Change, Grow, LiveIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 16 Feb 2016•Latest report 19 May 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
6

Naming this recipient

Published responses
33%

Found for named reports

Concerns addressed
5

Across all linked responses

Stated actions
28

Described in responses

Concerns and recipient responses

Statements from Change, Grow, Live linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Spencer George BARR · 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

    Spencer George BARR was found unresponsive at home on 9 December 2021 and was declared deceased by paramedics after an overdose involving opioids, cocaine and pregabalin. He had a long history of substance misuse and labile mental health and was under the care of probation, addiction and mental health services. The principal concerns were inadequate sharing of information and cooperation between agencies, the lack of central points of contact, and limitations on inter-agency referrals.

    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of central points of contact for inter-agency referrals and information sharing

    Wider context from the report

    “4. Additionally, I am concerned that there appear to be no central points of contact for agencies to facilitate that co-operation. I heard evidence that CGL has no central point of contact for referrals being made/to allow sharing of information - instead relying on information being conveyed via specific individuals. I am therefore concerned that where there is no central point of contact, there is a risk of information not being passed on in a timely manner when a specified person is absent from work for whatever reason. Consideration should be given to central points of contact being created within each agency, and ensuring that those points of contact are shared between agencies to ensure information can flow freely between them. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a universal approach to inter-agency cooperation

    Wider context from the report

    “3. I heard evidence that Birmingham Women's and Children's NHS Foundation Trust are now taking steps to improve intra-agency co-operation in an attempt to mitigate against the risk of further deaths in the future. However, I heard evidence that other agencies may not be aware of their own limitations when it comes to inter-agency co-operation. For instance, CGL gave evidence that they had no concerns regarding their co-operation with other services, but Birmingham Women's and Children's NHS Foundation Trust indicated that the connections between their respective agencies was poor. I am therefore concerned that there is no universal approach being taken by all agencies to improve inter-agency cooperation, and consideration should be given to the formation of a working group being set up between all agencies to ensure a coordinated approach is taken. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of organisations to accept direct referrals from other agencies

    Wider context from the report

    “5. Furthermore, I heard evidence that certain organisations do not accept direct referrals or share information between agencies. For instance, I heard that CGL solely depend on referrals from GP practices and do not allow referrals direct from other agencies. Consideration therefore should be given as to whether there a better system of interagency referral is possible ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share relevant information adequately between agencies

    Wider context from the report

    “2. I heard evidence that full circumstances surrounding Spencer's deterioration and drug relapse in November 2021 - namely that he had received a significant back payment of benefits totalling over £5,000 from the DWP resulting in him purchasing drugs and overdosing - were not adequately conveyed between agencies, and as such agencies were unaware of the heightened risk of potential self harm and death that was posed by these circumstances. Inter-agency co-operation therefore appears to be inadequate, and consideration should be given to ensuring clinicians receive better training when it comes to the sharing of relevant information between agencies. ”
    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

    Grant CGL licences to access important clinical patient details.

    Verbatim wording from the response

    “Response to matters of concern 4 & 5 In FTB both the service user’s named Core Worker and Lead Professional act as central point of contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts as a point of contact if the service user’s named Core Worker or lead professional is not available this ensures that there is always a specific allocated point of contact in the working day to share essential information. FTB is committed to ensuring information is shared across agencies to support patient safety and we have agreed to grant licences to CGL that will enable them to access important clinical patient details.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 4 · response
    Published 17 May 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a fast-track trusted-assessment pathway to expedite mental-health referrals from CGL.

    Verbatim wording from the response

    “CGL have direct access to referring into FTB and can directly refer young people where there are mental health concerns and substance misuse concerns this has been strengthened further with the agreement of the development of a fast-track pathway and expediting referrals for mental health assessment from CGL via a trusted assessment model. We believe this will support patients at the earliest opportunity addressing risk. The oversight of the task group and progress will be monitored through the Birmingham Joint Strategic Operational forum where all system partners are represented.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 3 · response
    Published 17 May 2022

    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

    Establish a multi-agency task group to review and strengthen dual-diagnosis pathways.

    Verbatim wording from the response

    “Response to matter of concern 3 Forward Thinking Birmingham have set up a multi-agency working party to ensure the dual diagnosis pathways between organisations providing mental health services and substance misuse services are reviewed and strengthened. The task group includes representatives invited from CGL, FTB, BSOL CCG, BCC and BSMHFT.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 3 · response
    Published 17 May 2022

    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

    Include alternative contact details in out-of-office messages when named professionals are unavailable.

    Verbatim wording from the response

    “When the Core Worker or lead professional is not available the out of office message will include the telephone number for colleagues who can redirect queries and make arrangements to make contact with patients in a crisis.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 4 · response
    Published 17 May 2022

    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

    CGL disputes that it lacks a central contact or accepts only GP referrals, citing established contacts and referrals from multiple agencies.

    Verbatim wording from the response

    “We would like to reassure you that CGL have an established central point of contact and have accepted referrals from any individual and agency since March 2015 when the service was commissioned in Birmingham. Referrals can be made via the telephone or the CGL website at the following link https://www.changegrowlive.org/drug-alcohol-service-birmingham/referrals.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 4 · response
    Published 17 May 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing named workers, duty workers and out-of-office arrangements provide central points of contact for information sharing and crisis queries.

    Verbatim wording from the response

    “Response to matters of concern 4 & 5 In FTB both the service user’s named Core Worker and Lead Professional act as central point of contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts as a point of contact if the service user’s named Core Worker or lead professional is not available this ensures that there is always a specific allocated point of contact in the working day to share essential information. FTB is committed to ensuring information is shared across agencies to support patient safety and we have agreed to grant licences to CGL that will enable them to access important clinical patient details.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 4 · response
    Published 17 May 2022

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Nicholas Jonathan SPOONER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Denial of mental health support for people in crisis with co-occurring substance abuse

    Wider context from the report

    “Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support. ”
    Open source report

    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

    Integrate Mental Health Liaison and Dual Diagnosis nursing work through joint meetings and client support.

    Verbatim wording from the response

    “Previously we also set out the principles which underpin SPFT's Co-occurring Substance Use and Mental Health 5-year strategy. Since then, we are pleased to be able to update you on the recruitment of two Dual Diagnosis Workers into SPFT's Assessment and Treatment Services (ATS) in Brighton. This has arisen as a result of additional funding being obtained, through the transforming community care plan, and has resulted in a Dual Diagnosis Worker for both East and West Brighton ATSs. Change Grow Live have made progress integrating the work of their Mental Health Liaison nurses with the newly appointed SPFT Dual Diagnosis nurses. Strategic meetings have taken place between Change Grow Live and SPFT managers and the nurses are working jointly to support some clients with dual diagnosis.”

    Source location

    Response from NHS Social Care
    Page 2 · response
    Published 2 November 2021

    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

    Require new mental health and substance misuse commissioning to address co-existing needs and involve NHS Sussex and the City Council.

    Verbatim wording from the response

    “We committed to ensuring that all new commissioned services for both substance misuse and mental health conditions specifically considers co-existing needs, and our update is that NHS Sussex and the City Council continue to be committed to involving and working with each other in the development of commissioning plans to best meet the needs of people with co-existing needs, and this will be a requirement of all providers of services across mental health and substance misuse. All service developments will be informed by the government guidance on providing better care for people with co-occurring mental health and alcohol/drug use conditions, Better care for people with co-occurring mental health and alcohol and drug use conditions (publishing.service.gov.uk)”

    Source location

    Response from NHS Social Care
    Page 3 · response
    Published 2 November 2021

    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

    Recruit two Dual Diagnosis Workers for the East and West Brighton Assessment and Treatment Services.

    Verbatim wording from the response

    “Previously we also set out the principles which underpin SPFT's Co-occurring Substance Use and Mental Health 5-year strategy. Since then, we are pleased to be able to update you on the recruitment of two Dual Diagnosis Workers into SPFT's Assessment and Treatment Services (ATS) in Brighton. This has arisen as a result of additional funding being obtained, through the transforming community care plan, and has resulted in a Dual Diagnosis Worker for both East and West Brighton ATSs. Change Grow Live have made progress integrating the work of their Mental Health Liaison nurses with the newly appointed SPFT Dual Diagnosis nurses. Strategic meetings have taken place between Change Grow Live and SPFT managers and the nurses are working jointly to support some clients with dual diagnosis.”

    Source location

    Response from NHS Social Care
    Page 2 · response
    Published 2 November 2021

    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 substance-misuse outreach, harm-minimisation and dual-diagnosis support through recovery coordinators and specialist nurses.

    Verbatim wording from the response

    “Additionally, currently, CGL provide substance misuse services which are designed to improve service users’ mental health and well-being, where dual diagnosis has been identified. Specialist recovery co-ordinators support clients living in supported accommodation and benefit from the support of the CGL dual diagnosis nurses to improve access to specialist mental health services. These workers offer outreach support and harm minimisation interventions to those living in supported housing or who are homeless. In June 2021, SPFT, set out its Co-occurring Substance Use and Mental Health (COSUMH) Conditions 5 year strategy. That strategy recognises that more needs to be done and adopts the principles of ‘everyone’s business’, ‘no wrong door’, integrated care plans, clinical leadership and facilitating access to mutual aid.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 2 · response
    Published 2 November 2021

    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

    Implement the COSUMH five-year strategy for co-occurring substance-use and mental-health conditions.

    Verbatim wording from the response

    “Additionally, currently, CGL provide substance misuse services which are designed to improve service users’ mental health and well-being, where dual diagnosis has been identified. Specialist recovery co-ordinators support clients living in supported accommodation and benefit from the support of the CGL dual diagnosis nurses to improve access to specialist mental health services. These workers offer outreach support and harm minimisation interventions to those living in supported housing or who are homeless. In June 2021, SPFT, set out its Co-occurring Substance Use and Mental Health (COSUMH) Conditions 5 year strategy. That strategy recognises that more needs to be done and adopts the principles of ‘everyone’s business’, ‘no wrong door’, integrated care plans, clinical leadership and facilitating access to mutual aid.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 2 · response
    Published 2 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commission a 24/7 crisis house for people in mental-health crisis, including those with substance-misuse support needs.

    Verbatim wording from the response

    “Also, the CCG is in the process of commissioning a new crisis house that will provide support to people in a mental health crisis who require 24/7 support and would otherwise be admitted to hospital. The tender for this service will be issued in October 2021 and the new service will start in the summer of 2022. The service will be for individuals with support needs for their mental health”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 1 · response
    Published 2 November 2021

    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 the Staying Well Crisis Café as an out-of-hours community mental-health crisis support service.

    Verbatim wording from the response

    “Currently, the CCG commission a Staying Well (Crisis Café service) which commenced in January 21. The service provides an out of hours (05:30 – 22:30 Weekdays, 3:30 – 22:30 Weekends) community space, where anyone on the verge of, or experiencing, a mental health crisis (self-defined) can access non-clinical mental health support. The aim of the service is to prevent an escalation of mental health need and/or to avert further crisis, to provide an alternative provision to attending A&E or accessing other urgent care services and to provide a step down from clinical services.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 1 · response
    Published 2 November 2021

    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

    Re-commission mental-health supported accommodation with greater care-model flexibility for people with substance-misuse needs.

    Verbatim wording from the response

    “BHCC and the CCG are also currently jointly re-commissioning mental health supported accommodation services with the intention of providing greater flexibility in the model of care. The timeline for this tender is the same as the crisis house and the same arrangements for people with substance misuse needs will apply.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 2 · response
    Published 2 November 2021

    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

    Require all newly commissioned substance-misuse and mental-health services to consider co-existing needs.

    Verbatim wording from the response

    “• ensure that all new commissioned services for both substance misuse and mental health conditions specifically considers co-existing needs.”

    Source location

    2021-0360-Response-from-BHCC-CCG-SPFT-and-CGL_Published
    Page 3 · response
    Published 2 November 2021

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Sean Daniel FEGAN · 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

    Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.

    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to account for autistic presentation when understanding mental health needs

    Wider context from the report

    “6. Autism awareness – I was concerned that Mr Fegan’s presentation acted as a barrier to a proper understanding of his mental health needs. In line with his autism diagnosis, he did not present in a socially typical way of expressing his feelings and emotions in a demonstrative manner, but rather ‘jumped’ to his view about what treatment he required, namely prescriptions. This was misunderstood by professionals on more than one 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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish informed agreement before withdrawing mental health services

    Wider context from the report

    “5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to proactively engage with family members and receive their concerns when services withdraw

    Wider context from the report

    “4. Liaison with family members – there was no evidence of proactive attempts to engage with family members, even when services withdrew. When a family member sought to share concerns, these were rebuffed. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of services for patients with dual diagnosis and significant drugs misuse problems

    Wider context from the report

    “3. Dual diagnosis – it was acknowledged that there was a ‘gap’ within the services in relation to dual diagnosis patients. There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide access to needed mental health treatment

    Wider context from the report

    “2. Access to mental health treatment – Mr Fegan had complex mental health conditions and experienced very high levels of distress and anxiety as a consequence. He was declined mental health treatment on two occasions by the Trust. Mr Fegan took an overdose due to his frustration at not being able to access mental health services which he needed. Whilst this was not the cause of Mr Fegan’s death, it created a dangerous state of affairs. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make secondary mental health care decisions using adequate information and assessment

    Wider context from the report

    “1. Decision making surrounding the need for secondary mental health care – as set out above, a decision was taken in December 2019 that Mr Fegan did not require mental health treatment at all in the absence of adequate information or assessment and for reasons which appeared incorrect. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Overriding care plans without assessment by decision-makers and review of the risk assessment

    Wider context from the report

    “5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required. ”
    Open source report

  4. Addressed to: the Chief Executive of CGL (Change, Grow, Live).

    Manchester South

    AI-generated summary

    Lindsey Theresa Hassall · 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

    Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.

    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to enter engagement notes into the electronic system contemporaneously

    Wider context from the report

    “• Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager. (Lifeline/CGL) ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to verify and coordinate necessary referrals from the 136 suite to the GP

    Wider context from the report

    “• The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make documentation accessible to all relevant staff

    Wider context from the report

    “• The documentation held by Pennine Care was not easily accessible to all of the staff working for Pennine Care which meant that the full history of engagement was not known to workers dealing with her. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to retain contemporaneous engagement notes

    Wider context from the report

    “• Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager. (Lifeline/CGL) ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to keep records of information provided verbally by Police Officers in the s.136 suite

    Wider context from the report

    “• There is no provision for a record to be kept of the information, which Police Officers provide verbally to the RAID practitioners in the s.136 suite. The inquest heard that there was a record of the initial circumstances but no further record was kept. (Pennine Care) ”
    Open source report

  5. Gloucestershire

    AI-generated summary

    Shane Dean Hardy · 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

    Shane Dean Hardy, a 29-year-old man with a history of substance misuse and involvement with mental health services, died after placing a belt around his neck and being found hanging from a tree on 8 March 2017. The report raised concerns that people with addiction and mental health difficulties can fall between services, and that agencies supporting an individual may not share information or identify a lead agency for 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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of information sharing between agencies providing support services

    Wider context from the report

    “(2) When multiple agencies are involved in providing support services to an individual, there can be a lack of information sharing between those agencies. No agency is identified as the lead agency for communication purposes. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of services to provide assistance to individuals with addiction and mental health difficulties

    Wider context from the report

    “(1) Individuals who suffer with addiction and mental health difficulties can fall between the services. Mental health services consider it not to be a mental health issue, and refer to alcohol treatment services. If the individual then refuses to engage with the latter, the individual is left receiving no assistance. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify a lead agency for communication

    Wider context from the report

    “(2) When multiple agencies are involved in providing support services to an individual, there can be a lack of information sharing between those agencies. No agency is identified as the lead agency for communication purposes. ”
    Open source report

  6. Nottinghamshire

    AI-generated summary

    Philip Anthony Denning · 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

    Philip Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.

    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Risk of future deaths from fragmented provision by a separate substance misuse organisation

    Wider context from the report

    “6. Even aside from the question of shared access to key records held by Nottinghamshire Healthcare and CRI, I am concerned that the current approach of having a separate organisation dealing only with substance misuse carries a risk of future deaths. Commissioners and providers will need to consider these matters carefully. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear remit of CRI in managing patients with co-occurring substance misuse and mental health problems

    Wider context from the report

    “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare

    Wider context from the report

    “5. As I understand it, the question of patients giving their consent for access to the records by CRI (and indeed for Nottinghamshire Healthcare to have access to CRI records) has not been considered by either organisation. Aside from potential cost and governance issues, none of the senior clinicians involved could tell me any disadvantage to such access being considered. It appears not to have been considered at all to date. There appears to be very little currently by way of joint working or information-sharing between CRI and Nottinghamshire Healthcare. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of primary care understanding of access routes and service roles for patients with co-occurring substance misuse and mental health problems

    Wider context from the report

    “7. It is also clear that there is a significant lack of understanding in primary care about how to access help for patients like Philip. The respective roles of CRI, Nottinghamshire Healthcare and primary care talking therapies appear to be widely misunderstood. I have included reference to GPs and primary care largely with a view to raising awareness in this area. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of CRI to provide or arrange additional psychological support for patients with co-occurring substance misuse and mental health problems

    Wider context from the report

    “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit. ”
    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 Change, Grow, Live; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of CRI access to Nottinghamshire Healthcare electronic patient records

    Wider context from the report

    “4. The CRI is an entirely separate entity from Nottinghamshire Healthcare and has no access to RiO, Nottingham Healthcare’s electronic record-keeping system. If, for instance, one of their patients had been seen regularly by Nottinghamshire Healthcare following overdoses, they would not be aware of this unless their patient told them about this. ”
    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

Data last updated 7 September 2026