20 Feb 2025 Duncan HOLLOWAY · Prevention of Future Deaths report Inner North London
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Concerns raised 5 Lack of a mechanism preventing psychotherapists unable to deal with suicidality from practising with clients who may experience it View source Failure to provide joined-up care between different agencies View source Omission of suicidality from BCAP-accredited psychotherapy training View source Lack of a minimum standard for psychotherapy consultation note keeping View source Failure to teach police contact in psychotherapy planning for missing or suicidal clients View source See 2 more concerns
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AI-generated summary
Duncan HOLLOWAY · 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
Duncan Holloway died after jumping from a bridge at approximately 5am on 18 July 2024, being killed by the impact with the railway tracks below. The concerns included psychotherapy note-keeping, training and response to suicidality, whether psychotherapists unable to manage suicidality should practise with at-risk clients, and a lack of joined-up care between agencies.
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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 British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism preventing psychotherapists unable to deal with suicidality from practising with clients who may experience it
Wider context from the report “4. The psychotherapist explained in court that she was angry that Mr Holloway’s friend disclosed to her that Mr Holloway had died, asking the friend: “Do you have any idea how this impacts me and my ability to do my job going forward?” The psychotherapist said that she (the psychotherapist) was in distress and shock.
In hindsight, the psychotherapist said that she wished she had referred Mr Holloway to a psychotherapist with more experience in suicidality, she said at inquest because she did not want to be in this situation again with this responsibility.
Should there be a mechanism of ensuring that a psychotherapist who is unable to deal with suicidality does not practise with clients who may experience this ?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Failure to provide joined-up care between different agencies
Wider context from the report “5. Mr Holloway was seen and fully assessed by North West London clinicians when he was taken to hospital by police following an episode of self harm on 30 June 2024. Police attendance had been prompted by Mr Holloway’s brother, calling from abroad.
Mr Holloway’s brother was particularly disappointed that it seemed as if Mr Holloway’s care was not joined up between the different agencies .
” 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 British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Omission of suicidality from BCAP-accredited psychotherapy training
Wider context from the report “2. The psychotherapist said that she had never before had a client who was suicidal. She said that this is not taught at university, though she had completed a post graduate course in working with suicidal ideation.
Can it be right that suicidality is completely omitted from BCAP accredited psychotherapy training ?
” 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 British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Lack of a minimum standard for psychotherapy consultation note keeping
Wider context from the report “1. Mr Holloway’s BCAP accredited psychotherapist did not make any notes of her consultations with him, because he had asked her not to. She gave evidence that she is not bound by law or ethics to keep any notes.
Is it appropriate that there is no minimum standard of note keeping following psychotherapy consultations ?
” 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 British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Failure to teach police contact in psychotherapy planning for missing or suicidal clients
Wider context from the report “3. When Mr Holloway’s friend contacted the psychotherapist to say that he was missing, knowing that he had neither attended nor cancelled their last consultation the psychotherapist was very concerned for his safety. She instructed the friend to go round to his home, but it did not occur to her to call the police.
The friend did this, but can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning ?
” 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 Prevent registration of individuals who have not passed an accredited course or equivalent certificate of proficiency.
Verbatim wording from the response “4. Should there be a mechanism of ensuring that a psychotherapist who is unable to deal with suicidality does not practise with clients who may experience this?” Source location Response from BACP
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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 Require accredited-course students to learn when confidentiality may be breached, including referral to emergency services where necessary.
Verbatim wording from the response “According to the BACP Accreditation of Training Courses, all students enrolled in BACP-accredited courses must be trained in making informed decisions about breaching confidentiality when necessary. This includes understanding when it is appropriate to refer clients, particularly in situations requiring emergency intervention.” Source location Response from BACP
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require members to keep accurate, necessary and data-protection-compliant records.
Verbatim wording from the response “All BACP members must adhere to BACP’s Ethical Framework.” Source location Response from BACP
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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 Require accredited courses to teach evidence-based risk assessment, safety planning, therapeutic contracting and referral to appropriate agencies.
Verbatim wording from the response “BACP accredited courses, must meet all the course requirements set by BACP. These requirements ensure that all students on accredited courses must be trained in evidenced-based risk assessment strategies and must be taught to negotiate an appropriate therapeutic contract which may include referral.” Source location Response from BACP
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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 members with evidence-based guidance resources on confidentiality and record keeping.
Verbatim wording from the response “In addition to BACP’s comprehensive Ethical Framework and Professional Conduct procedure, BACP also provides all its members with access to a range of Good Practice in Action (GPiA) resources. Our GPiA resources are based on current research and evidence and reviewed by member-led focus groups and experts in the field. We provide four guidance documents that relate to the keeping of records:” Source location Response from BACP
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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 A private psychotherapist cannot currently be included in integrated care planning, limiting the ability to coordinate care across agencies.
Verbatim wording from the response “As the psychotherapist contracted was a private practitioner there is currently no ability for them to be included in any integrated care planning that may have been available. Mr Holloway was under no obligation to inform his GP or any other care provider that he was seeking private psychotherapy. Consequently, it may have been that other agencies were unaware of this. BACP has no knowledge as to whether Mr Holloway did share this information or not.” Source location Response from BACP
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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 Existing accredited-course training and assessment requirements are considered sufficient to ensure registered members can support clients expressing suicidal ideation.
Verbatim wording from the response “4. Should there be a mechanism of ensuring that a psychotherapist who is unable to deal with suicidality does not practise with clients who may experience this?” Source location Response from BACP
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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 Existing ethical and contractual requirements, alongside client choice and practitioner judgment, are considered sufficient to govern psychotherapy record keeping.
Verbatim wording from the response “All BACP members must adhere to BACP’s Ethical Framework.” Source location Response from BACP
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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 Accredited courses teach emergency referrals and confidentiality decisions, but would not teach police contact solely on a third party’s assessment.
Verbatim wording from the response “3. ...can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning.” Source location Response from BACP
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25 Mar 2022 Natalie Melissa Turner · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of specific guidance for GPs managing eating disorder patients who are not engaging with treatment View source Failure by counsellors to disclose serious eating-disorder risks when breaching confidentiality is justified View source Lack of targeted eating-disorder guidance for counsellors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Review member resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
Stated completedThe respondent said that this action was complete when they made their response on 31 March 2022. View source
Action
Continue highlighting critical professional guidance through member bulletins, publications, the website and member events.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 March 2022. View source
Action
Continue reviewing guidance and resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 March 2022. View source
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AI-generated summary
Natalie Melissa Turner · 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
Natalie Melissa Turner had a long-standing eating disorder and abused laxatives, causing serious illness and repeated hospital admissions. She died at home on 27 October 2020 from the effects of laxative abuse. The concerns included insufficient guidance for GPs managing eating disorder patients who do not engage with treatment, and insufficient guidance for counsellors on when confidentiality should be breached to protect patients at risk of serious harm.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for GPs managing eating disorder patients who are not engaging with treatment
Wider context from the report “1. The first issue I raise with Parliamentary Under Secretary of State (Minister for Patient Safety and Primary Care), Department of Health & Social Care.
• The inquest received some helpful evidence from a GP, Dr ████████, of the Ash Tree House Surgery, Kirkham. In court, I acknowledged the response of that surgery to Natalie’s death which I have found to be thorough, open and constructive, and a genuine attempt to minimise the prospect of a recurrence in the future. Dr ████████ explained that notwithstanding her considerable experience as a GP, General Practitioners do not receive specific guidance in relation to eating disorders , which are often very complex in nature.
• It seemed to me that GPs can often find themselves in a difficult position when deciding how to approach dealing with a patient who has an eating disorder, but the situation is all the more challenging when the patient is unwilling to engage with medical professionals and accept treatment which is clearly necessary. Many of these patients ostensibly have capacity to make their own decisions, yet given the nature of their eating disorders may go on to make decisions that are not in their own interests. What the GP can and should do is often unclear.
