28 Jul 2017 SARAH LYNNE REED · Prevention of Future Deaths report London (City)
View report summary
Concerns raised 17 Insufficient information provided to prisoner visitors View source Excessive cancellation of prisoner visits View source Failure of ACCT Review team members to fully review the ACCT document View source Failure to make recorded prisoner observations accessible to all relevant team members View source Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner View source Failure to assign clear responsibility for obtaining fitness-to-plead reports View source Failure to facilitate prisoner visits despite behaviour-related barriers View source Failure to record prisoner observations immediately or as soon as practicable View source Failure to notify community care coordinators of prisoner release View source Failure to conduct ACCT reviews on a multidisciplinary basis View source Inappropriate reduction of observation frequency despite deteriorating mental state View source Failure to communicate the fitness-to-plead purpose of remand to the mental health team View source Delays in holding Care Programme Approach meetings View source Failure to require Duty Governor authorisation for cancelled visits View source Inadequate multidisciplinary participation in CPA meetings View source Inadequate quality and duration of CPA meetings View source Insufficient recording of cancelled visits View source See 14 more concerns
Responses linked to these concerns
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AI-generated summary
SARAH LYNNE REED · 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
Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient information provided to prisoner visitors
Wider context from the report “(18) The Coroner also observes that the information provided to visitors including close family was often short on detail and lacked helpful information .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive cancellation of prisoner visits
Wider context from the report “(14) The jury concluded that the number of cancelled visits was unacceptable , particularly for a prisoner such as Sarah with Emotionally Unstable Personality Disorder where engagement is a principal means of treatment.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT Review team members to fully review the ACCT document
Wider context from the report “(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make recorded prisoner observations accessible to all relevant team members
Wider context from the report “(10) The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be ‘detrimental’. For example, many helpful observations about Sarah’s behaviour were recorded in the prison medical notes on SystemOne by doctors and nurses, but they were not accessible to prison officers .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner
Wider context from the report “(1) The deceased had been remanded in custody for the sole purpose of the Court obtaining two reports by psychiatrists on her fitness to plead and stand trial. Yet by the time of her death, three months later, this objective had not been achieved and no date for a hearing of the issue had been fixed . It is clear from the evidence that Sarah was uncertain what was happening and when she would be going to court.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign clear responsibility for obtaining fitness-to-plead reports
Wider context from the report “(4) It was not clear on the evidence who took responsibility for obtaining the reports . The Court had ordered them, but the formal request for the first report, dated 27 October 2015, was (a) directed to HMP Holloway, but (b) sent by email from the Court to an administrative officer employed not by the prison but by the Central and North West London NHS Trust (CNWL) who worked from HMP Holloway. One month later, on 27 November 2015, a psychiatrist employed by CNWL in HMP Holloway wrote back to the Court, apologising for the delay and indicating that the request be directed not to CNWL but to the South London and Maudsley NHS Trust. As a result, by about six weeks after the Court’s order, no psychiatrist had yet agreed to prepare a report .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate prisoner visits despite behaviour-related barriers
Wider context from the report “(17) The Coroner also observes that with a little thought and effort arrangements could be made for a visit to Sarah even when her mental state had affected her behaviour . For example, on one occasion on 2 January 2016 (and apparently on one occasion only), Sarah’s mother was allowed to see Sarah in the adjudication room on the Segregation Unit (where Sarah was then housed). It is clear from the evidence that this visit was helpful to Sarah and that more completed visits would have assisted her . The jury so 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoner observations immediately or as soon as practicable
Wider context from the report “(11) In addition the Coroner observes that HMP Holloway maintained a practice of recording observations on prisoners which deviated from the national instruction. According to the national policy Management of prisoners at risk of harm to self, to others and from others (Safer Custody) (PSI 64/2011) observations should be recorded ‘immediately or as soon as practicable thereafter’ . According to the local policy at HMP Holloway, as implemented in this case, any observations at any time need be recorded only at four hour intervals in summary form .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify community care coordinators of prisoner release
Wider context from the report “(19) There was evidence from Sarah’s care coordinator in the community, a social worker with the START Team, that she was never informed by HMP Holloway of the release of any prisoner whom she had previously supported in the community , despite the care coordinator having close links with the prison, for example visiting prisoners she had supported and sometimes taking part in CPA meetings. The care coordinator said that this would be ‘incredibly helpful’.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct ACCT reviews on a multidisciplinary basis
Wider context from the report “(8) The jury also found that the above decision was not multi-disciplinary , which it should have been (as the senior Governor conceded in evidence).
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate reduction of observation frequency despite deteriorating mental state
Wider context from the report “(7) The jury concluded that the decision to reduce the frequency of observations on Sarah Reed at ACCT Review No.4 on 5 January 2016, six days before Sarah’s death, was inappropriate given the clear evidence of the deterioration of her mental state .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the fitness-to-plead purpose of remand to the mental health team
Wider context from the report “(5) The jury found that the evidence that key members of Sarah’s mental health team in HMP Holloway were unaware that the sole purpose of her remand in custody was for the preparation of fitness to plead reports was ‘incomprehensible’.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in holding Care Programme Approach meetings
Wider context from the report “(12) The jury concluded that the delay in holding a Care Programme Approach (CPA) meeting was unacceptable . The evidence showed that a CPA Meeting for assessing a prisoner’s long-term care should have been held within four weeks from reception . In this case it was held after nine weeks .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require Duty Governor authorisation for cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate multidisciplinary participation in CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate. It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality and duration of CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate . It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” 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 Disseminate prison-specific guidance on CPA management requirements to all prison sites for comment.
Verbatim wording from the response “We accept that in this case a CPA meeting should have been arranged sooner. Ms Reed’s mental health and social functioning had deteriorated to the degree that this should have been prioritised. Further, we recognise that a CPA meeting would have allowed more detailed discussion regarding medication management.” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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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 Ratify the new continuity-of-care discharge policy by 1 October 2017.
Verbatim wording from the response “A new discharge policy – “Continuity of Care on Release/Discharge or Transfer from Prison” has been written by CNWL Offender Care. This has been written in line with the recently published NICE guidance (Physical Healthcare of People in Prison (NG57) 2 November 2016, and will be used across all CNWL Offender Care sites. Once ratified, by 1 October 2017, the below will become standard and expected practice.” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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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 Implement pre-release assessments, comprehensive care summaries, post-release plans and liaison with receiving services under the discharge policy.
Verbatim wording from the response “A new discharge policy – “Continuity of Care on Release/Discharge or Transfer from Prison” has been written by CNWL Offender Care. This has been written in line with the recently published NICE guidance (Physical Healthcare of People in Prison (NG57) 2 November 2016, and will be used across all CNWL Offender Care sites. Once ratified, by 1 October 2017, the below will become standard and expected practice.” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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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 Formally ratify the prison-specific CPA management guidance as a new policy by 1 October 2017.
Verbatim wording from the response “As a result of this case CNWL Offender Care has produced prison specific guidance highlighting these requirements which has been disseminated to all prison sites” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply the prison-wide procedure defining healthcare staff responsibilities before, during and after ACCT reviews.
Verbatim wording from the response “CNWL Offender Care have developed a “Roles and Responsibilities for Attendance at ACCT Reviews” Local Operating Procedure for all of our staff at our prison sites. This has been written in conjunction with NOMS Prison Service Instruction 64/2011 and has been operationalised at all of our prison sites.” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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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 Route all external psychiatric-report requests promptly to the responsible consultant under the Standard Operating Procedure.
Verbatim wording from the response “It now forms part of our Standard Operating Procedures that any requests for reports are communicated to the Consultant as soon as they are received; this includes instructions from the Court, defence solicitors, Crown Prosecution Service and/or any other relevant external agencies including Probation Services.” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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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 HMPPS will provide the response regarding procedures for cancelling prison visits.
Verbatim wording from the response “We have had a discussion with HMPPS who have agreed to provide a response regarding the procedure for cancelling visits.” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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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 HMPPS will clarify the process and procedure for providing psychiatric reports to courts.
Verbatim wording from the response “We have had a discussion with Her Majesty’s Prison and Probation Service (HMPPS) who have agreed to clarify the process and procedure for the provision of psychiatric reports to Courts.” Source location 2017-0238-Response-by-CNWL-NHS-Trust
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21 Jun 2017 Michael Folley · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 13 Failure to complete SASH forms for risk information emerging outside current court detention View source Failure to ensure clarity about information available during prison reception View source Failure to ensure Detention Officer PER training is completed View source Failure to complete SASH forms for relevant recent self-harm or suicide risk View source Failure to ensure receipt and training for important medical and risk information at prison reception View source Cell safety features permitting door wedging and ligature use View source Radio connection delays affecting emergency information relay View source Failure to ensure secure handover of PER documentation View source Failure to provide PER staff with relevant previous self-harm and suicide risk information View source Failure of court custody staff to contribute relevant risk information to the PER View source Incomplete provision of anti-ligature protection on cell doors View source Failure to record checks of PER completion and quality View source Failure of regular maintenance checks to identify defective anti-barricade doors View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Folley · 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
Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for risk information emerging outside current court detention
Wider context from the report “I was also left with a concern that GEOAmey staff would only complete a SASH form if the current risk was identified during Mr Folley’s detention at Portsmouth magistrates’ court and not if anything came to the attention of the court detention officer to indicate there was a risk of self-harm or suicide within the last month before arrest .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clarity about information available during prison reception
Wider context from the report “During the inquest, it became apparent that despite extensive questioning of police/custody staff, GEOAmey staff, prison officers and healthcare professionals, it would not be possible to establish with any degree of certainty exactly what information was available during the induction process once Mr Folley arrived at prison.
I heard from prison officers and a senior nurse involved in the reception process but there was no clarity regarding exactly what information was available to them namely, the PER itself, the HDLS reports or information that had clearly been faxed to the prison by court staff such as the warrants setting out the grounds for the remand.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Detention Officer PER training is completed
Wider context from the report “c) Detention Officer PER training may not have been completed if a DO had many years of experience in the police force which would give what he referred to as “grandfather rights” .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for relevant recent self-harm or suicide risk
Wider context from the report “h) The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month . In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest. In this case the SASH form was never completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure receipt and training for important medical and risk information at prison reception
Wider context from the report “The nurse confirmed that at the time of Mr Folley’s reception checks he did not see the PER or HLDS reports but told me that he now does. In addition, he could not recall any specific training and the system for receipt of important medical information sounded haphazard as hardcopy documents were simply left on a desk .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Cell safety features permitting door wedging and ligature use
Wider context from the report “I heard evidence that prisoners are issued with plastic mirrors that are frequently used as wedges in cell doors . This means officers are vigilant to ensure prisoners only have one mirror each and if there are more in a cell than necessary they will be removed. It was suggested that a thicker mirror could be issued or a mirror/reflective panel could be inserted into the wall. This was an ongoing process of replacement in the prison.
Window design was also being considered and I was informed a trial had begun prison to roll out a new type of window but that this could take up to 2 years to complete .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Radio connection delays affecting emergency information relay
Wider context from the report “There was conflicting evidence during inquest about the effectiveness of when the Code Blue call was made and whether this resulted in any delay in the information being passed to the ambulance service. On balance of probabilities, the problem seemed to come from the fact that the custody manager did give the correct callsign but because there is a two second delay when pressing the radio button this may not have been picked up immediately in the control room . This is of significant concern both in respect of the safety prison officers but also the need to obtain medical help for prisoners and suggests the need to update the radio system
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure secure handover of PER documentation
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded.
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide PER staff with relevant previous self-harm and suicide risk information
Wider context from the report “b) Mr Folley was assessed as NCTS (no current thoughts of self-harm or suicide) and thus placed on the lowest observation rate of 60 minutes. However, access to previous data held on police (both internal and external) and other agency systems was not available to officers completing the PER and thus they could rely on current observations only . Despite this, it was essential to consider the risk of self-harm or suicide demonstrated and recorded over the previous months (July – September) not simply since detention on this occasion.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of court custody staff to contribute relevant risk information to the PER
Wider context from the report “I am concerned that the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from.
In addition, there was apparently no log of ████████ call to the court cells. The electronic PER had been checked and nothing was logged. There is no reason to believe ████████ call was not made and it is of concern that there was no apparent system for logging such a call let alone action in the contents of her request .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete provision of anti-ligature protection on cell doors
Wider context from the report “I also heard that steps had been taken to fit anti-ligature strips in some but not all cell doors .
All of these suggestions seemed eminently sensible yet the pace of these changes does need to be considered .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record checks of PER completion and quality
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry . This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded .
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of regular maintenance checks to identify defective anti-barricade doors
Wider context from the report “I heard evidence that every effort was made to gain quick access into Mr Folley self once it became apparent that he had barricaded the door. This was significantly hindered by painting the screws on the anti-barricade plate but significantly, by the fact that even when the plate was removed the bar would not open outwards towards this landing due to a brick hanging down in the door frame. Whilst it has to be accepted that Winchester prison is not a modern prison nevertheless this should have been picked up during regular maintenance checks . I was shown some records this tended to imply that either checks had not been carried out on a regular basis or the checks themselves were not adequate . Either way this is of concern.
” Open source report
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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 Circulate reception-screening expectations and provide a Trust-wide reception-screening guide for staff.
Verbatim wording from the response “As part of suicide prevention, clear expectations on reception screening have been circulated to staff including:” Source location 2019-0230-Response-by-CNWL-NHS-Trust
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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 Roll out standardised reception-screening training and competencies, restricting screening to trained and competent staff.
Verbatim wording from the response “The Trust is currently rolling out standardised training and competencies for reception screening. Reception screening is not allowed to be undertaken if the appropriate training has not been completed and the staff member deemed competent enough to carry out the reception screen.” Source location 2019-0230-Response-by-CNWL-NHS-Trust
Open published response
21 Feb 2017 JACK OLIVER PORTLAND · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 16 Failure of communication between healthcare staff and prison staff about healthcare records View source Failure to complete timely and accurate Root Cause Analysis reports View source Failure to establish and communicate a clear AWOL and leave authorisation procedure View source Failure to disclose contemporaneous RCA information View source Inadequate communication with families during the ACCT process View source Failure to obtain and update patients’ risk history and assessment View source Insufficient detail in ACCT caremaps and post-closure reviews View source Failure to complete leave observation charts contemporaneously and consistently View source Failure to maintain an accurate and reliable leave tracking system View source Failure to implement changes with clear timescales and adequate coverage of identified concerns View source Delays in identifying relevant witnesses and providing witness statements for coronial investigations View source Failure to coordinate complete and appropriately recorded disclosure for coronial investigations View source Failure to maintain contemporaneous records of AWOL actions View source Delays in completing ACCT post-closure reviews View source Failure to provide S17 leave records to required recipients View source Failure to adequately assess and manage discharge needs of vulnerable prisoners View source See 13 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.
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AI-generated summary
JACK OLIVER PORTLAND · 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
Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.
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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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between healthcare staff and prison staff about healthcare records
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so , notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete timely and accurate Root Cause Analysis reports
Wider context from the report “(5) The actions taken in relation to the preparation of two Root Cause Analysis reports were of concern in that the first RCA was founded on inaccurate information and the second RCA still contained inaccuracies and was not completed until some 11 months after the fatal event . The ability to react quickly to issues raised and to implement new policies and working practices may have been compromised by the delays and lack of robustness of the reports . The recommendations of the second RCA indicate reviews to be conducted by February/March 2017 but do not appear to address more urgent practical action or possible staff training needs.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and communicate a clear AWOL and leave authorisation procedure
Wider context from the report “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave . There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose contemporaneous RCA information
Wider context from the report “(6) Disclosure, initially to the Coroner, of contemporaneous interviews and information gathered during the early stages of the first RCA may have assisted in preventing subsequent delays and progressing the inquest process, enabling learning from any identified concerns to have been addressed at an earlier stage. In any event such notes and related documents did not form part of the disclosure .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with families during the ACCT process
Wider context from the report “(2) The standard letter notifying a family of the opening of an ACCT was non-specific and dependent upon prisoner consent , yet it was identified that the engagement of families in the ACCT process was important, particularly in the context of risk assessment . It appeared that the same letter is still in use, directing families to telephone extensions for prison staff and healthcare or a 24-hour help line. The family evidence was that communication with the prison in response to a letter received during the first ACCT was of significant concern and that they were not notified of the second ACCT. There was evidence suggesting that the helpline is now attended regularly and messages dealt with but the overall communication paths appear to remain the same .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and update patients’ risk history and assessment
Wider context from the report “(4) Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr Portland’s time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr Portland’s time at HMP Woodhill. It was acknowledged in evidence that knowledge of risk of self-harm recorded in the HMP Woodhill ACCT documents would have been helpful .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in ACCT caremaps and post-closure reviews
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review , late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete leave observation charts contemporaneously and consistently
Wider context from the report “(3) The manually-completed observation charts, forming the third element of an effective leave management process, were acknowledged to be filled out sometimes retrospectively, sometimes prospectively, sometimes by reference to the whiteboard (and evidence suggested amended later) rather than always being completed in the ward round. There was scope for human error and discrepancies between the various records of leave .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate and reliable leave tracking system
Wider context from the report “(2) A specific request for leave from the patient would be actioned by a nursing-level assessment, authorisation of the specific leave by the nurse in charge and implementation of the leave by a staff member. A Record of Leave of Absence would be completed and signed by the patient and the staff member and that staff member would usually then write up that patient’s name and the times out and due back on a whiteboard in the office. Evidence from witnesses confirmed that there was no particular order to the whiteboard . In the case of Mr Portland, his final leave had not been written on the whiteboard correctly and his absence was not identified until well over an hour after he was due back . The evidence indicated that the whiteboard is still used in the same way , notwithstanding that it was acknowledged that there was scope for human error and that addressing the issue was a matter of urgency.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement changes with clear timescales and adequate coverage of identified concerns
Wider context from the report “(7) Whilst there were indications that there were changes being implemented, there was no clear indication of timescales nor did they address the particular concerns identified during this investigation .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying relevant witnesses and providing witness statements for coronial investigations
Wider context from the report “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate complete and appropriately recorded disclosure for coronial investigations
Wider context from the report “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department . Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure . Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous records of AWOL actions
Wider context from the report “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing ACCT post-closure reviews
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review , communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide S17 leave records to required recipients
Wider context from the report “(1) The practical implementation of S17 leave involved, firstly, the grant of leave by the consultant psychiatrist and it was mandatory to provide copies of those Records of Grant not only to the patient, but also to the family of a patient along with the Inpatient clinical team and the MHA administrator . The Care Co-ordinator and GP were also optional recipients. No copies of any of Mr Portland’s S17 Records of Grant of Leave appeared to have been provided to anyone other than the patient . The family were unaware of changes to leave and were unable to participate in the leave process or assist Whiteleaf with regard to any heightened risks.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess and manage discharge needs of vulnerable prisoners
Wider context from the report “(3) There were concerns about the assessment and management of Mr Portland’s discharge needs from admission, particularly with regard to post-release accommodation and positive identification of registration with a GP , given that Mr Portland was homeless and that aftercare ultimately would be dependent upon GP engagement. It was accepted that it is mandatory for prisoner discharges to be undertaken in accordance with the relevant Prison Service Instruction and Early Days and Discharge Specification with all that those encompass. There remains a concern regarding the discharge of prisoners presenting with issues such as those of Mr Portland – a risk of self-harm, substance addiction, homelessness, resolving substance-induced psychosis, vulnerability .
” Open source report
27 Nov 2016 Matthew RUSSELL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation View source Inadequate foundation and ongoing ACCT-procedure training for staff responsible for patients in prison View source Failure to properly and regularly monitor repeat-prescription medication View source Lack of structured care plans for each patient View source Ineffective communication about patients’ needs with GPs and primary healthcare practitioners at HMP High Down View source Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls View source Failure to effectively use Read Codes to flag significant patient-care risk factors View source Failure to effectively follow up patients who miss pre-booked clinical appointments View source Failure of caseworkers to be aware of and attend ACCT Case Reviews View source Failure to conduct risk assessments for individual prisoners View source Inadequate foundation and ongoing ACCT-procedure training for staff View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew RUSSELL · 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
Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend .
• Risk Assessments in relation to individual prisoners.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate foundation and ongoing ACCT-procedure training for staff responsible for patients in prison
Wider context from the report “e. Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-going training in the ACCT procedure .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly and regularly monitor repeat-prescription medication
Wider context from the report “Central and North West London Foundation Trust
a. The proper and regular monitoring of all medication that is prescribed by way of a repeat prescription .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structured care plans for each patient
Wider context from the report “b. The preparation of structured care plans for each patient .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication about patients’ needs with GPs and primary healthcare practitioners at HMP High Down
Wider context from the report “g. Ensuring that there is regular effective communication about a patient’s needs with the GPs and the primary healthcare practitioners at HMP High Down .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls
Wider context from the report “b. Ensuring that all Gate House staff understand the proper procedure to adopt when receiving a call from a prisoner's family or friends expressing concerns for that prisoner’s safety or wellbeing .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively use Read Codes to flag significant patient-care risk factors
Wider context from the report “d. The effective use of Read Codes on the System One record, to flag up and highlight significant risk factors in a patient’s care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively follow up patients who miss pre-booked clinical appointments
Wider context from the report “c. An effective procedure for following up patients who fail to attend pre-booked appointments with clinicians .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of caseworkers to be aware of and attend ACCT Case Reviews
Wider context from the report “f. Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct risk assessments for individual prisoners
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend.
• Risk Assessments in relation to individual prisoners .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate foundation and ongoing ACCT-procedure training for staff
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure , with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend.
• Risk Assessments in relation to individual prisoners.
” 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 Develop a SystmOne training package covering system functionality and READ codes, and incorporate homepage login requirements into the Standard Operating Procedure.
Verbatim wording from the response “CNWL is currently developing a training package for staff on the effective use of SystmOne on the functionality of the system, and the use of READ codes. We recognise that the homepage is a vital screen for agencies communicating risk and essential information in relation to a patient’s care. All staff have been advised through local meetings of the requirement to log in via the homepage and this will be included in the CNWL Standard Operating Procedure going forward.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Standard Operating Procedure for primary-care management of dual diagnosis and comorbidity, then submit it for ratification.
Verbatim wording from the response “CNWL are currently reviewing our Standard Operating Procedure for working effectively with Primary care in managing dual diagnosis and co-morbidity via the Care Quality Management Meeting, and is due for review in February 2017 and ratification by the Clinical Director in April 2017.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Consultant Psychiatrist Complex Case Review Meetings including relevant healthcare and custodial partners.
Verbatim wording from the response “• Introduction of the CNWL Consultant Psychiatrist Complex Case Review Meetings at HMP Highdown to include GPs, Primary Care, Mental Health, Substance Misuse, Social Care, Safer Custody and Pharmacy that will commence in February 2017 to ensure that there is regular communication with all healthcare providers.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Best Practice Care Plan training to HMP Highdown staff.
Verbatim wording from the response “A Care Plan audit was undertaken in October 2016. The audit identified that 100% of patients on the In-reach caseload had care plans in place. The team is monitored on a monthly basis on:” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review SystmOne use across Surrey sites and make it a standing item in local Clinical Quality Meetings.
Verbatim wording from the response “CNWL has a dedicated Performance Lead for the Surrey cluster and we will ensure a full review of the use of SystmOne is undertaken in each site, and that this is a standing agenda item in all local Clinical Quality Meetings. We have recently appointed a performance and data analyst who is currently working with managers and senior clinicians across all our prison sites to improve local recording and support with local induction and ongoing support for teams.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate and share the In-Reach DNA procedure, including same-day follow-up, risk review and rebooking after missed appointments.
Verbatim wording from the response “The CNWL In-Reach Team has a DNA (Did Not Attend) Standard Operating Procedure in place which has been shared and discussed with all staff members.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver refresher training so CNWL staff can use SystmOne risk indicators and set the high-risk icon on patient records.
Verbatim wording from the response “CNWL recognises the need for improved interagency co-operation and communication in the local use of SystmOne. All CNWL staff using SystmOne upon login are taken to the patienthomepage which includes an “exclamation mark icon”. This icon identifies that a patient is of high risk of self-harm, open ACCTs, suicide risk and any other significant risk areas that staff need to be aware of. All CNWL staff will receive refresher training by the end of February 2017 to ensure they know how to set this icon up on the client record should the need arise.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review SystmOne use with partner agencies and develop a multi-agency protocol for risk communication and medicines optimisation.
Verbatim wording from the response “CNWL has been appointed as the Lead provider for Primary Care Services in HMP Highdown and across the Surrey prisons cluster. As part of the mobilization and transfer process, CNWL will undertake a full review of the system in conjunction with partner agencies to optimise system usage and risk assessment and management processes across prescribing and pharmacy services. This will include the development of a multi-agency protocol on the use of SystmOne that includes communication of risk and medicines optimisation.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run weekly Mental Health team meetings with GP access, distribute agendas and minutes, and communicate urgent matters to GPs.
Verbatim wording from the response “• Weekly Mental Health team meeting that includes standing open invitation to GPs. We do ensure that the agenda and minutes of the meeting are sent to the lead GPs. Urgent matters that arise in this meeting are communicated in a timely way to the GP’s if they are not present. Should the consultant psychiatrist not be present in the meeting then the responsible manager in that meeting contacts the Consultant Psychiatrist. Other or non-urgent matters are discussed at the Complex Case Review meeting (see point below).” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a daily Open ACCT Log and morning briefing to identify open ACCTs, arrange assessments and ensure mental-health attendance at reviews.
Verbatim wording from the response “Safer custody at HMP Highdown now provide CNWL with a Daily Open ACCT Log, which is sent to three managers within the team. This is then circulated to all staff on duty that day and a daily copy posted on the Inreach Staff Office Notice Board.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the Offender Care Psychosocial Strategy to support psychologically informed care and reduce reliance on dependence-forming medication where appropriate.
Verbatim wording from the response “A key element of the new CNWL model in the Surrey prisons is based on Medicines Optimisation for all patients, with pharmacy services focused on delivering individual” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out mandatory e-learning on ACCT processes and healthcare roles and responsibilities to CNWL secure-settings staff.
Verbatim wording from the response “CNWL have developed a new e-learning package that details the ACCT process and outlines the specific roles and responsibilities of healthcare within this process. This will be rolled out within the next 3 months.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ongoing monitoring of repeat antidepressant medication is the responsibility of the prescribing GP or CNWL prescriber, rather than solely CNWL mental health services.
Verbatim wording from the response “The prescriber is responsible for ensuring that a treatment plan is in place for the ongoing monitoring of repeat anti-depressant medication. In HMP Highdown we work in conjunction with other prescribers with the clear understanding that the prescriber is responsible for ensuring the ongoing monitoring of compliance and” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CNWL cannot always ensure mental health team attendance at every ACCT review because of mental health service capacity constraints.
Verbatim wording from the response “CNWL mental health pathway recognises the need for the Mental Health team to attend ACCT case reviews for all patients on the mental health caseload. Our pathway recognises as good practice that the Mental Health team should attend all ACCT reviews. However, while this is accepted as a gold standard for prison mental health teams, CNWL is sometimes unable to meet this standard due to the capacity of mental health services. Attendance is monitored via the monthly contract review meeting attended by the prison, and capacity and local inter-agency operational issues are discussed and recorded.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The prison is responsible for delivering ACCT training, so CNWL depends on the establishment’s training schedule for staff access.
Verbatim wording from the response “ACCT training is prison provided training. CNWL works closely with the establishment to facilitate staff access training as far as possible within their probationary period.” Source location 2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
Open published response
14 Dec 2015 Daniel Brendan Byrne · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners View source Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Brendan Byrne · 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 Brendan Byrne died at Milton Keynes Hospital on 27 February 2015 after being resuscitated following a suicide attempt by hanging in his cell at Woodhill Prison the previous day. The principal concerns were inadequate assessment of the risk of self-harm and suicide by healthcare staff and prison officers, failure to refer him for an urgent mental health assessment, and an inadequate first ACCT case review.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
Wider context from the report “In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says:
“ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT . There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare . Consideration should also be given to the introduction of a formal risk assessment tool.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners
Wider context from the report “In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says:
“ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners .” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT. There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare. Consideration should also be given to the introduction of a formal risk assessment tool.
” 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 Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.
Verbatim wording from the response “We have gone further and in the last year CNWL has been developing a new on-line e-learning training package, developed by our mental health staff, which will better equip staff in assessing the risk of self-harm and suicide. We have been concerned to raise the awareness of all staff but particularly those undertaking reception screening about both the risk of suicide and appropriate risk management processes. This package has been trialled across the Trust’s Offender Care services and all CNWL staff in HMP Woodhill will have completed this training by the end of February 2016. Once its effectiveness has been audited, the tool will be shared with NOMS and NHS England for use in prison healthcare services outside of the Trust.” Source location Daniel-Byrne-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.
Verbatim wording from the response “We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.” Source location Daniel-Byrne-Response
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 Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.
Verbatim wording from the response “From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.” Source location Daniel-Byrne-Response
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 Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.
Verbatim wording from the response “While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.” Source location Daniel-Byrne-Response
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 Train reception-screening staff, including agency staff where used, to apply the strengthened screening tool.
Verbatim wording from the response “While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.” Source location Daniel-Byrne-Response
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 Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.
Verbatim wording from the response “From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.” Source location Daniel-Byrne-Response
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 Check daily information-sharing and review ACCT records at each planned review meeting.
Verbatim wording from the response “We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.” Source location Daniel-Byrne-Response
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 Provide daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.
Verbatim wording from the response “From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre. The role of these staff is to support the system as a whole in assessing which of the men arriving within HMP Woodhill may pose a risk to themselves and ensuring that this risk is properly managed. NHS England has agreed additional funding for 2015-16 to increase staff capacity. In addition to the initial risk assessment on the first night, which includes a comprehensive risk assessment identifying self-harm and suicide indicators, there is now a secondary health screen carried out the next day that also screens for risks of self-harm. Further to this, a member of the Mental Health team is present at the First Night Centre (FNC) and carries out a risk assessment on all the men that arrived in the prison on the day before.” Source location Daniel-Byrne-Response
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 Provide ongoing support for prison ACCT training and prison-led ACCT management.
Verbatim wording from the response “We continue to work closely with NOMS, and all of the changes noted above have been discussed with them. We continue to provide support for ACCT training processes and support the prison in managing the prison-led ACCT process. CNWL staff actively check each day that relevant information has been appropriately shared and that we review ACCTs at each planned review meeting. We have audited our record keeping for staff attending ACCT reviews to ensure that risk related information is both appropriately recorded and shared. This monitoring will be on-going in HMP Woodhill and in our other services. We have discussed with the Prison Governor and the NOMS the use of ‘safer cells’ (where all ligature points have been removed) but we understand that there are no safer cells within HMP Woodhill at this time.” Source location Daniel-Byrne-Response
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 NOMS holds policy responsibility for suicide prevention and self-harm management.
Verbatim wording from the response “You stated that “there needs to be a review of the healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare”. In addition, that “consideration should be given to the introduction of a formal risk assessment tool”. We note that you raised similar concerns in Regulation 28 reports in 2014 and have considered the NOMS responses of 12 June and 31 October 2014. We note that the Equality, Rights and Decency Group of NOMS has policy responsibility for suicide prevention and self-harm management and will not repeat the description of the policy frameworks set out in the responses. We do however operate under the national frameworks set out in Prison Service Instructions (PSI) 74/2011 Early Days in” Source location Daniel-Byrne-Response
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 prison leads the ACCT process and is responsible for regularly assessing prisoners’ risk.
Verbatim wording from the response “It was also recognised that whilst those with complex Mental Health needs are ‘managed well’ there is very little resource available for those inmates who are primarily being supported by GPs. This will be picked up in the benchmarking exercise. There were a number of other recommendations including the need to regularly review and focus on the ACCT process recognising the importance of the prison risk assessing regularly and the quality and organisation of the process.” Source location Daniel-Byrne-Response
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 No nationally recognised best-practice risk-assessment tool exists beyond the processes specified in Prison Service Instructions.
Verbatim wording from the response “While there is no nationally recognised best-practice ‘tool’ or best practice guidance, beyond the process identified in the PSIs identified above, the reception screening tool has been strengthened and more detailed questioning around mental health, risk of self-harm and suicide has been added. CNWL staff undertaking the reception screening role have been trained in its use, with all staff due to complete training by March 2016. Agency staff, where used, will also be fully trained.” Source location Daniel-Byrne-Response
Open published response
6 Jul 2015 Mr Tommy Faegh Faisali · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Use of staff without appropriate qualifications to provide expert psychiatric referral advice View source Failure to communicate patient risks, including suicide risk, to other mental health team members View source Lack of continuity of care in team-based mental health care View source Failure to complete or appropriately document mental health team risk assessments View source Failure to ensure that psychiatric second-opinion referrals are assessed by appropriately qualified psychiatrists View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Tommy Faegh Faisali · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Tommy Faegh Faisali, who had hepatitis C causing cirrhosis and was methadone dependent, was found deceased in his accommodation on 30 September 2014. The inquest concluded that the medical causes of death included acute pulmonary oedema, methadone toxicity and liver failure due to cirrhosis, with the jury recording drug-related misadventure. Concerns included the lack of specialist psychiatric assessment despite GP referrals, inadequate risk assessment and documentation, and poor communication and continuity of care within mental health teams.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of staff without appropriate qualifications to provide expert psychiatric referral advice
Wider context from the report “(1) That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral.
(2) That a shortage of appropriately qualified doctors is being compensated for by staff without the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals .
(3) Those patients may be at increased risk because of (1) and (2) above.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patient risks, including suicide risk, to other mental health team members
Wider context from the report “(4) That staff within the mental health teams are not completing risk assessments or at least not appropriately documenting that they are.
(5) That risks to patients, including risk of suicide is thus not appropriately communicated to other team members , thereby increasing the risks to those patients.
(6) That risks arising from (5) are even more increased given the team approach to care and lack of continuity of care inherent in such ways of working.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care in team-based mental health care
Wider context from the report “(4) That staff within the mental health teams are not completing risk assessments or at least not appropriately documenting that they are.
(5) That risks to patients, including risk of suicide is thus not appropriately communicated to other team members, thereby increasing the risks to those patients.
(6) That risks arising from (5) are even more increased given the team approach to care and lack of continuity of care inherent in such ways of working .
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or appropriately document mental health team risk assessments
Wider context from the report “(4) That staff within the mental health teams are not completing risk assessments or at least not appropriately documenting that they are .
(5) That risks to patients, including risk of suicide is thus not appropriately communicated to other team members, thereby increasing the risks to those patients.
(6) That risks arising from (5) are even more increased given the team approach to care and lack of continuity of care inherent in such ways of working.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that psychiatric second-opinion referrals are assessed by appropriately qualified psychiatrists
Wider context from the report “(1) That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral.
(2) That a shortage of appropriately qualified doctors is being compensated for by staff without the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals.
(3) Those patients may be at increased risk because of (1) and (2) above.
” Open source report
22 Apr 2014 Tanya Rosemary Marion Oladejo · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Failure to communicate medication changes between the GP practice and responsible clinician View source Failure to ensure medication directions and labels correspond to the prescribed use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tanya Rosemary Marion Oladejo · 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
Tanya Rosemary Marion Oladejo was found collapsed and unresponsive on her bed after a friend had not heard from her for approximately one week; police confirmed there were no suspicious circumstances. The inquest concluded misadventure, with the medical cause of death recorded as amitriptyline intoxication. The principal concern was inadequate communication between the GP practice and the responsible clinician about medication, including unilateral changes to amitriptyline prescribing that were not communicated to the responsible clinician.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate medication changes between the GP practice and responsible clinician
Wider context from the report “(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation.
(2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation.
(3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings.
(4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medication directions and labels correspond to the prescribed use
Wider context from the report “(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation.
(2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation.
(3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings.
(4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition
” 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 Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considered its communication systems effective in this case and did not identify a need to change them.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-NHS-Trust
Open published response
19 Feb 2014 Simon William McAndrew · Prevention of Future Deaths report South London
View report summary
Concerns raised 5 Failure to ensure key clinical staff can access important electronic information held in different NHS trusts View source Lack of formal written care plans with clear crisis-management guidance for distant residential homes View source Failure to share and recognise information about psychiatric responsibility between NHS trusts View source Failure to provide prominent accurate and up-to-date information identifying the responsible mental health professional View source Inadequate contact with discharged in-patients living distant from their base hospital and key caseworkers View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Simon William McAndrew · 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
Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.
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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure key clinical staff can access important electronic information held in different NHS trusts
Wider context from the report “Mr McAndrew had a drug misuse issue and a mental health issue. Each was dealt with by different specialist psychiatrists. After a long period of in-patient treatment at the Gordon Hospital Mr McAndrew was located in a residential home in another Borough. His key caseworker was not easily able to keep in touch with him. His methadone management was managed by Lantern House, a local NHS facility in the London Borough of Croydon. When acute psychiatric issues arose Lantern House staff ordinarily worked in close liaison with the local acute mental health trust (SLAM). At the material time it was not appreciated that Mr McAndrew’s psychiatric care remained with the Gordon Hospital.
Correspondence from one trust to another was copied to the consultant psychiatrist at Lantern Hall but was not seen by her. This might have been because she was on leave when it was received and the copy letter was then scanned into the electronic patient record but not left in the consultant’s ‘in-tray’ for perusal on her return. An opportunity was missed to ensure effective communication with the Gordon Hospital staff. Junior staff, whether medical or nursing, had no ‘front page’ on the electronic patient record that contained information that the primary psychiatric care was held by the Gordon Hospital; so an inappropriate referral was made to SLAM.
For so long as the national computer database for all NHS patients is a far-off ideal, some better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust . This is especially important in psychiatric illness, where patients may not be able to provide the relevant, important information themselves.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal written care plans with clear crisis-management guidance for distant residential homes
Wider context from the report “Please will you also consider whether a formal, written care plan should be provided to the distant residential home with clear guidance as to what is to happen in defined circumstances of crisis. If the staff at Jordan Lodge had had the benefit of a care plan, they might have contacted the acute psychiatric team on 30th June 2011 to seek advice as how best to manage the immediate crisis. In the absence of a care plan, and with residential home staff who are not mental health professionals, the staff who were on duty on the day were left to deal with the crisis as best they could. Is that state of affairs capable of improvement?
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share and recognise information about psychiatric responsibility between NHS trusts
Wider context from the report “Mr McAndrew had a drug misuse issue and a mental health issue. Each was dealt with by different specialist psychiatrists. After a long period of in-patient treatment at the Gordon Hospital Mr McAndrew was located in a residential home in another Borough. His key caseworker was not easily able to keep in touch with him. His methadone management was managed by Lantern House, a local NHS facility in the London Borough of Croydon. When acute psychiatric issues arose Lantern House staff ordinarily worked in close liaison with the local acute mental health trust (SLAM). At the material time it was not appreciated that Mr McAndrew’s psychiatric care remained with the Gordon Hospital.
Correspondence from one trust to another was copied to the consultant psychiatrist at Lantern Hall but was not seen by her. This might have been because she was on leave when it was received and the copy letter was then scanned into the electronic patient record but not left in the consultant’s ‘in-tray’ for perusal on her return. An opportunity was missed to ensure effective communication with the Gordon Hospital staff. Junior staff, whether medical or nursing, had no ‘front page’ on the electronic patient record that contained information that the primary psychiatric care was held by the Gordon Hospital; so an inappropriate referral was made to SLAM.
For so long as the national computer database for all NHS patients is a far-off ideal, some better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust. This is especially important in psychiatric illness, where patients may not be able to provide the relevant, important information themselves.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prominent accurate and up-to-date information identifying the responsible mental health professional
Wider context from the report “The Trust may also like to consider the unintended consequences of the use of different computer databases in Trusts and how this might better be managed. Even within individual computer systems, the evidence heard in this case suggests that the information may be available but often staff - particularly junior staff - do not know to look for it, may not know where to look for it and might not have the time to delve deep into the electronic record to find it. If a "front of file" note could be created in each case to record basic, essential information this may assist medical staff in discerning the appropriate mental health professional with overall care in any particular case. Of course, such information must be accurate and up-to-date.
” 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 Central and North West London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate contact with discharged in-patients living distant from their base hospital and key caseworkers
Wider context from the report “An additional point is that where discharged in-patients are resident in homes far distant from the ‘base hospital’ and their key caseworkers, a better means must be devised of keeping in touch with the patient. In this case the key caseworker conceded that she did not keep in touch with Simon as much as would have been the case had he remained resident locally. At best regular contact would have been by telephone rather than face-to-face, albeit that occasional face-to-face contact was being arranged.
” 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