Bexley ADAPT Service

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First report 21 Feb 2020•Latest report 21 Feb 2020

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Bexley ADAPT Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South London

    AI-generated summary

    Billy James Jenkins · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Over-reliance on alcohol and drug use in assessing suicidal ideation

    Wider context from the report

    “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete assessment sufficient to identify mental health diagnosis requiring treatment

    Wider context from the report

    “(3) As a direct consequence of the limited information gathering Billy Jenkins was not properly assessed and it was not known whether he had a mental health diagnosis which required treatment. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a proforma of assessment questions

    Wider context from the report

    “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify training or support requirements for the Community Mental Health Nurse

    Wider context from the report

    “(4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish lessons learned by teams involved in care and treatment

    Wider context from the report

    “(4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain sufficient assessment information before multidisciplinary mental health review and decision-making

    Wider context from the report

    “(1) The findings of the internal investigation by Oxleas NHS were that the assessment undertaken by the Community Mental Health Nurse did not illicit sufficient information to enable the multidisciplinary team to properly review Mr Jenkins’ mental health. Despite this the multi-disciplinary team proceeded with a review and decided that he did not have a mental health condition, without seeking a further assessment ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to develop robust plans addressing protective factors and harm minimisation

    Wider context from the report

    “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bexley ADAPT Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document clinical formulation or impression

    Wider context from the report

    “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026