12 Feb 2015 Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 8 Delay in allocating a key worker View source Poor and perfunctory risk assessment documentation View source Failure to update risk assessments with emerging risks View source Failure to set boundaries for patient leave View source Failure to communicate and review relevant clinical information before risk decisions View source Failure to discuss risk assessments with relevant staff View source Failure to conduct planned medication, diagnosis and treatment reviews View source Unavailability of ligature-proof doors and adequate ligature-risk controls View source See 5 more concerns
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AI-generated summary
Jane Marie Clark and Isobel Griffin · 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
Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.
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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 Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Delay in allocating a key worker
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August . The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor and perfunctory risk assessment documentation
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented .
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory .
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances .
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk assessments with emerging risks
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th .
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment .
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to set boundaries for patient leave
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return .
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and review relevant clinical information before risk decisions
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave . Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss risk assessments with relevant staff
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct planned medication, diagnosis and treatment reviews
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Berrywood Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ligature-proof doors and adequate ligature-risk controls
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk .
” 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