• The number of patients affected is not insignificant: indeed, the inquest heard that this one local surgery had recently identified thirteen of their patients were facing challenges relating to an eating disorder. GPs can resort to the current mental health legislation, MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guidance, and NICE (Eating Disorders Recognition and Treatment) guidance which offers some assistance, but it seems to me that in the absence of guidance which focuses on eating disorder patients and what can be done when a patient is not engaging with treatment, GPs are often left unsure about how to help these patients , and in the absence of some guidance on this issue patients may go without treatment and with potentially fatal consequences.
• In response to Natalie’s death, the Lancashire & South Cumbria NHS Foundation Trust has also responded in a constructive manner and have demonstrated a clear plan to avoid a repetition. This response has included the creation of new posts within the Trust who local GPs will be able to access for guidance and these include a Consultant Dietician and a Consultant Nurse, and hopefully local GPs make use of this new assistance, but this is not always the case elsewhere in 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 British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Failure by counsellors to disclose serious eating-disorder risks when breaching confidentiality is justified
Wider context from the report “2. The second issue I raise with the British Association for Counselling and Psychotherapy (BACP):
• The inquest heard from a BACP Accredited Counsellor, with whom Natalie shared some 63 counselling privately funded counselling sessions between January and October 2020.
• BACP guidance includes a set of core principles which ought to guide counsellors, and the guidance makes clear that in exceptional circumstances the need to safeguard clients from serious harm “may require practitioners to override a commitment to make a client’s wishes and confidentiality the primary concern”. The guidance makes clear that a breach of confidentiality may be justified.
• The Counsellor had developed a good therapeutic relationship with Natalie, but in my judgement she felt unduly constrained by the wishing to avoid breaching Natalie’s confidence , despite she herself having formed the view given what Natalie was disclosing to her about the extent of her ongoing laxative abuse she was at risk of self harm and of dying. These circumstances were exceptional, it is hard to think of a clearer example where to disclose her concerns to others would have been justified but she preferred not to because she did not feel she could betray her confidence . This was despite having regular discussions with her supervisor, and knowing that Natalie was not accessing the medical monitoring that she needed from her GP.
• The Counsellor explained in court that she personally has not knowingly counselled an eating disorder patient before. The potential complexities of these conditions were not fully appreciated.
• Patients with eating disorders will commonly prefer to avoid contact with mainstream medical care and treatment, and their families. It follows that such patients may be attracted to discussing their condition privately with a private counsellor.
• Although the therapeutic relationship between counsellor and patient is fundamentally important, as the BCAP guidance makes clear there are occasions when a breach of confidentiality is justifiable. Counsellors who begin a course of therapy with an eating disorder patient need to appreciate that refraining from breaching confidentiality may well mean the patient goes without necessary and potentially life-saving care and treatment . Even if patients try to reassure counsellors that they are seeking medical help elsewhere, such claims may well not be credible because these patients may be claiming they are being treated as a distraction.
• The Counsellor informed the court she did not have the benefit of guidance on eating disorders. More information may have highlighted the particular risks eating disorder patients may pose, particular as regards whether to breach confidentiality or not. In the absence of such guidance, I am concerned that there is a risk that vulnerable patients – who may in fact benefit from a disclosure by their counsellor – will miss out on necessary and potentially life – saving treatment.
• Whilst acknowledging that on the BACP website [www.bacp.co.uk], within a section headed “Events & resources”, there is a series of articles which explore some of the issues eating disorders may pose for counsellors, the Counsellor who gave evidence at Natalie’s inquest did not appear to be familiar with these articles. This arguably reinforces the need for this subject to be raised with counsellors in a more targeted way.
” 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 British Association For Counselling And Psychotherapy; that does not assign responsibility.
PFD Monitor interpretation Lack of targeted eating-disorder guidance for counsellors
Wider context from the report “2. The second issue I raise with the British Association for Counselling and Psychotherapy (BACP):
• The inquest heard from a BACP Accredited Counsellor, with whom Natalie shared some 63 counselling privately funded counselling sessions between January and October 2020.
• BACP guidance includes a set of core principles which ought to guide counsellors, and the guidance makes clear that in exceptional circumstances the need to safeguard clients from serious harm “may require practitioners to override a commitment to make a client’s wishes and confidentiality the primary concern”. The guidance makes clear that a breach of confidentiality may be justified.
• The Counsellor had developed a good therapeutic relationship with Natalie, but in my judgement she felt unduly constrained by the wishing to avoid breaching Natalie’s confidence, despite she herself having formed the view given what Natalie was disclosing to her about the extent of her ongoing laxative abuse she was at risk of self harm and of dying. These circumstances were exceptional, it is hard to think of a clearer example where to disclose her concerns to others would have been justified but she preferred not to because she did not feel she could betray her confidence. This was despite having regular discussions with her supervisor, and knowing that Natalie was not accessing the medical monitoring that she needed from her GP.
• The Counsellor explained in court that she personally has not knowingly counselled an eating disorder patient before. The potential complexities of these conditions were not fully appreciated.
• Patients with eating disorders will commonly prefer to avoid contact with mainstream medical care and treatment, and their families. It follows that such patients may be attracted to discussing their condition privately with a private counsellor.
• Although the therapeutic relationship between counsellor and patient is fundamentally important, as the BCAP guidance makes clear there are occasions when a breach of confidentiality is justifiable. Counsellors who begin a course of therapy with an eating disorder patient need to appreciate that refraining from breaching confidentiality may well mean the patient goes without necessary and potentially life-saving care and treatment. Even if patients try to reassure counsellors that they are seeking medical help elsewhere, such claims may well not be credible because these patients may be claiming they are being treated as a distraction.
• The Counsellor informed the court she did not have the benefit of guidance on eating disorders . More information may have highlighted the particular risks eating disorder patients may pose, particular as regards whether to breach confidentiality or not . In the absence of such guidance, I am concerned that there is a risk that vulnerable patients – who may in fact benefit from a disclosure by their counsellor – will miss out on necessary and potentially life – saving treatment.
• Whilst acknowledging that on the BACP website [www.bacp.co.uk], within a section headed “Events & resources”, there is a series of articles which explore some of the issues eating disorders may pose for counsellors, the Counsellor who gave evidence at Natalie’s inquest did not appear to be familiar with these articles. This arguably reinforces the need for this subject to be raised with counsellors in a more targeted way .
” 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 member resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
Verbatim wording from the response “In response to your report, we have conducted a thorough review of our member resources relating to confidentiality and when to breach it (including safeguarding and duty of care), working within own limits of competence and guidance on eating disorders specifically.” Source location Response from British Association for Counselling and Psychotherapy
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue highlighting critical professional guidance through member bulletins, publications, the website and member events.
Verbatim wording from the response “We will continue to keep our guidance and resources under review and to take every opportunity to highlight the critical importance of the professional points and draw them to our members’ attention through our different channels of communication which include” Source location Response from British Association for Counselling and Psychotherapy
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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 guidance and resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
Verbatim wording from the response “We will continue to keep our guidance and resources under review and to take every opportunity to highlight the critical importance of the professional points and draw them to our members’ attention through our different channels of communication which include” Source location Response from British Association for Counselling and Psychotherapy
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is unclear whether breaching confidentiality would have saved the client’s life because her situation was already known to medical services and her partner.
Verbatim wording from the response “Where confidentiality may need to be broken the therapist is expected to go through an ethical decision-making process with support and guidance from their supervisor and involving the client where possible. What is not clear however, is whether breaking confidentiality would have saved Natalie’s life given that her situation was already known to her GP and specialist medical services and known to her partner.” Source location Response from British Association for Counselling and Psychotherapy
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation As a professional rather than training body, it does not directly deliver specialist training or monitor individual competence in specialist areas.
Verbatim wording from the response “As a professional body rather than a training body we can and do offer guidance on specific client issues such as eating disorders and set standards for accredited courses, but we don’t directly deliver the training or monitor individual competence in specialist areas. We are, however, very clear that members should not work outside their limits of competence.” Source location Response from British Association for Counselling and Psychotherapy
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations