Hillview Lodge View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms. Kimberley Parsons · 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
Ms. Kimberley Parsons, who had a history of mental health problems and suicidal ideation, was found hanging in her room at Sycamore Ward on 16 March 2014 after repeated self-harm during her admission. She was transferred to intensive care but died from her injuries on 24 March 2014. Concerns included serious patient-safety deficiencies at Hillview Lodge, including incomplete observation records, shortcomings in resuscitation equipment and training, and deficiencies in care planning and pathways for patients with emotionally unstable personality 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. The report was sent to Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of published evidence supporting assisted self-harming as a treatment approach
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal . Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research .
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals.
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of proper procedures for introducing and using novel treatments
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research.
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals .
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss proposed treatment with the consultant in charge
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research.
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals.
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded.
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record proposed treatment discussions
Wider context from the report “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research.
(2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals.
(3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion . The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded .
” 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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address identified patient-safety deficiencies at Hillview Lodge
Wider context from the report “(1) That serious deficiencies affecting the safety of patients at Hillview Lodge which had been identified in March 2014 had not been addressed by the Trust by the time of the CQC inspection in June 2014.
” Open source report
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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 research into whether harm minimisation strategies are appropriate for use.
Verbatim wording from the response “The Medical Director has liaised with the national expert in this field. ████████ who will soon be joining the University of Bristol and our trust. We will be looking at the possibility of research into the appropriateness, or not, of employing harm minimisation strategies.” Source location 2015-0077-Response-by-Avon-Wiltshire-NHS-Trust
Open published response
12 Sep 2013 Felix Stefan CEMBROWICZ · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to transfer important historical mental health records, including relapse management plans, into the electronic Rio record system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Felix Stefan CEMBROWICZ · 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
Felix Stefan CEMBROWICZ was found hanging after deterioration in his mental health while awaiting a planned mental health assessment, was admitted to Bristol Royal Infirmary, and subsequently died. The report raised concerns that the electronic Rio record system did not transfer important records, including relapse management plans, for some discharged patients, potentially leaving staff unaware of relevant histories or delaying assessments.
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 Avon and Wiltshire Mental Health Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer important historical mental health records, including relapse management plans, into the electronic Rio record system
Wider context from the report “The electronic Rio record system used by staff to access patient histories was introduced in May 2011 when only the documentation for current patients at that date was migrated across to the new system . Discharged patients, with both a long and recent history of contact with mental health services do not appear to have had important records transferred including relapse management plans leaving staff unaware of a patients history or delaying assessments until old records can be obtained .
” Open source report
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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 Communicate the new record-checking requirements through staff supervision processes.
Verbatim wording from the response “We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages. We also see the inclusion of this information in the RiO record as a clinical and quality indicator and plan to audit the implementation of this change through our records audit plan.” Source location 2013-0204-Response-by-Avon-Wiltshire-NHS
Open published response
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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 RiO and information-governance training packages to reflect the new requirements.
Verbatim wording from the response “We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages. We also see the inclusion of this information in the RiO record as a clinical and quality indicator and plan to audit the implementation of this change through our records audit plan.” Source location 2013-0204-Response-by-Avon-Wiltshire-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to check for historic relapse or other management plans in RiO when patients are re-referred.
Verbatim wording from the response “In response to your concerns, we have taken the following steps:” Source location 2013-0204-Response-by-Avon-Wiltshire-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to search historic electronic and paper records for specified recent clinical documents and copy identified documents into RiO.
Verbatim wording from the response “In response to your concerns, we have taken the following steps:” Source location 2013-0204-Response-by-Avon-Wiltshire-NHS
Open published response
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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 Audit implementation of the record-checking and document-transfer requirements through the records audit plan.
Verbatim wording from the response “We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages. We also see the inclusion of this information in the RiO record as a clinical and quality indicator and plan to audit the implementation of this change through our records audit plan.” Source location 2013-0204-Response-by-Avon-Wiltshire-NHS
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations