20 May 2024 James Furlong and 2 others · Prevention of Future Deaths report Central Criminal Court
View report summary
Concerns raised 6 Failure to maintain and disseminate an adequate intelligence picture View source Failure to provide an adequate and integrated response to identified risk View source Failure to address consequential risks created by inadequate intelligence dissemination View source Failure to provide adequate secondary mental healthcare in prison View source Failure to provide adequate mental healthcare in the community View source Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms View source See 3 more concerns
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
James Furlong and 2 others · 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
James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three deaths.
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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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and disseminate an adequate intelligence picture
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequate and integrated response to identified risk
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address consequential risks created by inadequate intelligence dissemination
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate secondary mental healthcare in prison
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate mental healthcare in the community
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Maintain named CMHT representatives’ participation in MAPPA discussions and liaison for inpatient and crisis teams.
Verbatim wording from the response “BHFT recognises that we play a key role in sharing communications particularly around risk. While we are not responsible for the organisation of MAPPA meetings, we are committed to supporting these processes, ensuring that the right people attend the meetings and that we continue to have named representatives from each CMHT within BHFT. This attendance includes contributing to discussions/providing advice to MAPPA case discussions for those that may not be under CMHT. In addition, those named workers will act in a liaison role for inpatients and CRHTT. CRHTT and inpatient teams are less likely to be in a position to attend MAPPA, particularly at short notice, and CMHT representatives are best placed to communicate into and out of MAPPA where inpatient or CRHTT may have been involved in a case.” Source location Response from Berkshire Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out a named key worker for all service users open to services or awaiting treatment, with a defined coordinating role.
Verbatim wording from the response “The MDT will identify a named worker when agreeing individual plans for those referred into services. The named worker will be assigned to anyone who is opened to services and receiving treatment, and a named worker will be assigned to people awaiting treatment held on waiting lists. A workstream dedicated to defining the elements of the named worker role is established and the named key worker role will be formally rolled out in September 2024. As set out in the national guidance, there will be a named key worker for all service users open to BHFT services with a multidisciplinary team approach at Place (i.e. geographical locality) taking overall responsibility for coordinating care - this will be integrated with social care and VCSE and an example is offered above.” Source location Response from Berkshire Healthcare
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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 Continue implementing the One Team model, including One Assessment and place-based multidisciplinary post-assessment meetings.
Verbatim wording from the response “BHFT have continued the development of the One Team model as described in February and helpfully summarised in the Regulation 28 report. This is an ongoing and gradual roll out of associated changes to service delivery. There are monthly team updates and a number of engagement events that have taken place with BHFT staff, external stakeholders (such as local authorities in Berkshire, Primary Care Networks,” Source location Response from Berkshire Healthcare
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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 Establish additional escalation processes with Prison, Probation and partner agencies for people released from custody with mental health vulnerabilities.
Verbatim wording from the response “Our Reconnect service has seen increasing numbers of service users over time and are playing a valuable role in bridging the gap between leaving prison and accessing the best community support to meet the needs of vulnerable people. Reconnect offers the bridge between prison, probation and health, and we have good evidence of those workers playing a key role in engaging prisoners prior to leaving prison, or soon after, with community services that best support their needs. For example, supporting people to attend housing appointments or drug and alcohol appointments. We have noted below the additional challenges that early release may bring alongside mitigations agreed with Probation colleagues. BHFT will be closely monitoring impacts and escalating concerns locally and nationally as they arise.” Source location Response from Berkshire Healthcare
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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 Establish and operate a Harm to Others multidisciplinary risk panel providing specialist input to care planning.
Verbatim wording from the response “An escalation Standard Operating Procedure was produced for the Judge Coroner at the Inquests. Since the Inquests, escalation processes have been further aligned with the new One Team model. The MDT described above will enable shared decision making and where agreement cannot be reached this will be escalated to Heads of Service. An enhanced MDT can be arranged to support this process. On the rare occasion that the Head of Service decision and enhanced MDT is challenged, this will be escalated to the Clinical Director who will make the final decision regarding the plan. In addition to the Positive Risk Panel referred to in the inquest proceedings, an additional ‘Harm to Others’ MDT risk panel is being established. This is in recognition of the increasing awareness of vulnerable individuals who may not fit neatly into a forensic pathway but carry a level of risk.” Source location Response from Berkshire Healthcare
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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 Strengthen community-custody transitions through proactive Prison and Probation engagement, named-worker handovers and explicit responsibility arrangements.
Verbatim wording from the response “Where individuals move between the community and custody, there will be greater proactive engagement with Prison and Probation colleagues both principally and on a case-by-case basis. Where someone receives a short sentence, it would be important to maintain CMHT input and involvement in planning for post release. For more lengthy sentences requiring ongoing mental health input in custody, they will transition from community (e.g. CMHT) to Prison Mental Health Services. In such situations, the named worker in the community will ensure that a handover takes place with prison colleagues. The Reconnect roles, as described above, will allow for easier transition back into CMHT's on release if required.” Source location Response from Berkshire Healthcare
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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 Use the new streamlined risk assessment form, including enhanced consideration of risk to others.
Verbatim wording from the response “There will be a streamlined, holistic, personalised care and support plan, co-produced between the service user and the named key worker and regularly reviewed. A new risk form went live on 15 June 2024, and this is a more streamlined record of risk assessment that is easier to navigate for all clinicians involved.” Source location Response from Berkshire Healthcare
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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 Launch a new care plan format aligned with multidisciplinary formulation and named-worker care coordination.
Verbatim wording from the response “More focus within this assessment has been given to risk to others. Alongside this more contemporary risk assessment is a new care plan format which will complement the risk assessment and is due to be launched in July 2024.” Source location Response from Berkshire Healthcare
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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 revised risk-training programme incorporating response learning and real clinical case studies.
Verbatim wording from the response “The MDT described above will agree a clear formulation which will help inform the care plan, as well as identify the best person to lead on the plan of care using the named key worker approach. Where mental health services are not indicated, a clear rationale will be communicated to referrers and any other relevant parties. Risk training has been reviewed and a new programme of risk training has started which will encapsulate elements discussed within this response and case studies based on real clinical cases will help to inform this training.” Source location Response from Berkshire Healthcare
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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 Expand the Nurse Consultant Network’s clinical support and continue twice-yearly harm-to-others learning sessions for staff and Probation colleagues.
Verbatim wording from the response “Our Nurse Consultant Network has expanded, and this has allowed for an enhanced focus on supporting our teams to improve clinical effectiveness across our inpatient and community services. The evidence presented at the Inquests described a pilot project between Probation and BHFT using Nurse Consultants as a conduit to offer a layer of decision-making where conflict arises. This project has now been evaluated. Recommendations have been made to Probation and BHFT are building upon the learning that has come from the Pilot. The Nurse Consultants will continue to offer this additional support to Probation colleagues, and the learning sessions delivered by the Nurse Consultants to Probation will continue twice yearly. Internally, BHFT sessions have been reviewed to reflect the findings of the project alongside the learning from these Inquests.” Source location Response from Berkshire Healthcare
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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 For longer custodial sentences requiring ongoing mental health input, responsibility transfers from community services to prison mental health services, with handover.
Verbatim wording from the response “Where individuals move between the community and custody, there will be greater proactive engagement with Prison and Probation colleagues both principally and on a case-by-case basis. Where someone receives a short sentence, it would be important to maintain CMHT input and involvement in planning for post release. For more lengthy sentences requiring ongoing mental health input in custody, they will transition from community (e.g. CMHT) to Prison Mental Health Services. In such situations, the named worker in the community will ensure that a handover takes place with prison colleagues. The Reconnect roles, as described above, will allow for easier transition back into CMHT's on release if required.” Source location Response from Berkshire Healthcare
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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 The organisation is not responsible for organising MAPPA meetings, but will support the process and ensure appropriate attendance and advice.
Verbatim wording from the response “BHFT recognises that we play a key role in sharing communications particularly around risk. While we are not responsible for the organisation of MAPPA meetings, we are committed to supporting these processes, ensuring that the right people attend the meetings and that we continue to have named representatives from each CMHT within BHFT. This attendance includes contributing to discussions/providing advice to MAPPA case discussions for those that may not be under CMHT. In addition, those named workers will act in a liaison role for inpatients and CRHTT. CRHTT and inpatient teams are less likely to be in a position to attend MAPPA, particularly at short notice, and CMHT representatives are best placed to communicate into and out of MAPPA where inpatient or CRHTT may have been involved in a case.” Source location Response from Berkshire Healthcare
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30 Apr 2024 Mohamed Ahmed Hany Ellaboudy · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Insufficiently robust care coordination for patients discharged from mental health settings View source Unclear regularity and thresholds for MDT discussions View source Lack of clear policy or expectation for correspondence with primary care after hospital discharge View source Absence of a clear route for family to report concerns View source Reliance on telephone rather than face-to-face appointments View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Conduct a reflective workshop and disseminate case learning to the wider team, including family concerns, communication, medication monitoring and relapse prevention.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Develop and implement an advisory panel enabling carers to obtain consultation, support and signposting about family members’ mental-health care.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024. View source
Action
Update the transfer and discharge policy to require appropriate discharge correspondence with GPs and inclusion of 72-hour follow-up in care plans.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Deliver five-day clinical-skills training covering named-worker responsibilities, targeted interventions, relapse prevention, discharge planning, 72-hour follow-up and evidence-based care.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024. View source
Action
Roll out the new community mental-health care coordination and delivery model focused on planned, intervention-based care.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024. View source
Action
Implement quarterly audits of documented rationales for remote outpatient appointments and share results at divisional safety and quality meetings.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024. View source See 3 more actions
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AI-generated summary
Mohamed Ahmed Hany Ellaboudy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mohamed Ahmed Hany Ellaboudy, known as Moh, died after deliberately placing himself in front of a moving train; his mental state and capacity to form intention were unclear. The report raised concerns about care coordination after discharge from mental health services, reliance on telephone rather than face-to-face appointments, the regularity of multidisciplinary discussions, routes for family to report concerns, and correspondence with primary care.
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× 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust care coordination for patients discharged from mental health settings
Wider context from the report “1. I am concerned about whether systems are in place for sufficiently robust care coordination for patients who have been discharged from a mental health setting , particularly in the context of detained/recently detained patients .
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear regularity and thresholds for MDT discussions
Wider context from the report “3. Regularity / thresholds for MDT discussions.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear policy or expectation for correspondence with primary care after hospital discharge
Wider context from the report “5. Policy / expectation for correspondence with primary care , particularly in the time after discharge from hospital .
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear route for family to report concerns
Wider context from the report “4. Absence of a clear route for family to report concerns , even where a patient does not wish confidential information to be given to their family .
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on telephone rather than face-to-face appointments
Wider context from the report “2. Reliance on telephone rather than face to face appointments.
” 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 Conduct a reflective workshop and disseminate case learning to the wider team, including family concerns, communication, medication monitoring and relapse prevention.
Verbatim wording from the response “Staff are also encouraged to utilise the Multiagency Risk Frameworks and other safeguarding frameworks to ensure comprehensive risk management involving all relevant agencies and stakeholders especially when concerns around medication concordance, safeguarding or engagement with services are identified. This facilitates a multi-agency care plan to address issues. The provision of these various forums ensures that staff have multiple avenues to address concerns, collaborate on care plans, and manage risks effectively. For this particular case, a reflective workshop took place with the service involved to reflect on the concerns and to ensure the learning is shared with the wider team.” Source location Response from Berkshire Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement an advisory panel enabling carers to obtain consultation, support and signposting about family members’ mental-health care.
Verbatim wording from the response “In addition, a new panel is being developed (for implementation in October 2024) in response to direct feedback from carers that they would value an opportunity to have a voice and seek a second opinion on care plans for their family when they are worried or have concerns. The panel will act in an advisory, supportive capacity to carers/family. The panel's remit will be to:” Source location Response from Berkshire Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the transfer and discharge policy to require appropriate discharge correspondence with GPs and inclusion of 72-hour follow-up in care plans.
Verbatim wording from the response “Supervision of individual members of staff following training is embedded into the model, with audit and peer review processes to ensure new standards are being met. This aspect will commence in October 2024. The Trust’s Transfer and Discharge from Mental Health and Learning Disability In-Patient Care Policy CCOR45b has been updated from June 2024 to reflect the changes.” Source location Response from Berkshire Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver five-day clinical-skills training covering named-worker responsibilities, targeted interventions, relapse prevention, discharge planning, 72-hour follow-up and evidence-based care.
Verbatim wording from the response “To support staff to deliver within the new model new five-day clinical skills training is now in place, that we are progressing staff through. This includes the responsibilities of the Named Worker such as spending time face to face with the person and those important to them, to collaboratively work out what might be helpful in their situation and to determine the outcomes they want to achieve, what strengths and resources they have to achieve these outcomes and what interventions and support are available. Furthermore, the need to provide targeted interventions, including relapse prevention as well as a focus on robust discharge planning, 72 hour follow up after discharge from an inpatient mental health setting and the provision of evidence-based interventions is also included in this work that commenced on the 12th June 2024.” Source location Response from Berkshire Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the new community mental-health care coordination and delivery model focused on planned, intervention-based care.
Verbatim wording from the response “Berkshire Healthcare are progressing changes to the way care is coordinated, planned, and delivered for our mental health patients, treated in the community. We have commenced a programme of work to move away from the Care Programme Approach (CPA). This is in line with guidance from NHS England and the national Community Mental Health Framework (which has been co-produced with service users, carers and professionals) and calls for providers to move away from care planning as an intervention in itself and focus on delivering compassionate, meaningful, intervention-based care which has been planned between the service user and their care team. The roll out of this new model has commenced.” Source location Response from Berkshire Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement quarterly audits of documented rationales for remote outpatient appointments and share results at divisional safety and quality meetings.
Verbatim wording from the response “As explained, in evidence at the inquest, face to face appointments are the default mode of treatment for out-patient appointments and this is set out in standard work for the Named Worker. However, there will be occasions where a remote appointment is considered to be more appropriate, for example, where this is more convenient for patients, or the team are using alternative strategies to promote engagement. Where a decision is made for an appointment to be undertaken remotely, the rationale must be provided and documented. A quarterly audit process is being designed and implemented to ensure compliance with” Source location Response from Berkshire Healthcare NHS Trust
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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 Discussing every patient weekly in multidisciplinary meetings is not feasible because of high caseloads, so risk-based thresholds and prioritisation apply.
Verbatim wording from the response “MDT (Multi-Disciplinary Team) meetings occur weekly within the Community Mental Health Teams and are open to all staff to discuss concerns, complex cases, risk, safeguarding concerns, and discharges. These meetings are structured to ensure comprehensive review and coordination of patient care. The threshold for discussing cases in MDTs includes any significant change in a patient's condition, risk factors, or treatment plan. Additionally, any concerns raised by family members or primary care providers can be brought to these meetings for discussion. This priority system is in place as it is not feasible to discuss every patient every week due the high number of patients being held on caseloads. There is documented standard work for our MDT meetings which sets out the criteria for which cases should be brought to this meeting.” Source location Response from Berkshire Healthcare NHS Trust
Open published response
28 Mar 2024 Daniela Vitalia PANI · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of Samaritan signs at the train station View source Failure to implement identified suicide-risk mitigation measures at the train station View source Training and guidance failing to address service users declining a visit or meeting View source Inability of staff to carry out face-to-face assessments in all possible cases View source Car park line-side fencing being too low 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
Daniela Vitalia PANI · 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
Daniela Vitalia PANI died on 29 June 2023 after entering a train station, jumping onto the tracks and being struck by a train. Concerns were raised that potential suicide-risk mitigation measures at the station had not been implemented, and that mental-health staff lacked specific guidance and training for situations where service users declined face-to-face 72-hour reviews.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Samaritan signs at the train station
Wider context from the report “1. A lack of Samaritan signs on the platforms or within the stations.
The mitigation proposed was conspicuously placed posters and/or additional signage.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement identified suicide-risk mitigation measures at the train station
Wider context from the report “The report was submitted on the 25th July 2023. Despite the passage of nearly 9 months from submission of the report to the date of the inquest the BTP officer giving evidence could not inform me whether these changes had been actioned. I was advised that this information had been requested from South Western Railways but had not been provided.
On the 18th March 2024 I requested an update from BTP about the actions taken and invited them to attend the final hearing on the 25th March 2024. No information was submitted and no-one from BTP attended the final hearing.
I am therefore concerned that measures to mitigate the risk of future suicides at the train station have not been implemented .
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Training and guidance failing to address service users declining a visit or meeting
Wider context from the report “I heard evidence from a number of members of the CMHT regarding the policies, procedures and training around the completion of this important review meeting.
During the course of this I heard that training and guidance did not specifically address how to deal with service users declining a visit or meeting.
This is a complex area with competing demands of the duty of care, mental capacity and the autonomy of an individual to make decisions about their own care and treatment. The evidence from the CMHT Joint Service Manager was that guidance and/or training would be important for staff seeking to deal with this challenging area .
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability of staff to carry out face-to-face assessments in all possible cases
Wider context from the report “I am concerned that the staff not being able to carry out face to face assessments in all possible cases gives rise to the risk of future deaths.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Car park line-side fencing being too low
Wider context from the report “2. Car park line side fencing being too low.
The proposed mitigation was replacement of the fencing.
” 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 Provide 72-hour follow-up guidance and a staff film explaining how to manage refusal or postponement of face-to-face appointments.
Verbatim wording from the response “In addition to this we have provided additional guidance for 72-hour follow up and a short film clip for staff on how to deal with a person refusing or postponing the face-to-face appointment (this approach would still require a clinical judgement).” Source location Response from Berkshire Healthcare NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide inpatient pre-discharge guidance requiring 72-hour review expectations, importance and attendance barriers to be included in discharge safety plans.
Verbatim wording from the response “In addition to the above, we have also provided additional pre discharge guidance for staff in the inpatient setting on including the detail, expectations and importance of 72-hour reviews within the discharge safety plan. During this conversation any barrier to attending the 72-hour review will also be explored.” Source location Response from Berkshire Healthcare NHS
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 Enhance clinical risk training and guidance with collaborative risk formulation, safety planning, patient engagement, escalation and family or carer involvement.
Verbatim wording from the response “Therefore, the approach the Trust has taken focuses on enhancing the existing clinical risk training and guidance for staff to include an increased focus on a collaborative risk formulation and safety planning. This includes a specific skills component on:” Source location Response from Berkshire Healthcare NHS
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 Trust disputes that enforcing face-to-face reviews in every case would prevent future deaths, stating it could harm therapeutic relationships and increase suicide risk.
Verbatim wording from the response “In light of the guidance and also our clinical experience the Trust do not feel having a blanket rule about enforcing a face-to-face meeting in all possible cases would be helpful for the patient/practitioner relationship, nor would this approach prevent a future death, it may even increase the risk of suicide by adversely impacting the therapeutic relationship and increasing feelings of hopelessness.” Source location Response from Berkshire Healthcare NHS
Open published response
21 Mar 2024 Sarah Elizabeth ADAMS · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Lack of training for practitioners in the discharge process, including issues arising from out of area admissions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Elizabeth ADAMS · 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
Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.
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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for practitioners in the discharge process, including issues arising from out of area admissions
Wider context from the report “That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions
” 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 Implement revised Clinical Risk training with increased focus on high-risk discharge situations.
Verbatim wording from the response “All clinical staff in the Mental Health Divisions undertake Clinical Risk training which includes a focus on admission and discharge from inpatient services. We have now reviewed and revised this training offer across the organisation to ensure that moving forward there will be an increased focus on high-risk situations such as:” Source location Response from Berkshire Healthcare NHS Foundation Trust
Open published response
22 Jun 2023 Lucy Anne Walles · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 10 Failure of safeguarding audit systems to identify and address ongoing issues View source Failure to ensure crisis-team discharges include additional support when needed View source Insufficient training on Section 42 thresholds and options for concerns below the threshold View source Failure to ensure patients in crisis situations are offered appropriate support View source Failure of systems to make involved agencies aware of safeguarding referrals and concerns View source Delays in review and triage of safeguarding referrals View source Inadequate or unsafe resourcing of mental health services View source Inadequate or unsafe resourcing of the safeguarding service View source Inadequate inter-agency interaction and guidance on arranging joint meetings for service users View source Failure to speak to individuals about whom safeguarding concerns have been raised View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Make the Integrated Multi-Disciplinary Team operational to discuss complex cases, share information, formulate risk, and determine suitable pathways and care plans.
Stated plannedThe respondent said that this action was planned when they made their response on 23 June 2023. View source
Action
Review community mental health service leadership to determine the appropriate operational support and workforce deployment across Berkshire.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 June 2023. View source
Action
Implement targeted recruitment, apprenticeships, university links, social media, and recruitment campaigns to strengthen the mental health workforce.
Status unclearThe respondent did not make the status of this action clear when they made their response on 23 June 2023. View source
Action
Maintain the Nurse Consultant network to provide specialist support, education, research, development, complexity intervention, and workforce-capacity monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 23 June 2023. View source
Action
Work with the Safeguarding Adults Review panel and respond to its recommendations.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 June 2023. View source
Action
Conduct caseload reviews to ensure patients are on appropriate pathways and receive evidence-based treatment and support.
Status unclearThe respondent did not make the status of this action clear when they made their response on 23 June 2023. View source
Action
Implement the One Team community mental health model with multi-agency working, clear safety plans, named workers, feedback, and wider community support.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 June 2023. View source
Action
Complete the community mental health service reconfiguration bringing East and West services together to improve resilience and deploy resources safely.
Stated completedThe respondent said that this action was complete when they made their response on 23 June 2023. View source
Action
Make outreach workers fully operational to provide short-term support and safety planning for people unable to access existing services.
Stated plannedThe respondent said that this action was planned when they made their response on 23 June 2023. View source
Action
Commission and accept referrals for Elmore floating support for people with complex needs who risk falling between existing services.
Stated completedThe respondent said that this action was complete when they made their response on 23 June 2023. View source
Action
Provide monthly restorative supervision through trained professional nurse advocates to reduce burnout-related staff turnover.
Stated completedThe respondent said that this action was complete when they made their response on 23 June 2023. View source See 8 more actions
×
AI-generated summary
Lucy Anne Walles · 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
Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of safeguarding audit systems to identify and address ongoing issues
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure crisis-team discharges include additional support when needed
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training on Section 42 thresholds and options for concerns below the threshold
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients in crisis situations are offered appropriate support
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of systems to make involved agencies aware of safeguarding referrals and concerns
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in review and triage of safeguarding referrals
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate or unsafe resourcing of mental health services
Wider context from the report “Berkshire Health Care
1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically:
a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February?
b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?
2) Do they consider that resourcing of these services is adequate and safe?
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate or unsafe resourcing of the safeguarding service
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate inter-agency interaction and guidance on arranging joint meetings for service users
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to speak to individuals about whom safeguarding concerns have been raised
Wider context from the report “Reading Borough Council
1) Time scales for review and triage of safeguarding referrals.
2) Requirements to speak to the individual about whom safeguarding concerns have been raised.
3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry.
4) Systems for making other involved agencies aware of safeguarding referrals and concerns.
5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training.
6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ?
7) Whether they consider that the resourcing of this service is adequate and safe.
8) Systems for auditing, and what will happen if the auditing reveals ongoing issues.
” 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 Make the Integrated Multi-Disciplinary Team operational to discuss complex cases, share information, formulate risk, and determine suitable pathways and care plans.
Verbatim wording from the response “• Integrated Multi-Disciplinary Team
Complex cases can be discussed to enable a clear formulation of risk and needs. This forum will ensure the person gets the most suitable pathway and care plan to enable the patient to achieve their personal and treatment goals. It is also a place where important information can be shared across agencies pathways, for example,the ARRs worker could present a case here to ensure the correct pathway is in place, adult social care staff can attend to share any concerns. This function will be operational by December 2023.” Source location Response from Berkshire Healthcare NHS Foundation 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 community mental health service leadership to determine the appropriate operational support and workforce deployment across Berkshire.
Verbatim wording from the response “• The reconfiguration of community mental health services as part of the One Team project seeks to ensure the resources we have are being utilised in the right place. Significant changes have already been made to bring the East and West services together to improve resilience and make best use of staff resources and expertise. The leadership of these services is currently under review with the aim of ensuring the right level of operational support is in place, and that staff can be mobilised across the whole of Berkshire, reducing unwanted variation and moving resource around as required making services safer.” Source location Response from Berkshire Healthcare NHS Foundation 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 targeted recruitment, apprenticeships, university links, social media, and recruitment campaigns to strengthen the mental health workforce.
Verbatim wording from the response “• Human Resource initiatives to focus on recruitment include targeted recruitment, apprenticeship schemes, linking with universities, using social media and recruitment campaigns.” Source location Response from Berkshire Healthcare NHS Foundation 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 Maintain the Nurse Consultant network to provide specialist support, education, research, development, complexity intervention, and workforce-capacity monitoring.
Verbatim wording from the response “• A Nurse consultant network is also now in place; these are senior specialist roles that attract mental health nurses by providing an opportunity to practice in a senior clinical role, as well as having protected time to focus on education and research and a clear development pathway. The Nurse Consultants can also intervene when there is complexity, which helps with resourcing as staff are supported with caseload capacity and complexity. Nurse Consultants also have a role to play in monitoring workforce capacity to ensure safety.” Source location Response from Berkshire Healthcare NHS Foundation 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 the Safeguarding Adults Review panel and respond to its recommendations.
Verbatim wording from the response “The resourcing of mental health care remains a challenge. However, patient safety is at the heart of everything that we as a Trust do, and we feel that the initiatives we have implemented, and which are ongoing will optimise the deployment of available resources to ensure we support and safeguard our patients as best we can. We are aware that further learning may arise from the ongoing Safeguarding Adults Review (“SAR”), we are working closely with the panel and will respond to the recommendations.” Source location Response from Berkshire Healthcare NHS Foundation 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 Conduct caseload reviews to ensure patients are on appropriate pathways and receive evidence-based treatment and support.
Verbatim wording from the response “• Case load reviews - Historically in all mental health services, patients would remain on CMHT caseloads for many years, which can impact significantly on safety as thresholds for acceptance and waits for CMHT due to capacity are directly linked to this. The review will increase resources available by ensuring people are on the correct pathway and receiving the correct evidence based treatment and support.” Source location Response from Berkshire Healthcare NHS Foundation 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 the One Team community mental health model with multi-agency working, clear safety plans, named workers, feedback, and wider community support.
Verbatim wording from the response “NHS Trusts are changing and improving the way mental health services are provided in the community to support people with mental illness. In Berkshire Health Care we are calling this programme of work “One Team”. This transformation of services is happening across the country following the publication of the Community Mental” Source location Response from Berkshire Healthcare NHS Foundation 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 Complete the community mental health service reconfiguration bringing East and West services together to improve resilience and deploy resources safely.
Verbatim wording from the response “• The reconfiguration of community mental health services as part of the One Team project seeks to ensure the resources we have are being utilised in the right place. Significant changes have already been made to bring the East and West services together to improve resilience and make best use of staff resources and expertise. The leadership of these services is currently under review with the aim of ensuring the right level of operational support is in place, and that staff can be mobilised across the whole of Berkshire, reducing unwanted variation and moving resource around as required making services safer.” Source location Response from Berkshire Healthcare NHS Foundation 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 Make outreach workers fully operational to provide short-term support and safety planning for people unable to access existing services.
Verbatim wording from the response “• Outreach workers
These workers are able to offer short term support and safety planning to those who do not meet threshold or who are unable to access community mental health teams and/or psychological therapy. Will be fully operational by December 2023” Source location Response from Berkshire Healthcare NHS Foundation 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 and accept referrals for Elmore floating support for people with complex needs who risk falling between existing services.
Verbatim wording from the response “• Elmore complex needs floating support service.
This is a charity we have commissioned to provide support to people with a wide range of complex needs, who are at risk of falling between the gaps of existing services. Alongside the Trust’s existing offer Elmore provides innovative ways to build trust, increase patients’ engagement with relevant agencies and deliver support tailored to the people who need it. The target group is those who have multiple support needs and complexity. For example, homelessness and rough sleeping, substance misuse, offending, physical disability, self-harm, learning difficulties, domestic abuse, sex working, or experience of abuse and neglect. A motivated team, with wide ranging expertise has been identified to work as part of our personality disorder pathway to provide this individual support.” Source location Response from Berkshire Healthcare NHS Foundation 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 Provide monthly restorative supervision through trained professional nurse advocates to reduce burnout-related staff turnover.
Verbatim wording from the response “• Utilising professional nurse advocates to provide staff with restorative supervision through dedicated staff trained as professional nurse advocates on a monthly basis, to reduce staff turnover as a result of burnout.” Source location Response from Berkshire Healthcare NHS Foundation 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 patient was not discharged without additional support; community support, group support, online support and a medication review were already arranged.
Verbatim wording from the response “At the time Lucy was discharged from CRHTT on the 2nd of February 2022, she had a 16 hours per week of community support in place provided by Adult Social Care (ASC) with a planned move to accommodation with support available 24/7. Lucy also had access to the Service User Network (SUN) which provides group support, and Shout (which provides support with stress, anxiety, suicidal thoughts, and links to many other sources of support for example autism and mental health, bullying, relationships). A Pharmacist review of medication was planned for 17th February 2022. In the new model the following additional support could also be offered in” Source location Response from Berkshire Healthcare NHS Foundation Trust
Open published response
2 Mar 2020 Sophie Hannah May Boothe · Prevention of Future Deaths report Hampshire (Central)
View report summary
Concerns raised 2 Failure to identify, review and understand relevant clinical information from foreign jurisdictions during referral triage View source Poor communication between departmental services 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
Sophie Hannah May Boothe · 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
Sophie Hannah May Boothe had a history of mental health issues and died in a hotel in Hook on 19 June 2019 after an overdose and subsequent contact with mental health services. Concerns were raised that information about her treatment in Australia was not properly reviewed or understood, contributing to the downgrading of her urgent referral, and that poor communication between services led to missed opportunities for assessment and intervention.
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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify, review and understand relevant clinical information from foreign jurisdictions during referral triage
Wider context from the report “It became very clear in evidence that the overseas involvement was not properly flagged up when the CPE came to triage Sophie’s referral ; this includes both the discharge summary and Sophie’s own self-referral via email whilst she was in Australia. The full discharge summary from Australia was sent by the GP along with his referral on the 8th May 2019 to ensure that all relevant information was shared at the earliest stage. These notes were either not fully reviewed and/or understood by the CPE and this appears to have contributed to the downgrading of Sophie’s referral. It became clear in evidence that the UK services did not understand that “Scheduled” is the Australian equivalent of being “Sectioned” and there was a lack of probity and curiosity to as what this meant and what treatment Sophie had in Australia ; albeit that the evidence was not convincing (or even persuasive) that the Australian discharge summary had been thoroughly read at all on being received by the CPE.
Overall, there appears, on the evidence, to be very poor communication between the departmental services and, as a result, opportunities appear to have been missed to fully appreciate Sophie’s full clinical presentation when making an assessment about the timeliness of appropriate interventions and assessments. I believe that whilst the service remains disjointed, with insufficient exploration of information sent from foreign jurisdictions , there remains a risk that future death will continue to occur.
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication between departmental services
Wider context from the report “It became very clear in evidence that the overseas involvement was not properly flagged up when the CPE came to triage Sophie’s referral; this includes both the discharge summary and Sophie’s own self-referral via email whilst she was in Australia. The full discharge summary from Australia was sent by the GP along with his referral on the 8th May 2019 to ensure that all relevant information was shared at the earliest stage. These notes were either not fully reviewed and/or understood by the CPE and this appears to have contributed to the downgrading of Sophie’s referral. It became clear in evidence that the UK services did not understand that “Scheduled” is the Australian equivalent of being “Sectioned” and there was a lack of probity and curiosity to as what this meant and what treatment Sophie had in Australia; albeit that the evidence was not convincing (or even persuasive) that the Australian discharge summary had been thoroughly read at all on being received by the CPE.
Overall, there appears, on the evidence, to be very poor communication between the departmental services and, as a result, opportunities appear to have been missed to fully appreciate Sophie’s full clinical presentation when making an assessment about the timeliness of appropriate interventions and assessments. I believe that whilst the service remains disjointed , with insufficient exploration of information sent from foreign jurisdictions, there remains a risk that future death will continue to occur.
” 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 shared mechanisms for recording referrals and risk information and escalating cases to CPE.
Verbatim wording from the response “Notwithstanding these immediate changes and the significant learning embedded following Sophie’s death, the transformation of the Trust’s wellbeing services is a much larger piece of work with changes that are designed to ensure that missed opportunities to share such referral information are minimised as far as is possible. Ongoing work within Talking Therapies will focus on clear shared mechanisms for recording referrals, risk information and escalating to the CPE.” Source location 2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
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 Pilot a requirement for triage workers to contact every referrer before downgrading referrals.
Verbatim wording from the response “Following learning from this case, the CPE service is piloting a policy that requires triage workers to contact all referrers before downgrading referrals. This is explored further below. This pilot has the additional benefit that there is dialogue between CPE and referrers in relation to specific cases. The information within the referral forms can be discussed and evaluated as there is the opportunity for professional discussion and challenge over the rationale for downgrading. This provides specific feedback and education to referrers about how the information they provide on referral forms is used and interpreted, and how they can improve the content.” Source location 2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
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 Transform wellbeing services so Talking Therapies becomes the planned front door, gathers referral information and provides timely feedback.
Verbatim wording from the response “In light of these resource pressures, the Trust has recognised that the current model of triaging referrals needs re-evaluating. It is in a process of transformation of all of its wellbeing services which will aim to address these issues. The final permutation of this transformation remains a work in progress, however the current plan is that Talking Therapies will be the ‘front door’ for all referrals. Talking Therapies will undertake the initial triage and ensure sufficient information is obtained from the referrer. As part of this new model all referrals will receive timely feedback on their referrals.” Source location 2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
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 Share case learning through learning events, team meetings and joint training for Talking Therapies and CPE staff.
Verbatim wording from the response “The learning from this case has been explored and discussed in a learning event and also in team meetings to ensure the team are consistent in terms of decision making relating to triaging.” Source location 2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
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 Implement e-referrals with clearer referral information, service-remit prompts and feedback to GPs.
Verbatim wording from the response “The Transformation Team is working to improve the referral system through e-referrals, which will include timescales for ‘drop-downs’, and immediate feedback to GPs. The E referrals went live” Source location 2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
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 Refer all referrals with a substantive international element to a manager for triage.
Verbatim wording from the response “The Trust has recognised that the CPE triage team may not always have sufficient time to complete the due diligence required to interpret and translate referrals with substantial additional information from abroad. As a result, all referrals with a substantive international element are now referred up for triage by a manager. This has been taking place successfully since Sept 2019.” Source location 2020-0142-Response-from-Berkshire-NHS-Foundation-Trust.pdf
Open published response
11 May 2015 Miss Chandni Nigam · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Failure to obtain relevant history and treatment input from private clinicians 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
Miss Chandni Nigam · 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
Miss Chandni Nigam, a 19-year-old woman with a history of depression and suicidal ideation, died after being struck by a train at Twyford Railway Station on 4 February 2014. The report raised concern that the NHS Mental Health Team did not obtain relevant history or input from her previous private clinicians when care transferred to the NHS.
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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain relevant history and treatment input from private clinicians
Wider context from the report “(1) During the course of her on-going care, Miss Nigam was being seen by private psychiatrist and psychologist. When she reverted to NHS Mental Health Team Care she still had on-going sessions with the private psychologist. There was an opportunity to gain history and input from the private clinicians as to Miss Nigam’s history, previous treatment and what had been successful and less successful. No attempt to obtain that history or any input from the previous private clinicians appears to have been made. There was an opportunity to obtain helpful and effective historical information that may have assisted in the treatment of Miss Nigam by the Mental Health Team.
” Open source report
15 Jul 2014 Stephen Peter Church · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 4 Lack of joint working to address high self-harm risk promptly View source Insufficient knowledge and understanding of the interagency mental health working protocol View source Breakdown of the British Transport Police chain of command for detention responsibilities View source Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment View source See 1 more concern
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
Stephen Peter Church · 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
Stephen Church was found dead at the entrance to the multi-storey car park at Royal Berkshire Hospital on 13 May 2011 after absconding while detained under section 136 of the Mental Health Act 1983. The concerns included a broken chain of command resulting in only one police officer being responsible for his detention, insufficient understanding of an interagency working protocol, inadequate joint working to keep him safe, and delay in contacting an approved mental health professional to arrange a Mental Health Act assessment.
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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint working to address high self-harm risk promptly
Wider context from the report “(3) There was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and psychiatric liaison service staff members to ensure that Stephen Church was safe and the high risk of him self-harming addressed promptly .
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient knowledge and understanding of the interagency mental health working protocol
Wider context from the report “(2) There was insufficient knowledge and understanding amongst members of the psychiatric liaison service and the Royal Berkshire Hospital as regards the "Interagency joint Working Protocol for the Management of Mental Health Thames Valley Area"
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Breakdown of the British Transport Police chain of command for detention responsibilities
Wider context from the report “(1) The chain of command within the British Transport Police was broken unacceptably leading to only one police officer responsible for detaining Mr Church .
” 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 Berkshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment
Wider context from the report “There was a lack of appreciation amongst the psychiatric liaison service, Royal Berkshire Hospital staff and British Transport Police as to the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations