Concerns raised 3 Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English View source Failure to establish the contents of an infant’s bottle feed View source Lack of culturally informed professional curiosity in infant feeding assessment 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
Izzah Fatima Ali · 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
Izzah Fatima Ali, a nine-month-old infant, died after developing profound iron-deficiency anaemia associated with consumption of cow’s milk. The report identified concerns about healthcare professionals failing to establish what was in her bottles, insufficient consideration of cultural practices, and the repeated absence of an interpreter during ante- and post-natal visits.
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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved , contrary to guidance .
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the contents of an infant’s bottle feed
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry . In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle . It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact .
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle .
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of culturally informed professional curiosity in infant feeding assessment
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices : while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries , for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity .
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” Open source report
Concerns raised 3 Shortage of availability for psychological therapies such as CBT View source Delays in obtaining Gender Identity Clinic appointments View source Delays and gaps in psychological therapy support pending substantive treatment 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
Daniel France · 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
Daniel France was a 17-year-old vulnerable teenager living in a YMCA hostel who died by asphyxiation by hanging; the inquest concluded that his death was suicide. The principal concern was that vulnerable young people known to local authorities and mental health services may not receive adequate support while awaiting substantive treatment, particularly where they are assessed as not requiring urgent intervention but face lengthy waits for psychological therapy.
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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of availability for psychological therapies such as CBT
Wider context from the report “The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic, and about the shortage of availability for psychological therapies such as CBT .
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining Gender Identity Clinic appointments
Wider context from the report “The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic , and about the shortage of availability for psychological therapies such as CBT.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and gaps in psychological therapy support pending substantive treatment
Wider context from the report “My concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment . Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation . That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person , where there is a chronic risk of an impulsive act. I understand that there is a long term plan to extend young people’s services to age 25, but I remain concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment.
” Open source report
Concerns raised 8 Failure of managerial policy-change controls to prevent recurrence of superseded-policy confusion View source Insufficient knowledge, guidance and supervision among education inclusion officers and social workers supporting adolescents at risk of self-harm or suicide View source Reluctance to use a Borderline Personality Disorder diagnosis View source Unavailability of in-area supported accommodation for adolescent mental health patients View source AWOL policy failing to provide concise and usable live-incident guidance View source Lack of an agreed pathway for securing overnight assistance for adolescent mental health patients cared for at home View source Lack of drills, training exercises and information packs for nurses managing AWOL incidents View source Conflicting or confusing AWOL policies View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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
Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.
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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of managerial policy-change controls to prevent recurrence of superseded-policy confusion
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient knowledge, guidance and supervision among education inclusion officers and social workers supporting adolescents at risk of self-harm or suicide
Wider context from the report “(2) Involvement of CCC alongside CPFT in complex adolescent mental health cases where the risk is of suicide / self-harm (For CCC). In some respects CCC’s involvement in Chris and Sam’s care (social care and education) lacked direction, focus, knowledge and efficiency. I heard evidence of improvements in training in the relevant education and social work teams, and concerning the new Strong Families, Strong Communities Securing Best Outcomes for Children Strategy (March 2021). Further, that CCC is restructuring all of its early help and adolescent services and will be implementing a formal contextual safeguarding framework and that these developments will be in place by the end of 2021. I am concerned that in the midst of restructuring and new guidance, there remains a risk that education inclusion officers and social workers on the ground may still not have sufficient knowledge, guidance and supervision to ensure that CCC give practical and robust support to parents and adolescent patients, alongside treating healthcare agencies, where the main risk of serious harm to the child is from self-harm or suicide arising from adolescent mental health disorders , rather than neglect of harm by a third party.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reluctance to use a Borderline Personality Disorder diagnosis
Wider context from the report “(3) Diagnosis of Borderline Personality Disorder (For CPFT). I am concerned that the evidence in Chris’ case, in particular, suggested a degree of age-related reluctance consistently to use the terminology of Borderline Personality Disorder (or Emerging Personality Disorder or EUPD) , even when a highly specialist second opinion had supported this and appeared to have been accepted. There are risks associated with a reluctance to use a personality disorder diagnosis (c.f. Position Statement from the Royal College of Psychiatrists dated January 2020). I received evidence that there have already been some changes/improvements in the preparedness to recognise Borderline Personality Disorder and that further consideration will be given in the context of the new ICD 11.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of in-area supported accommodation for adolescent mental health patients
Wider context from the report “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC. I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area , so that admission to a mental health unit becomes more likely.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation AWOL policy failing to provide concise and usable live-incident guidance
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident . In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed pathway for securing overnight assistance for adolescent mental health patients cared for at home
Wider context from the report “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC . I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area, so that admission to a mental health unit becomes more likely.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of drills, training exercises and information packs for nurses managing AWOL incidents
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Conflicting or confusing AWOL policies
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed ; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 discussing with the CCG and Local Authority how to meet needs for 24/7 in-home care, including bespoke arrangements or a fully funded service.
Verbatim wording from the response “The discussion about the need for 24/7 in home care will continue with the CCG and the Local Authority and whether any needs are best met though bespoke arrangements, or the demand is such as to require a fully funded service.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_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 diagnostic processes in light of the coroner’s recommendations and ICD-11 changes.
Verbatim wording from the response “CPFT have been reviewing diagnostic processes in the light of the coroner’s recommendations and the new ICD 11 (International classification of Disease). National implementation of the ICD 11 will follow in January 2022. ICD 11 changes many of the current diagnostic classifications including removing the diagnosis of emotionally unstable personality disorder. Rather than identifying discrete personality disorders the new ICD 11 defines mild, moderate or severe personality disorder and then and optional clarifying behaviour description. There six subtype descriptions any number of which can be combined. One of these is “borderline pattern”.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_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 Remind all doctors of ICD-11 diagnostic changes.
Verbatim wording from the response “In CPFT we will be reminding all doctors of the changes to ICD 11 and we have contacted our electronic medical records provider to ask that they confirm that the changes will be embedded in the system.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_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 Clarify which AWOL policy has been superseded.
Verbatim wording from the response “CPFT accepts the concerns with regard to the AWOL policy and has commenced the process of reviewing this. In order to ensure that the concerns about meaningfulness and useability are fully addressed this will involve engagement with staff groups, service users and carers. That work is expected to be completed by October 2021. In the meantime clarity has been given with regard to the superseded policy.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_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 all Trust policies to align them with best-practice guidance and make them understandable and usable for staff.
Verbatim wording from the response “The Trust is currently undertaking a full review of all policies which will ensure that they are fully in line with the latest best practice guidance and that they are written in such a way that they are clearly understandable and usable by all members of staff. The review is led by myself as Medical Director and ████████, the Director of Nursing, Allied Health Professions and Quality, and will run over the next six months.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_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 the AWOL policy with staff, service users and carers to address its meaningfulness and usability concerns.
Verbatim wording from the response “CPFT accepts the concerns with regard to the AWOL policy and has commenced the process of reviewing this. In order to ensure that the concerns about meaningfulness and useability are fully addressed this will involve engagement with staff groups, service users and carers. That work is expected to be completed by October 2021. In the meantime clarity has been given with regard to the superseded policy.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
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 concern about council involvement in complex adolescent mental health cases has been directed to the local authority.
Verbatim wording from the response “CPFT has considered with care the issues that you raised, and I will now address points (1), (3) and (4) in turn. (Point (2) has been directed to CCC).” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
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 Teenagers are unlikely to meet the personality disorder diagnostic threshold before age 16 because ICD-11 requires symptoms to persist for at least two years.
Verbatim wording from the response “CPFT have been reviewing diagnostic processes in the light of the coroner’s recommendations and the new ICD 11 (International classification of Disease). National implementation of the ICD 11 will follow in January 2022. ICD 11 changes many of the current diagnostic classifications including removing the diagnosis of emotionally unstable personality disorder. Rather than identifying discrete personality disorders the new ICD 11 defines mild, moderate or severe personality disorder and then and optional clarifying behaviour description. There six subtype descriptions any number of which can be combined. One of these is “borderline pattern”.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
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 home treatment service is not commissioned to provide 24/7 in-home support; funding would need to be secured through designated funding arrangements.
Verbatim wording from the response “Additionally, the CCG have commissioned a CAMHS home treatment team. Recruitment to this is ongoing. It will work intensively with young people and families as an alternative to hospitalisation. This is a multi-disciplinary team and will be able to operate 9-9 with up to 3 contacts per day in the family home to provide treatment to young people and families. This will include supporting rapid discharge of patients from hospital who may not be best helped by hospital admission. As part of this the home treatment team is developing a DBT treatment programme for children with severe self-harm.
This service is not commissioned to provide 24/7 in home support for young people. If this level of support were needed then this would be raised through either the joint funding panel or through the CCG Section 117 funding stream.” Source location 2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
Open published response
Concerns raised 6 Lack of clear responsibility for care pending further mental health appointments View source Failure to provide medication risks and further-assistance contact information View source Failure of GPs to recognise their responsibility for prescribing and medication advice View source Failure to ensure patients know how to request discussion with a consultant psychiatrist View source Non-prescriber mental health staff advising GPs on medication View source Failure to ensure GPs know how to contact the duty psychiatrist 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
Edward Angus Mallen · 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
Edward Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.
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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care pending further mental health appointments
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal. In either event he should have been told who to call to get further assistance.
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments .
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medication risks and further-assistance contact information
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal . In either event he should have been told who to call to get further assistance .
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to recognise their responsibility for prescribing and medication advice
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status. The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients know how to request discussion with a consultant psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment .
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Non-prescriber mental health staff advising GPs on medication
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status . The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure GPs know how to contact the duty psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment.
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this .
” Open source report
Concerns raised 2 Lack of clear policy on staff-to-patient ratios for escorted leave from psychiatric wards View source Failure to communicate with all relevant parties before changes in identified risk level 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
Christopher James MORGAN · 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
Christopher Morgan, a voluntary patient at Fulbourn Hospital, died from multiple injuries after diving in front of a train at or near Ely Railway Station after leaving the hospital earlier that day. The report identified concerns about communication with family and carers before changes in risk or leave arrangements, and about staffing ratios for escorted leave from psychiatric wards.
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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear policy on staff-to-patient ratios for escorted leave from psychiatric wards
Wider context from the report “The Trust should ensure that a clear practice and policy is adopted in relation to the ratio of staff to patient as to staff that should accompany patients on escorted leave from psychiatric wards
” 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 Cambridgeshire and Peterborough NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate with all relevant parties before changes in identified risk level
Wider context from the report “That before any change in identified level of risk is decided upon, particularly in relation to access to leave, there is communication with all relevant parties concerned including family and carers to elicit their views .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations