6 Mar 2025 Andrea Denise MANN · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 4 Lack of an overarching management tool for scrutinising and measuring care View source Delays in access to psychological therapy View source Failure to provide requested psychiatric appointments View source Insufficient mental healthcare appointments View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Have the administration team book consultant psychiatrist appointments for assessed referrals, using urgent slots when risk-based assessment indicates greater urgency.
View source
Action
Create a timebound recovery plan addressing assessment waits through demand-and-capacity analysis, additional staffing and administration, and streamlined clinical processes.
View source
Action
Deliver a continuous-improvement programme to enable access to a meaningful intervention within four weeks of referral.
View source
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AI-generated summary
Andrea Denise MANN · 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
Andrea Denise MANN was discovered hanging at her home on 10 February 2024 and died in hospital the following day after invasive medical care was withdrawn and palliative care was provided. The inquest identified concerns about limited Community Mental Health Trust involvement, the absence of a requested psychiatric appointment, delays in psychological therapy, and the lack of an overarching tool to scrutinise and measure the care provided.
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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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an overarching management tool for scrutinising and measuring care
Wider context from the report “2) That no evidence of any overarching management tool existed to provide scrutiny of the care given to the deceased, or measure the success or efficacy of such care , and as such there were many lost opportunities to provide to the deceased and her family sufficient, consistent, controlled and bespoke care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to psychological therapy
Wider context from the report “1) That during the period of her involvement with the Community Mental Health Trust between the period 25/04/2023 and 04/12/2023 the care given to the deceased was limited to 2 appointments only within which she was referred back to her GP for medication adjustment which had been seen to be ineffective, and referral to Psychological therapy sessions which had a waiting period of 6 months despite an earlier private consultation having been proved ineffective,
That the frequent requests of the deceased and her family for a Psychiatric appointment had not been provided to her, with the result that the deceased had to seek a private consultation.
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide requested psychiatric appointments
Wider context from the report “1) That during the period of her involvement with the Community Mental Health Trust between the period 25/04/2023 and 04/12/2023 the care given to the deceased was limited to 2 appointments only within which she was referred back to her GP for medication adjustment which had been seen to be ineffective, and referral to Psychological therapy sessions which had a waiting period of 6 months despite an earlier private consultation having been proved ineffective,
That the frequent requests of the deceased and her family for a Psychiatric appointment had not been provided to her , with the result that the deceased had to seek a private consultation.
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental healthcare appointments
Wider context from the report “1) That during the period of her involvement with the Community Mental Health Trust between the period 25/04/2023 and 04/12/2023 the care given to the deceased was limited to 2 appointments only within which she was referred back to her GP for medication adjustment which had been seen to be ineffective, and referral to Psychological therapy sessions which had a waiting period of 6 months despite an earlier private consultation having been proved ineffective,
That the frequent requests of the deceased and her family for a Psychiatric appointment had not been provided to her, with the result that the deceased had to seek a private consultation.
” 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 Have the administration team book consultant psychiatrist appointments for assessed referrals, using urgent slots when risk-based assessment indicates greater urgency.
Verbatim wording from the response “7. For those referrals that have been assessed as requiring an appointment with a consultant psychiatrist, this will be booked by the admin team. At present, routine appointments are being booked 4-6 weeks in advance however the urgency of the appointment is based on the formulation of risk based on the assessment findings and a Multi-Disciplinary Team discussion. If it is felt that the individual needs to be seen more urgently, medics have urgent appointment slots for this purpose.” Source location Response from Bradford District Care 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 Create a timebound recovery plan addressing assessment waits through demand-and-capacity analysis, additional staffing and administration, and streamlined clinical processes.
Verbatim wording from the response “5. Improvement activities were agreed and a timebound recovery plan created to stabilise, mitigate and improve waits into the Community Mental Health Assessment Team. This included:” Source location Response from Bradford District Care 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 Deliver a continuous-improvement programme to enable access to a meaningful intervention within four weeks of referral.
Verbatim wording from the response “8. We are committed to continuous improvement utilising BDCFT quality improvement methodology to improve the timeliness of support available, and a programme of work has been established, commencing April 2025, to ensure that people are able to access a meaningful intervention within four weeks of referral.” Source location Response from Bradford District Care NHS Trust
Open published response
10 Jan 2020 Miles Glynn Naylor · Prevention of Future Deaths report West Yorkshire (West)
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Concerns raised 2 Doors permitting access to the hinge pin side View source Failure to adequately manage ligature risks from personal items View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Review ligature assessments and new ligature incidents through the monthly Ligature Environmental Risk and Safety group to identify learning.
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Action
Continue reviewing processes for managing patients’ personal belongings and associated ligature risks.
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Action
Develop and submit a business case for environmental improvements and high-specification full-door alarms on identified bedrooms across eight high-risk wards.
View source
Action
Implement standard multidisciplinary ligature-risk assessments using the Manchester Audit Tool, with documented mitigations, staff access, induction materials, visual aids and training.
View source See 1 more action
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AI-generated summary
Miles Glynn Naylor · 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
Miles Glynn Naylor, a patient detained under section 2 of the Mental Health Act 1983, died in his room on the Oakdale Ward after suspending himself from a ligature made from his trouser belt and wedged in the door hinge side. The inquest jury raised concerns about the management of ligature risks from personal items and the design of the ward doors, including access to the hinge pin side.
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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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Doors permitting access to the hinge pin side
Wider context from the report “(1) The jury formally recorded their opinion as part of the conclusion to the inquest that the Bradford District Care NHS Foundation Trust should carry out a review of its management of its ligature risks from personal items.
(2) During the course of evidence, questions were raised about the design of the doors on Oakdale ward , and whether access to the hinge pin side of the doors might be prevented by the use of covers similar to the finger guards in use in children’s nurseries and similar premises).
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately manage ligature risks from personal items
Wider context from the report “(1) The jury formally recorded their opinion as part of the conclusion to the inquest that the Bradford District Care NHS Foundation Trust should carry out a review of its management of its ligature risks from personal items .
(2) During the course of evidence, questions were raised about the design of the doors on Oakdale ward, and whether access to the hinge pin side of the doors might be prevented by the use of covers similar to the finger guards in use in children’s nurseries and similar premises).
” 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 Review ligature assessments and new ligature incidents through the monthly Ligature Environmental Risk and Safety group to identify learning.
Verbatim wording from the response “All ligature risk assessments are reviewed and monitored by the monthly Ligature Environmental Risk and Safety group. The group also assesses all new ligature incidents that are with or without an anchor point to consider any learning requirements.” Source location 2020-0005-Response-from-Bradford-District-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 Continue reviewing processes for managing patients’ personal belongings and associated ligature risks.
Verbatim wording from the response “The Trust continues to review the processes which are in place regarding personal belongings. In doing this the Trust recognise there is a balance to be struck of ensuring a patient’s safety against taking steps that may be seen as negatively impacting on a patient’s improvement in their mental health.” Source location 2020-0005-Response-from-Bradford-District-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 Develop and submit a business case for environmental improvements and high-specification full-door alarms on identified bedrooms across eight high-risk wards.
Verbatim wording from the response “The Trust acknowledges the concerns raised during the inquest and a need to review the design of the doors in our in-patient wards. In June 2019, a business case was developed and submitted to the Trust Board which included environmental improvements and the introduction of high specification full door alarms on identified bedrooms on 8 high risk wards, including Oakburn. Work has begun installing these doors in designated rooms on high risk wards as part of phase 1 development and is due to be completed by April 2020.” Source location 2020-0005-Response-from-Bradford-District-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 standard multidisciplinary ligature-risk assessments using the Manchester Audit Tool, with documented mitigations, staff access, induction materials, visual aids and training.
Verbatim wording from the response “In April 2019 the Trust undertook a review of how ligature risks are assessed and managed in our in-patient areas. A new approach has been introduced (Manchester Audit Tool) which grades ligature risk based on four factors. The four factors are:” Source location 2020-0005-Response-from-Bradford-District-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replacing all inpatient doors is constrained by significant capital expense, so improvements are being delivered through the ongoing capital programme in stages.
Verbatim wording from the response “The Trust acknowledges the concerns raised during the inquest and a need to review the design of the doors in our in-patient wards. In June 2019, a business case was developed and submitted to the Trust Board which included environmental improvements and the introduction of high specification full door alarms on identified bedrooms on 8 high risk wards, including Oakburn. Work has begun installing these doors in designated rooms on high risk wards as part of phase 1 development and is due to be completed by April 2020.” Source location 2020-0005-Response-from-Bradford-District-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Potential ligature items are not routinely removed; individual risk assessment, care planning and increased observations are used where clear clinical risk exists.
Verbatim wording from the response “The Trust continues to review the processes which are in place regarding personal belongings. In doing this the Trust recognise there is a balance to be struck of ensuring a patient’s safety against taking steps that may be seen as negatively impacting on a patient’s improvement in their mental health.” Source location 2020-0005-Response-from-Bradford-District-NHS-Trust
Open published response
29 May 2018 Brian Leonard Bicat · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Unavailability of verbal fire-risk warnings from healthcare professionals for retail and online purchases View source Lack of accurate national data on fire incidents involving paraffin-based skin products View source Inconsistent fire-risk alerts and warnings across NHS prescribing systems View source Lack of healthcare professional awareness of the fire hazard from low-paraffin emollient creams View source Failure to display fire-risk warnings on all product packaging View source Fire hazard from paraffin-based ointments and low-paraffin emollient creams View source See 3 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Display emollient risk messages on Trust screens and repeat the messages twice yearly.
View source
Action
Raise staff awareness of emollient risks and include the issue in all fire training.
View source
Action
Produce and disseminate a patient safety leaflet on paraffin-based products and laundering clothing and bedding.
View source
Action
Conduct annual community nursing audits of leaflet distribution and documented discussions of emollient hazards with patients.
View source
Action
Repeat staff awareness surveys every six months to identify concerns about emollient hazards.
View source
Action
Provide existing community nursing patients with safety leaflets and advice about emollient risks.
View source
Action
Create a SystmOne alert identifying patients at risk when emollient treatment is entered in the clinical record.
View source
Action
Produce and disseminate a fire hazard poster on paraffin-based products across clinical service areas and organisational communication channels.
View source
Action
Maintain liaison with the Fire Service to update teams on laundering evidence and ongoing emollient hazards.
View source
Action
Upload the leaflet and poster to the NHSI improvement hub and disseminate them nationally through NHSI.
View source See 7 more actions
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AI-generated summary
Brian Leonard Bicat · 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
Brian Leonard Bicat sustained severe burns at home on 22 September 2017 when his dressing gown caught fire while he was smoking a cigarette. He died later that day from his extensive cutaneous burns, with evidence indicating that paraffin-based emollient creams and ointments increased the speed and intensity of the fire. The principal concerns were that low-paraffin emollients may pose a fire hazard, that warnings were not displayed consistently on packaging or communicated by healthcare professionals, and that related prescribing alerts and incident data were inconsistent or incomplete.
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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of verbal fire-risk warnings from healthcare professionals for retail and online purchases
Wider context from the report “Members of the public are able to purchase such products in retail outlets and online where verbal warnings from healthcare professionals are not given
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate national data on fire incidents involving paraffin-based skin products
Wider context from the report “Consider a review of the current effectiveness of obtaining fire incident reports involving paraffin based skin products since there is currently a lack of accurate national data involving paraffin based skin products
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent fire-risk alerts and warnings across NHS prescribing systems
Wider context from the report “The NHS prescribing systems (system One and Optimise) appear to be updated by individual CCG’s resulting inconsistent alerts and warnings .
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional awareness of the fire hazard from low-paraffin emollient creams
Wider context from the report “Health care professionals in both hospital and community setting may not be aware of the potential fire hazard poised by emollient creams which contain a low level of paraffin
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to display fire-risk warnings on all product packaging
Wider context from the report “Warnings of such risks are not displayed on all product packaging
” 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 Bradford District Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fire hazard from paraffin-based ointments and low-paraffin emollient creams
Wider context from the report “Paraffin based ointments and emollient creams which contain a low level of paraffin pose a potential fire hazard 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 Display emollient risk messages on Trust screens and repeat the messages twice yearly.
Verbatim wording from the response “9. The message regarding the risks of using emollients have been shown on the Trusts computer screens on Screen savers. This will be repeated on a bi-annual basis within BDCFT to ensure that the risk of emollients remain paramount.” Source location 2018-0277-Response-by-Bradford-District-Care-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 staff awareness of emollient risks and include the issue in all fire training.
Verbatim wording from the response “4. Awareness has been raised with all staff within Bradford District Care Foundation Trust and this issue is included in all fire training.” Source location 2018-0277-Response-by-Bradford-District-Care-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 Produce and disseminate a patient safety leaflet on paraffin-based products and laundering clothing and bedding.
Verbatim wording from the response “1. The Trust has produced a safety information leaflet for patients in relation to using paraffin-based products, in particular regarding the laundering of clothing and bedding. This leaflet has been disseminated locally across all Bradford Clinical Commissioning Groups and A cute Trust providers and Leeds Community Services.” Source location 2018-0277-Response-by-Bradford-District-Care-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 Conduct annual community nursing audits of leaflet distribution and documented discussions of emollient hazards with patients.
Verbatim wording from the response “7. A yearly audit will be undertaken within all community nursing services within BDCFT to demonstrate that staff distribute the safety leaflets on initial contact of patients who are prescribed emollients. The audit will also demonstrate that there is documented evidence of discussion by staff with patients regarding the hazards of emollients.” Source location 2018-0277-Response-by-Bradford-District-Care-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 Repeat staff awareness surveys every six months to identify concerns about emollient hazards.
Verbatim wording from the response “6. The Trust has undertaken a survey of staff’s awareness of the hazards of emollients. This survey will be undertaken six monthly and any areas of concern will be addressed following the results” Source location 2018-0277-Response-by-Bradford-District-Care-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 Provide existing community nursing patients with safety leaflets and advice about emollient risks.
Verbatim wording from the response “8. A piece of work has been completed by the community nursing services to ensure that all existing patients have the relevant patient information leaflet and advice has been given by staff to patients regarding the risks of using emollients.” Source location 2018-0277-Response-by-Bradford-District-Care-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 Create a SystmOne alert identifying patients at risk when emollient treatment is entered in the clinical record.
Verbatim wording from the response “5. An alert has been created on our clinical records system, SystmOne. This is an electronic icon indicating that a patient is at risk when emollient is entered into the clinical record.” Source location 2018-0277-Response-by-Bradford-District-Care-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 Produce and disseminate a fire hazard poster on paraffin-based products across clinical service areas and organisational communication channels.
Verbatim wording from the response “2. The Trust has produced a fire hazard poster in relation to using paraffin-based products, which has been disseminated for display throughout clinical services areas and this has also been communicated electronically across the organisation.” Source location 2018-0277-Response-by-Bradford-District-Care-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 Maintain liaison with the Fire Service to update teams on laundering evidence and ongoing emollient hazards.
Verbatim wording from the response “10. The fire officer for BDCFT will continue to liaise with the Fire service to ensure all teams are updated on the most recent evidence regarding the laundering of clothes and the ongoing hazards of emollients.” Source location 2018-0277-Response-by-Bradford-District-Care-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 Upload the leaflet and poster to the NHSI improvement hub and disseminate them nationally through NHSI.
Verbatim wording from the response “3. The leaflet and poster have been uploaded onto the NHSI improvement hub website under the heading of patient safety. Communication has been undertaken with the Trust’s lead for CCG and NHSI. Work has been undertaken to disseminate this information nationally through NHSI.” Source location 2018-0277-Response-by-Bradford-District-Care-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations