28 Jun 2021 Nicholas Jonathan SPOONER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Denial of mental health support for people in crisis with co-occurring substance abuse 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
Nicholas Jonathan SPOONER · 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
Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.
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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Denial of mental health support for people in crisis with co-occurring substance abuse
Wider context from the report “Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support .
” Open source report
28 May 2021 KEVIN JOHN FITTON · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 12 Poor or inadequate implementation of Care Act assessments View source Failure to seek specialist Acquired Brain Injury support View source Failure to respond to deterioration in living conditions, physical health and drug use View source Failure to repeat Care Act assessments annually View source Lack of training on the Mental Capacity Act and Care Act Codes of Practice View source Lack of lead and coordination View source Failure to use best interests policy appropriately View source Failure to understand how Acquired Brain Injury affects abilities View source Failure to understand the interaction between Acquired Brain Injury and substance use View source Poor communication between teams and individuals View source Inadequate staff training in Acquired Brain Injury View source Lack of capacity assessments View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
KEVIN JOHN FITTON · 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
Kevin Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.
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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Poor or inadequate implementation of Care Act assessments
Wider context from the report “(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented . It should have been repeated annually – it was not.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to seek specialist Acquired Brain Injury support
Wider context from the report “(2) There was a failure to seek specialist support regarding Acquired Brain Injury (ABI) .
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to deterioration in living conditions, physical health and drug use
Wider context from the report “(7) There was a failure to react to the deterioration in Mr Fitton’s living conditions, his being cuckooed, the downward slide in his physical health and the increase in his drug use .
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat Care Act assessments annually
Wider context from the report “(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented. It should have been repeated annually – it was not.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training on the Mental Capacity Act and Care Act Codes of Practice
Wider context from the report “(8) Staff received no adequate training in dealing with ABI. There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act .
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of lead and coordination
Wider context from the report “(6) Lead and Co-ordination were lacking.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to use best interests policy appropriately
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately .
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to understand how Acquired Brain Injury affects abilities
Wider context from the report “(3) There was a failure to understand the way Mr Fitton’s ABI impacted on his abilities .
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the interaction between Acquired Brain Injury and substance use
Wider context from the report “(4) There was a failure to understand how ABI impacted on Mr Fitton’s substance use and vice versa .
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Poor communication between teams and individuals
Wider context from the report “(5) Communication between the various teams and individuals were poor.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in Acquired Brain Injury
Wider context from the report “(8) Staff received no adequate training in dealing with ABI . There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity assessments
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately.
” 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 Continue acquired brain injury training while increasing practitioner engagement and extending its content and duration.
Verbatim wording from the response “• We will continue to provide standalone training courses on Acquired Brain Injury and will encourage practitioner engagement in this training course as well as extending the content depth and duration.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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 Explore joint commissioning with health to establish specialist access for capacity assessments involving acquired brain injury.
Verbatim wording from the response “• We will take forward the area of Social Work practitioner access to specialists when undertaking capacity assessments with people with new or historic ABI and/or when the specific brain impairment necessitates a specialist. We will explore a joint commissioning arrangement with health to agree a pathway for our health and adult social care practitioners to access.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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 Continue attending the police-led multi-agency cuckooing meeting, promote directorate awareness and seek wider learning.
Verbatim wording from the response “• We will continue to attend the police led multi agency cuckooing meeting and encourage increased awareness of this within our directorate and we will seek opportunities for wider learning from this meeting.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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 Care Act training and adjust it to refresh multi-agency coordination and consideration of review.
Verbatim wording from the response “• We will review our Care Act training on offer and make any adjustments necessary to ensure that the key aspect of co-ordination in multi-agency work, and consideration of review, are refreshed features.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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 internal casework risk-management protocols to strengthen organisational oversight.
Verbatim wording from the response “• We will review our internal risk management protocols for casework to strengthen our organisational oversight.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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 and refresh Mental Capacity Act training, monitor attendance and refresher completion, and communicate attendance requirements to frontline teams.
Verbatim wording from the response “• We will review our existing Mental Capacity Act (In Practice) training which includes the Code of Practice, and guidance on use of the Best Interests process and refresh the message on ensuring good practice of this. We will monitor practitioner take up of the training, percentage attended and those who have refreshed, and communicate with front line teams to ensure practitioners attend these and refresh regularly.” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
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 standalone training on mental capacity assessments and executive functioning.
Verbatim wording from the response “• We will develop a stand-alone training course on Mental Capacity Assessments and executive functioning/capacity” Source location 2021-0169-Responses-from-Sussex-NHS-Commissioners-and-Brighton-and-Hove-City-Council_Published
Open published response
23 Nov 2020 Elena WELLS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 4 Lack of clear allocation of overall responsibility for care View source Failure to provide advice about the available place of safety View source Lack of a clear inter-organisational working policy View source Failure to provide routine out-of-hours review and support for patients awaiting urgent admission 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
Elena WELLS · 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
Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear allocation of overall responsibility for care
Wider context from the report “1. Both the Local Authority and the Trust were involved in the care of Miss Wells for the last 24 hours of her life. Evidence showed that there was a grey area in respect of responsibility for her care, at this time. There was no clear guidance as to who held overall responsibility for her care and there was no clear policy of how the two organisations should work together in these kinds of situations. It is requested that the Local Authority and the Trust consider how to improve communication and clearly define responsibility between the two organisations which could improve the safety of patients with serious mental health difficulties who were waiting for urgent admission to a mental health unit.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advice about the available place of safety
Wider context from the report “2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team, and no advice offered on the existence of a place of safety at the local Mental Health Hospital . Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so. It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear inter-organisational working policy
Wider context from the report “1. Both the Local Authority and the Trust were involved in the care of Miss Wells for the last 24 hours of her life. Evidence showed that there was a grey area in respect of responsibility for her care, at this time. There was no clear guidance as to who held overall responsibility for her care and there was no clear policy of how the two organisations should work together in these kinds of situations . It is requested that the Local Authority and the Trust consider how to improve communication and clearly define responsibility between the two organisations which could improve the safety of patients with serious mental health difficulties who were waiting for urgent admission to a mental health unit.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide routine out-of-hours review and support for patients awaiting urgent admission
Wider context from the report “2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team , and no advice offered on the existence of a place of safety at the local Mental Health Hospital. Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so . It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found.
” Open source report
25 Mar 2020 Mr. Joseph John MOCHAN (otherwise Joseph John LOPEZ) · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2 Fragmented provision of homeless care and support services requiring extensive travel between locations View source Lack of safe accommodation and associated basic hygiene, bedding, food and drink for people sleeping rough View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr. Joseph John MOCHAN (otherwise Joseph John LOPEZ) · 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
Joseph John Mochan, otherwise Joseph John Lopez, was living in a tent in Brighton and died on 11 October 2019. The inquest concluded that the death was misadventure and drug-related. The report raised concerns about homelessness and the lack of coordinated access to safe accommodation, hygiene, food, warmth, and healthcare services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Fragmented provision of homeless care and support services requiring extensive travel between locations
Wider context from the report “There is it seems a political will to help homeless people in Brighton.
On any given night there may be 50 to 200 people sleeping rough on the streets of the city.
Many of them will be using drugs with the violence and criminality associated with this world.
Many will have (associated) mental health problems and likely physical ailments as well.
They have no toilet or washing facilities, no basic hygiene equipment; no change of clothing; no proper bedding; no access to healthy food and drink.
The City has a large number of organisations some charitable, who are dedicated to trying to help and to give the care and support which is needed.
████████ explained to me that there are things which could help.
Such helps centres around a safe place to be and availability of the services which are needed, provided at or adjacent to the safe place.
He told me that it is quite possible for a homeless person to walk 5 to 10 miles a day around the city trying to access the different places where help might be available.
By the time they have arrived at one place they have probably missed another appointment on the other side of the City.
████████ said that he felt there were two main things which if they could be put in place would dramatically improve the plight of the people who are the subject of this report.
Additionally, and in many ways as importantly for all those involved, the services would reduce the amount of spending. Such services, if they existed would provide joined up care, accommodation and support.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of safe accommodation and associated basic hygiene, bedding, food and drink for people sleeping rough
Wider context from the report “There is it seems a political will to help homeless people in Brighton.
On any given night there may be 50 to 200 people sleeping rough on the streets of the city.
Many of them will be using drugs with the violence and criminality associated with this world.
Many will have (associated) mental health problems and likely physical ailments as well.
They have no toilet or washing facilities, no basic hygiene equipment; no change of clothing; no proper bedding; no access to healthy food and drink.
The City has a large number of organisations some charitable, who are dedicated to trying to help and to give the care and support which is needed.
████████ explained to me that there are things which could help.
Such helps centres around a safe place to be and availability of the services which are needed, provided at or adjacent to the safe place.
He told me that it is quite possible for a homeless person to walk 5 to 10 miles a day around the city trying to access the different places where help might be available.
By the time they have arrived at one place they have probably missed another appointment on the other side of the City.
████████ said that he felt there were two main things which if they could be put in place would dramatically improve the plight of the people who are the subject of this report.
Additionally, and in many ways as importantly for all those involved, the services would reduce the amount of spending. Such services, if they existed would provide joined up care, accommodation and support.
” 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 Explore shelter models and evidence-based practice, including expansion of Housing First, to improve outcomes for rough sleepers.
Verbatim wording from the response “4.3 Brighton & Hove City Council is exploring models of shelter provision being provided in other areas of the UK and is looking at evidence based practice to design services which gives rough sleepers the best opportunity to recover from homelessness. This includes the expansion of Housing First a model of support with a strong evidence base of positive outcomes for rough sleepers. At present, there is no identified budget or building for the provision of a Nightshelter for all rough sleepers.” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_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 Commission and complete a feasibility report defining a new integrated healthcare facility for homeless and disadvantaged people.
Verbatim wording from the response “5.5 Homeless Healthcare services in the city are recognised as an exemplar model by NHSE/I with the potential to be replicated across the country. The CCG acknowledges the Coroner’s direction to develop a homeless healthcare hub with all necessary services under one roof. We believe the current commissioned service could be enhanced to develop a more integrated service with the Local Authority. A Feasibility Report has been commissioned to develop a strategic definition and preparation of the brief on behalf of Arch Health CIC for the development of a new healthcare facility for homeless and disadvantaged people in Brighton.” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_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 Commission an integrated homeless healthcare service providing primary care, hospital outreach, community engagement, day-centre outreach and citywide leadership.
Verbatim wording from the response “5.2 In responding to the Coroner’s Direction, the CCG commissions as successful and integrated service model through Arch Health who provide integrated healthcare to homeless people in Brighton & Hove. In February 2017, Arch took over the Integrated Homeless Healthcare Hub contract, which includes a GP surgery, hospital in reach services, community health engagement, outreach to day centres and citywide leadership.” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_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 Review the healthcare feasibility report to incorporate learning from the Covid-19 response and homeless population needs.
Verbatim wording from the response “5.7 The Feasibility Report was concluded in February 2020. Subsequently, the CCG has had to focus on the response to the Covid-19 crisis. As we enter the recovery period following the initial phase of Covid response, we will be reviewing the feasibility report to include learning from the Covid response in” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_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 Expand winter night shelter provision through an open-access weekend shelter service.
Verbatim wording from the response “2.11 Extending Night Shelter Provision” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local authority is responsible for delivering the response and actions concerning the safe night shelter direction.
Verbatim wording from the response “1.4 Brighton & Hove City Council (BHCC) is responsible for providing the night shelter and homelessness services, therefore is responsible for delivering a response to and actions towards the direction A.” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_Redacted
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 A year-round night shelter cannot currently be provided because there is no identified budget or suitable building.
Verbatim wording from the response “4.3 Brighton & Hove City Council is exploring models of shelter provision being provided in other areas of the UK and is looking at evidence based practice to design services which gives rough sleepers the best opportunity to recover from homelessness. This includes the expansion of Housing First a model of support with a strong evidence base of positive outcomes for rough sleepers. At present, there is no identified budget or building for the provision of a Nightshelter for all rough sleepers.” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_Redacted
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 Existing accommodation provision is considered sufficient to prevent rough sleeping during the poorest weather.
Verbatim wording from the response “2.3 In addition, during the winter period there is a direct access Severe Weather Emergency protocol shelter, which is open when the temperature is predicted to be ‘feels like’ zero or below or there is an amber weather warning.” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_Redacted
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 Available evidence does not show that night shelters improve rough sleepers’ health or substance-misuse outcomes, and vulnerable people may not access them.
Verbatim wording from the response “3.1 The final consideration for the provision of a Nightshelter for all rough sleepers is the need for evidence that this model will have a positive impact on the outcomes of rough sleepers. Evidence of the impact of Nightshelters on rough sleepers is very limited. The data provided by Homeless Impact in the link below concludes that Nightshelter provision does not have a positive outcome on health or substance misuse outcomes for rough sleepers.” Source location 2020-0078-Response-from-Sussex-NHS-Commissioners_Redacted
Open published response
11 Mar 2019 David Alexander MOBSBY · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 10 Lack of management training for managers View source Unavailability of first-aid or designated emergency personnel on site View source Failure to undertake risk assessments for work tasks View source Failure of health and safety assessment templates and audits to address work at height View source Failure to control lone and unsupervised working View source Failure to plan work methods and equipment View source Failure to monitor and instruct staff undertaking work View source Failure to carry out annual employee appraisals View source Exposure of workers to heat and direct sunlight View source Lack of working-at-height training View source See 7 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
David Alexander MOBSBY · 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 Alexander MOBSBY fell while working at Blatchington Mill School on 3 August 2018 and was found unconscious after working alone. The report raises concerns about inadequate health and safety arrangements for work at height, lack of training, supervision and risk assessment, and delays in providing CPR, including the absence of a first aider or designated person on site.
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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of management training for managers
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of first-aid or designated emergency personnel on site
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake risk assessments for work tasks
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of health and safety assessment templates and audits to address work at height
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height .
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to control lone and unsupervised working
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to plan work methods and equipment
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and instruct staff undertaking work
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work .
He was allowed to choose how, when and where he worked .
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did , even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out annual employee appraisals
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually .
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Exposure of workers to heat and direct sunlight
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height.
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly , from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of working-at-height training
Wider context from the report “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety.
They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS.
This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height.
(2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work.
He was allowed to choose how, when and where he worked.
Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height .
• On the 3rd August 2018 he was unchallenged when he announced his work programme for the day.
• His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers.
• No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use.
• There was no risk assessment undertaken in respect of any of the jobs that he did.
• He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day.
• His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade.
• He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs.
• It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed.
• Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him.
• They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually.
• There was no evidence at all to suggest that Mr MOBSBY had ever been appraised.
I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country.
” Open source report
5 Dec 2014 Paul Leslie HYDE · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 6 Delays in appropriately addressing referrals within the 28-day period View source Failure to contact the GP about the referral View source Poor documentation of referral-management decisions View source Failure to provide face-to-face psychiatric medication reviews View source Lack of a referral follow-up system View source Lack of a facility for psychiatrists to participate in assessment and determine a course of treatment View source See 3 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
Paul Leslie HYDE · 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
Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.
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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in appropriately addressing referrals within the 28-day period
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the GP about the referral
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Poor documentation of referral-management decisions
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face psychiatric medication reviews
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a referral follow-up system
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” 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 Brighton and Hove City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a facility for psychiatrists to participate in assessment and determine a course of treatment
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations