27 Oct 2025 Shannon Lee Jordan · Prevention of Future Deaths report Black Country
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Concerns raised 2 Lack of clarity regarding required intervals for observation checks View source Lack of a national standard for observation-check intervals 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
Shannon Lee Jordan · 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
Shannon Lee Jordan was admitted to hospital after her mental health deteriorated and she reported plans to run in front of cars. While detained and subject to observations, she was found unresponsive after tying a ligature around her neck and was pronounced deceased on 1 March 2023. The principal concern was confusion about whether 15-minute observations could be completed within a 15-to-30-minute range, with no national standard for observation intervals.
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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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity regarding required intervals for observation checks
Wider context from the report “2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.
3. There is no national standard, and each Trust can implement its own time interval for observation checks to be completed.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a national standard for observation-check intervals
Wider context from the report “2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.
3. There is no national standard, and each Trust can implement its own time interval for observation checks to be completed.
” 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 Implement and communicate a clear 15-minute requirement for Level 2 intermittent observations through policy, training materials and intranet resources.
Verbatim wording from the response “2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.” Source location Response from Black Country Healthcare NHS Foundation
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trust policies, training and resources unambiguously require Level 2 intermittent observations within 15 minutes and contain no reference to 30 minutes.
Verbatim wording from the response “2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.” Source location Response from Black Country Healthcare NHS Foundation
Open published response
15 Feb 2024 Thomas Peter LOXTON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4 Lack of collaborative working to establish and embed the process for notifying of patient deaths View source Failure to complete BCH Root Cause Analysis recommendations within their target timeframes View source Failure to complete the patient-death notification process action within its target timeframe View source Lack of collaborative working to establish and embed the process for notifying of patient deaths View source See 1 more concern
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
Thomas Peter LOXTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Peter LOXTON was found unresponsive at home on 21 September 2023 and was subsequently declared deceased. The post-mortem examination determined that his death was due to an overdose of multiple prescription medications, and the inquest concluded suicide. Concerns included administrative errors that led to clinicians sending contact letters to his family after his death, insufficient collaborative working between two mental health trusts, and outstanding actions intended to reduce the risk of future 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of collaborative working to establish and embed the process for notifying of patient deaths
Wider context from the report “2. Secondly, in this inquest, there was evidence that Thomas' family received letters from clinicians from Dudley Integrated Health and Care NHS Trust (DIH) requesting that Thomas made contact, which were sent after his death, causing obvious distress to his family. It is not difficult to see that this type of administrative error could lead to significant distress to families who are already vulnerable by virtue of their bereavement, and which could give rise to a risk of death. An RCA carried out by DIH identified that action was to be taken - namely that DIH should work with colleagues at BCH to establish and embed the process for notifying of patient deaths . However, this does not appear to be an action that has been identified in BCH's RCA report , and I am concerned by the apparent lack of collaborative working to ensure this process is carried out .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete BCH Root Cause Analysis recommendations within their target timeframes
Wider context from the report “1. The evidence on behalf of Black Country Healthcare NHS Foundation Trust (BCH) was that there are numerous recommendations as detailed in its Root Cause Analysis (RCA) report that remain outstanding that have target completion dates that arise after the conclusion of this inquest. These dates have been pushed back once already . I am concerned that if these targets are pushed back further and/or are not met , for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that the targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the patient-death notification process action within its target timeframe
Wider context from the report “2. Secondly, the evidence on behalf of DIH was that the above action to be taken remains outstanding and has a target completion date that arises after the conclusion of this inquest . I am concerned that if this target is pushed back and/or is not not met , for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that the targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of collaborative working to establish and embed the process for notifying of patient deaths
Wider context from the report “1. In the inquest, there was evidence that Thomas' family received letters from clinicians from Dudley Integrated Health and Care NHS Trust (DIH) requesting that Thomas made contact with them, which were sent after his death, causing obvious distress to his family. It is not difficult to see that this type of administrative error could lead to significant distress to families who are already vulnerable by virtue of their bereavement, and which could give rise to a risk of death. An RCA carried out by DIH identified that action was to be taken - namely that DIH should work with colleagues at Black Country Healthcare NHS Foundation Trust (BCH) to establish and embed the process for notifying of patient deaths . However, this does not appear to be an action that has been identified in BCH's RCA report , and I am concerned by the apparent lack of collaborative working to ensure this process is carried out .
” 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 Work with the local ICB and primary care colleagues to explore improved management of death notifications.
Verbatim wording from the response “In addition, we recognise that a patient’s GP will often be best placed to receive death notifications, reflective of their role as being at the heart of individual patient care. However, it is not always possible for each GP to be able to easily recognise all of the relevant organisations which would require being informed. Both DIHC & BCH have therefore raised this issue with our local Black Country ICB to explore how we might be able to better manage this with our primary care colleagues.” Source location Response from Black Country Healthcare
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 Explore opportunities to improve death notification through full implementation of local medical examiner services.
Verbatim wording from the response “We have also identified that the full implementation of local medical examiner services also provides an excellent opportunity to improve the death notification process for all organisations and so are also exploring this with the relevant colleagues.” Source location Response from Black Country 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 Implement an enhanced cross-organisation process for confirming patient deaths and preventing inappropriate post-death correspondence.
Verbatim wording from the response “Building on the collaborative working arrangements we already have in place between Dudley Integrated Healthcare and Black Country Healthcare, we have implemented a more enhanced process across both organisations to try to minimise any opportunities for delay and to expand this might have on families, as well as identified some broader actions to help develop further improvements:” Source location Response from Black Country 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 Continue working with community services to embed action-plan changes and monitor their impact.
Verbatim wording from the response “We have enclosed alongside this letter a copy of the action plan presented to you during inquest on the 15th February 2024. This update provides further insight into the completion of all areas of learning identified as a result of our investigation. Where applicable we have referenced the assurance processes” Source location Response from Black Country Healthcare
Open published response
19 Feb 2021 Ms Lisa Grant · Prevention of Future Deaths report Black Country
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Concerns raised 1 Significantly increased risk of deep vein thrombosis associated with obesity, inactivity and a rare recognised Risperidone side effect 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
Ms Lisa Grant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Lisa Grant was admitted to Hallam Street Hospital in July 2019 and collapsed on the ward on 1 August 2019, later dying at Sandwell Hospital. The inquest identified bilateral pulmonary embolism due to deep vein thrombosis, and concerns included her increased DVT risk associated with obesity and inactivity, alongside a recognised rare risk associated with risperidone, despite an assessment that no further DVT treatment or assessment was required.
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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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Significantly increased risk of deep vein thrombosis associated with obesity, inactivity and a rare recognised Risperidone side effect
Wider context from the report “1. Evidence emerged during the inquest that both the consulting Psychiatrist and the Hospital’s Manager said that Ms Grant was assessed upon admission to hospital in accordance with the national guidelines for the assessment for Deep vein thrombosis (DVT). As per the guidance criteria checklist, the clinician considered that there was no significant reduction in mobility, and therefore no further treatment or assessment for this condition was required.
2. Miss Grant had a significantly increased risk of DVT due to the effects of obesity and inactivity. In addition, there was a rare but recognised side effect of Risperidone.
” Open source report
6 Dec 2019 Ms Safoora Alam · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 7 Lack of information gathering before social worker visits View source Inconsistent sharing of documentation and case notes between agencies View source Lack of joint Mental Health Trust and social care packages for patients with complex physical health needs View source Lack of opportunities to convene multi-agency meetings View source Urgent referral mechanisms via safeguarding teams and GPs failing to work effectively View source Failure to contact the Mental Health Trust before social worker visits View source Failure to carry out an assessment before the visit View source See 4 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
Ms Safoora Alam · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Safoora Alam had complex physical health problems, ongoing pain and mobility issues, and a history of impulsive overdoses and suicidal thoughts. On 28 January 2019, she set fire to her bed and herself, sustained burns to at least 80% of her body, and died later that day. The principal concerns were inconsistent sharing of documentation between agencies, inadequate joint working and information gathering, and a slow and ineffective urgent referral process when risks to her mental health escalated.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of information gathering before social worker visits
Wider context from the report “3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent sharing of documentation and case notes between agencies
Wider context from the report “1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the agencies involved .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint Mental Health Trust and social care packages for patients with complex physical health needs
Wider context from the report “2. There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi-agency meetings.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of opportunities to convene multi-agency meetings
Wider context from the report “2. There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi-agency meetings.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Urgent referral mechanisms via safeguarding teams and GPs failing to work effectively
Wider context from the report “4. The Local authority housing officers did recognise the escalating risk in her mental health state but the mechanism for urgent referral via the safeguarding team and GP was a slow and cumbersome process which didn’t work .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the Mental Health Trust before social worker visits
Wider context from the report “3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out an assessment before the visit
Wider context from the report “3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took place .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a joint database or protocol containing current service contacts, organisational hierarchies, governance arrangements and escalation processes.
Verbatim wording from the response “The General Manager for Black Country Partnership and the Service Manager for the Local Authority have agreed to set up task and finish groups to look at joint agency protocols in both organizations and review them. Furthermore, they agreed that there should be a joint database or protocol which contains all contacts and services that each organisation provides. This will provide staff with an up to date contact list of services in order to support and promote joint working.” Source location 2019-0426-Response-from-Black-Country-Partnership-NHS-Foundation-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the steering group to consider introducing joint complex-care panels for shared risk assessment, information sharing and working.
Verbatim wording from the response “Both senior managers were able to identify common goals and aims in existing organizational protocols and will instigate a steering group of senior clinicians and managers from both organisations to look at introducing joint complex care panels that will look at risk assessments for patients with complex needs that require joint information sharing and joint working.” Source location 2019-0426-Response-from-Black-Country-Partnership-NHS-Foundation-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority is responsible for reviewing social worker training and obtaining accurate, up-to-date information before visits.
Verbatim wording from the response “2. Social Services may wish to consider reviewing their training for the social workers involved and the importance of obtaining accurate and up to date information prior to any visit.” Source location 2019-0426-Response-from-Black-Country-Partnership-NHS-Foundation-Trust
Open published response
12 Jul 2019 David Jonathon Jukes · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to follow through plans made to discuss and assess patients View source Failure to maintain accurate records of contacts, decisions and risk assessments View source Failure of the system to carry out necessary psychiatric assessments in police custody View source Failure to use all available means to locate patients requiring assessment View source Failure to ensure staff compliance with record-keeping duties is detected View source Failure to provide material arrest information for mental health assessments in custody View source Failure to attempt timely assessment after a high-risk patient re-establishes contact View source Failure to pass reliable information between mental health services View source Insufficient HTT capacity to maintain progress notes and risk assessments View source See 6 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
David Jonathon Jukes · 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
David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow through plans made to discuss and assess patients
Wider context from the report “5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him . No explanation was provided in evidence for why evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of contacts, decisions and risk assessments
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes . Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment . There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the system to carry out necessary psychiatric assessments in police custody
Wider context from the report “3. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team. It is not known why this was. Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use all available means to locate patients requiring assessment
Wider context from the report “4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was treating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance . There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff compliance with record-keeping duties is detected
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited . Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide material arrest information for mental health assessments in custody
Wider context from the report “1. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody . She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threatened suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt timely assessment after a high-risk patient re-establishes contact
Wider context from the report “6. On the 9th October 2018 an HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018 . By this time he was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact . The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk . No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pass reliable information between mental health services
Wider context from the report “2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of his previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred . Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise . If reliable information is not being passed there is a risk to life from ill-informed decision making.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient HTT capacity to maintain progress notes and risk assessments
Wider context from the report “8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from a combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team . Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments . If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk.
” 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 Implement MERIT access arrangements to enable cross-trust access to relevant mental-health records.
Verbatim wording from the response “Unfortunately we have yet to ascertain why on this occasion the L&D staff member was advised by BSMHT that the patient was not known to services however meetings with Trust leads from BSMHT are being planned to consider how we can jointly strengthen communication pathways to prevent reoccurrence. Implementation of the MERIT system will further enable staff access to information from mental health Trusts in Birmingham and Coventry. Likewise Birmingham and Coventry staff will be authorised for access to MERIT, for mental health information about those records held on both Oasis systems covering the whole of the Black Country.” Source location 2019-0329-Response-by-Black-Country-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the report’s outcome and learning with police through quarterly Joint Operational Group meetings, stressing full handover before every assessment.
Verbatim wording from the response “L&D leads will raise awareness of the outcome and learning from the regulation 28 PFD report through the Joint Operational Group held with police on a quarterly basis to engage with police colleagues and stress the need for a full handover prior to assessment in each and every case.” Source location 2019-0329-Response-by-Black-Country-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement CONNECT access for Liaison and Diversion staff, including wider custody information and nursing read-write risk recording.
Verbatim wording from the response “At present Liaison and Diversion (L&D) nursing staff have read access only to the current electronic custody record (ICIS) and in line with standard operational procedures are instructed to ensure checks are undertaken and all available content on ICIS is reviewed. This is further supported by obtaining a verbal update from the police. To improve” Source location 2019-0329-Response-by-Black-Country-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Liaison and Diversion staff access to the Spine for wider pan-mental-health information.
Verbatim wording from the response “Before acting on any referral, L&D staff will do full background checks. This is part of the triage process to establish previous history, risk, current care plans, treatment, compliance and medication for example so staff can make an informed judgement on who needs to be seen and the level of urgency. Local mental health databases are reviewed however when staff don’t have immediate access, neighbouring services will be telephoned to attain all relevant information. Across the L&D services we are also rolling out staff access to the Spine to give staff wider access to pan-mental health information.” Source location 2019-0329-Response-by-Black-Country-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet BSMHT Trust leads to consider jointly strengthening communication pathways between services.
Verbatim wording from the response “Unfortunately we have yet to ascertain why on this occasion the L&D staff member was advised by BSMHT that the patient was not known to services however meetings with Trust leads from BSMHT are being planned to consider how we can jointly strengthen communication pathways to prevent reoccurrence. Implementation of the MERIT system will further enable staff access to information from mental health Trusts in Birmingham and Coventry. Likewise Birmingham and Coventry staff will be authorised for access to MERIT, for mental health information about those records held on both Oasis systems covering the whole of the Black Country.” Source location 2019-0329-Response-by-Black-Country-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other concerns concerned NHS bodies and services not provided by the respondent, so the respondent did not comment on those outcomes.
Verbatim wording from the response “Please note that all other concerns raised within the Regulation 28 report affected other NHS bodies and services not provided by BCPFT and therefore we have not commented on these outcomes. We have however approached both BSMHT and CWPT to consider” Source location 2019-0329-Response-by-Black-Country-Partnership-NHS-Trust
Open published response
Concerns raised 5 Lack of a joint multidisciplinary and interagency care plan for responding to relapse indicators View source Excessive reliance on mental health tribunal decisions in care planning View source Inadequate follow-up engagement and monitoring after discharge View source Failure to provide assertive care coordination for patients at risk of disengagement and relapse View source Failure to coordinate multidisciplinary review and mental health act assessment when considering hospital admission View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Peter Lawrence (PL) · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a joint multidisciplinary and interagency care plan for responding to relapse indicators
Wider context from the report “2. There was a lack of a joint multi-disciplinary/agency care plan (between Local authority and Mental Health Trust) which could have resulted in delays in a timely response to known relapse indicators .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on mental health tribunal decisions in care planning
Wider context from the report “5. When PL was successful at the mental health tribunal and was discharged from Section 3 following his last admission to hospital in October 2017 against the view of the multidisciplinary team. The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate follow-up engagement and monitoring after discharge
Wider context from the report “5. When PL was successful at the mental health tribunal and was discharged from Section 3 following his last admission to hospital in October 2017 against the view of the multidisciplinary team. The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assertive care coordination for patients at risk of disengagement and relapse
Wider context from the report “3. A more assertive approach with consistency of care coordinator for a patient with a history of disengagement and relapse could possibly have been implemented reducing the likelihood of disengagement with services and promoted necessary concordance with medication .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate multidisciplinary review and mental health act assessment when considering hospital admission
Wider context from the report “4. A decision to admit to hospital under the mental health act following concerns being raised about self-care and disengagement could potentially have followed a coordinated MDT review and mental health act assessment and prevented deterioration in his mental health.
” Open source report
18 Apr 2018 Mr Colin Johns · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Inadequate communication and history-taking during mental health assessment View source Failure to record significant self-harm and access-to-medication risks View source Failure to find a suitable bed for a high-risk patient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Colin Johns · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Colin Johns, a 71-year-old man with a history of low mood, alcohol dependency and previous self-harm, was discharged home after presenting with suicidal thoughts and requesting psychiatric admission. He subsequently took an overdose of co-codamol and died after being found collapsed at home. Concerns included inadequate communication and history-taking about self-harm attempts and insufficient efforts to find a suitable inpatient bed.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication and history-taking during mental health assessment
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and history taken as part of the assessment process by the MHLS nurse . Specifically there were failures to record the fact he had attempted to strangle/suffocate himself whilst in the A and E department and gain entry to the drugs trolley.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant self-harm and access-to-medication risks
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and history taken as part of the assessment process by the MHLS nurse. Specifically there were failures to record the fact he had attempted to strangle/suffocate himself whilst in the A and E department and gain entry to the drugs trolley .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to find a suitable bed for a high-risk patient
Wider context from the report “2. Further efforts should have been made to find a suitable bed given his high level of risk and previous history .
” Open source report
4 May 2017 Mr Reginald Frank Lewis · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Insufficient ward capacity for patients requiring continuous observation View source Lack of capacity to safely manage additional confused, wandering or aggressive patients View source Failure to ensure admission decisions reflect senior clinical assessment of patient suitability View source Failure to maintain supervision of patients when family visitors leave the ward 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
Mr Reginald Frank Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Reginald Frank Lewis was admitted to hospital after a fall, later fell again while on Ward C19 and sustained a head injury causing an intracerebral bleed; he died on 17 January 2017. Concerns included inadequate communication of his confusion, falls risk and blindness during transfer, his being left unsupervised after family visitors left, and pressure to accept him into a ward already managing several patients requiring continuous observation.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ward capacity for patients requiring continuous observation
Wider context from the report “2. On ward c19, there were already six patients on the ward required to be observed 24 hours a day in two bays . Two bays were subsequently closed to diarrhoea and vomiting .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity to safely manage additional confused, wandering or aggressive patients
Wider context from the report “3. Evidence emerged from nursing staff on Ward C19 that they were unable to take any more patients that are confused, wandering or aggressive . This was based on the enhanced scoring tool and the number of patients that required one to one observation .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure admission decisions reflect senior clinical assessment of patient suitability
Wider context from the report “4. Despite initial reservations, junior nursing staff did eventually accept Mr Lewis into Ward C19 on the basis he had mild confusion and claimed they felt “under some pressure” from senior nursing staff to accept him . This was in contrast to the opinion of the senior Charge Nurse on ward C19 who gave evidence that he still would not have accepted the patient in the circumstances .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain supervision of patients when family visitors leave the ward
Wider context from the report “1. Evidence emerged during the inquest that the patient was left alone unsupervised when family visitors left the ward . It transpired that staff didn’t know relatives had left the ward .
” Open source report
3 Apr 2017 Ms Abigail Baynham · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to make further referrals back to the Mental Health Liaison Service after hospital discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Abigail Baynham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Abigail Baynham had a history of suicidal ideation and was found deceased at her flat after taking her own life. The inquest heard that no further referral to the Mental Health Liaison Service was made when she left hospital, which may have led to a further assessment of her mental state and risk of self-harm.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make further referrals back to the Mental Health Liaison Service after hospital discharge
Wider context from the report “1. Evidence emerged during the inquest that when Ms Baynham had left hospital on the 22 November 2017, there was no further referral made back to Mental Health Liaison Service . This may have triggered a further assessment about her mental state and risk of self-harm.
” Open source report
24 Jan 2017 Mrs Kaur · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Zopiclone addiction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Kaur · 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
Mrs Kaur had a history of diabetes and recurrent depressive disorder and had used zopiclone for around five years, becoming reliant on it. She died by hanging at her home on 5 November 2017; concerns included her long-term use and apparent addiction to zopiclone and the decision to stop it immediately to prevent serious self-harm, although she subsequently continued receiving it and it was tapered over several weeks.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Zopiclone addiction
Wider context from the report “1. Evidence emerged during the inquest that Mrs Kaur had been a long term user of zopiclone and had effectively become addicted to this drug .
” Open source report
21 Apr 2016 Richard Paul Martin Grant · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to refer patients who have attempted suicide to the right mental health team within a reasonable time View source Delays in sending assessment circumstances and outcomes to GPs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Paul Martin Grant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Paul Martin Grant was found deceased in his car in his garage on 7 January 2016 following inhalation of helium gas. He had previously self-harmed and threatened suicide, but his counselling referral was sent to the wrong team and an appointment was arranged for 22 February 2016. The report identified concerns about delays and failures in referring him to the appropriate mental health service and in informing his GP about the assessment and its outcome.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients who have attempted suicide to the right mental health team within a reasonable time
Wider context from the report “(1) Mental Health Nurse Catherine Collins of the Oak Unit Mental Health Liaison Team gave evidence that the referral to the Black Country Partnership Single Point of Referral (‘SPOR’) team was faxed on the 7th December 2015. Only when Mr. Grant chased with Oak Unit why he had not received an appointment or further contact from Mental Health Services on the 4th January 2016 was it identified that his referral ought to have been sent to the Birmingham and Solihull Mental Health NHS Foundation Trust single point of access team . Ms. Collins and the Black Country Partnership have provided no explanation for what happened to Mr. Grant’s referral between it being sent on the 7th December and the 4th January 2016.
A clear risk to life clearly arises from patients who have been referred because of suicide attempt not being referred to the right team within a reasonable time.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in sending assessment circumstances and outcomes to GPs
Wider context from the report “(2) A letter detailing ████████ assessment and the outcome of it was not sent to Mr. Grant’s GP until at least the 22nd December 2015 , ████████ did not know why there was such a delay nor whether it was typical. There is a clear risk to life from GPs not being aware of the circumstances and outcome of assessments of patients who have attempted suicide for such an extended period.
” 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 an MHLS checklist prompting postcode reviews to prevent incorrect referral routes.
Verbatim wording from the response “1. A MHLS checklist is being developed and shared through team meetings which include prompts to review postcodes of patients to avoid incorrect referral route – Timescale for completion May 2016. (Completed)” Source location 2016-0157-Response-by-Black-Country-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 Review the MHLS protocol to introduce the Common Assessment Tool and Clustering Tool for direct referrals.
Verbatim wording from the response “3. MHLS protocol being reviewed to encompass use of Common Assessment Tool and Clustering Tool to enable direct referrals from MHLS. Timescale for completion August 2016.” Source location 2016-0157-Response-by-Black-Country-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 Implement an MHLS standard requiring assessment letters to be drafted within the same or following shift and dispatched within three working days.
Verbatim wording from the response “4. MHLS standard developed requiring all letters are drafted within the same or following shift and are dispatched within 3 working days. (Completed)” Source location 2016-0157-Response-by-Black-Country-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 Revise the SPOR duty system to prevent inappropriate referrals being returned, enable direct onward signposting, and confirm referral receipt by telephone.
Verbatim wording from the response “2. Review of SPOR duty system is underway and will include ceasing practice of sending inappropriate referrals back to referrer. Clinician will continue to review all referrals and will forward / signpost referrals directly onwards. System will also include confirmation of receipt by telephone call. Timescale for completion May 2016. (Completed)” Source location 2016-0157-Response-by-Black-Country-NHS
Open published response
17 Oct 2014 Kirsty Lisa Pritchard · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Failure to report post-discharge patient contact to the responsible consultant in a timely manner View source Lack of effective systems to action worsening symptoms and associated self-harm or suicide risk after discharge View source Deficiencies in systems for promptly contacting and locating patients at immediate risk of self harm View source Failure to ensure that the responsible consultant is made aware of worsening symptoms after discharge View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kirsty Lisa Pritchard · 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
Kirsty Lisa Pritchard had complex medical needs and a history of self-harm and suicidal ideation. After being discharged from hospital, she contacted the community team several times reporting thoughts of self-harm and suicide; she was later found deceased at home, hanging with a belt around her neck, and was pronounced deceased at 14:15 on 20 January 2013. The report raised concerns about delayed communication of worsening symptoms and risk to the responsible consultant, and deficiencies in systems for contacting and locating her after an immediate risk was reported.
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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report post-discharge patient contact to the responsible consultant in a timely manner
Wider context from the report “(1)The Root cause analysis report by the Black Country Partnership NHS Trust confirmed that there were issues in relation to the communication of information. Specifically, the evidence presented at the inquest confirmed that CHTT contact with Ms Pritchard following discharge were not reported back to the inpatient Consultant in charge for review and assessment of risk of self harm in a timely fashion .
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective systems to action worsening symptoms and associated self-harm or suicide risk after discharge
Wider context from the report “(2) I am concerned that the ability to undertake effective management of patient risks of self harm and suicide ideation upon discharge may be compromised if the Consultant in charge or equivalent is not made aware of worsening symptoms and that effective systems are not in place to action this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in systems for promptly contacting and locating patients at immediate risk of self harm
Wider context from the report “(3) In addition, I am concerned that there were deficiencies in the systems in place for contacting and finding the patient . In this case the patient had contacted the CHTT with a real and immediate risk of self harm and it took over 5 hours to find her despite the fact that the Police managed to locate her very quickly when they were subsequently contacted.
” 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 Black Country Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that the responsible consultant is made aware of worsening symptoms after discharge
Wider context from the report “(2) I am concerned that the ability to undertake effective management of patient risks of self harm and suicide ideation upon discharge may be compromised if the Consultant in charge or equivalent is not made aware of worsening symptoms and that effective systems are not in place to action this.
” 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 Generate a start-of-shift list of patients referred to A&E and follow up attendance, taking further action where required.
Verbatim wording from the response “Ms Pritchard was advised to attend A&E on 16 January 2013 having contacted CHITT, however there is no evidence that she presented herself at A&E on that occasion. Action has now been taken to ensure that at the start of each shift the CHITT team leader generates a list of all patients referred to A&E so that these can be followed up to ascertain if the patients did attend. This ensures that further action is taken if required. (the protocol for cold calls will be followed if non-attendance is established – see further explanation below).” Source location 2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and apply a protocol requiring timely cold calls and police safe-and-well checks when immediate-risk service users cannot be contacted or located.
Verbatim wording from the response “In response to the concerns raised regarding the timescale for this response, a protocol has now been developed to address these issues. Where a service user is assessed to be in immediate risk of harm or death, and if telephone contact cannot be established with the service user within 30 minutes the CHITT are to carry out a cold call of the service user’s home address/ last known location within 1 hour. If CHITT are unable to gain access or locate the service user they are to contact the police to conduct a ‘safe and well’ check.” Source location 2014-0565-Response-by-Black-County-NHS-Trust_Redacted
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 Recirculate the medical escalation flow chart to CHITT and inpatient staff to clarify escalation routes for risk concerns.
Verbatim wording from the response “• The communication with consultants to raise any concerns has been reinforced by recirculating the medical escalation flow chart (Appendix 1) to all CHITT and inpatient staff both clinical and non-clinical so that it is clear which individual any concerns about risk should be raised with.” Source location 2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Open published response
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Request correction
Addressed to Dudley Integrated Health and Care NHS Trust, now represented here by Black Country Healthcare NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations